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PERIOPERATIVE CARE PLAN

Student Name:_________________________________________ Date submitted ____________________


PATIENT INITIALS: __________________Date of Surgery:
_______________________
Prior Medical/Surgical History:______________________________________________________________
Preop VS:
Temp _________ BP ______________ HR___________ RR_______________
Allergy Profile:__________________________________________________________________________
Preoperative checklist completed: Yes No
Consent Signed: Yes No
Preoperative lab/diagnostics on the chart: Yes No
Abnormal lab/diagnostics: Yes No If yes, Describe:________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
NPO: Yes No Since______________(enter time)
Preoperative prep/medications ordered: Yes No Administered: Yes No
If administered, describe:_____________________________________________________________
_______________________________________________________________________________________
Preoperative teaching given: Yes No
If given, describe:__________________________________________________________________
_______________________________________________________________________________________
Surgical Procedure:
_______________________________________________________________________________________
_______________________________________________________________________________________
Reason for surgery: Diagnostic Curative Restorative Palliative Cosmetic
Urgency of Surgery: Elective
Urgent
Emergent
Assessment of Surgical Risk:
Review the medical record and check off the box below if any of the following factors are present.
AGE
Age greater than 65 years
MEDICATIONS

Antihypertensive therapy
Tricyclic antidepressants

Anticoagulants
NSAIDS/ASA

MEDICAL
HISTORY

Decreased immunity
Diabetes
Pulmonary disease
Infection

Cardiac disease
Hemodynamic instability
Multisystem disease
Hypertension
Hypotension

PRIOR
SURGICAL HX

Anesthesia reactions

Postoperative complications

HEALTH
HISTORY

Malnutrition
Obesity

Alcohol use
Substance abuse

Tobacco use

FAMILY
HISTORY

Malignant hyperthermia

Bleeding disorder

Cancer

SURGERY
PLANNED

Neck, oral or facial


procedure

Chest or high abdominal


procedure

Abdominal surgery

Coagulation disorder
Anemia
Dehydration
Any chronic disease

PERIOPERATIVE CARE PLAN


Review the Intraoperative Report:
Type of Anesthesia: General Conscious Sedation Spinal Epidural Regional Block Local
Position: supine prone lithotomy lateral jackknife fracture table other
Safety equipment used: ____________________________________________________________________
_______________________________________________________________________________________
Airway maintenance: endotracheal tube modified jaw thrust
oral airway
none
Oxygenation: mechanical ventilator supplemental oxygen, type:________________ none
Monitoring Equipment: Cardiac monitoring Pulse Oximetry Arterial monitoring CVP monitoring
Non Invasive Blood Pressure monitoring Other ___________________________________________
Estimated blood loss (in ccs) ______________________________
Blood Products administered: Yes No If yes, indicate type:__________________________________
Amount:_________________________________
IV Fluids Given: Yes No If yes, indicate type:____________________________________________
Amount:____________________________________________
Total Intake:___________________cc Total Output: __________________________________cc
Dressings: (site/condition)_________________________________________________________________
Drains/Tubes: (site/type of drainage)_________________________________________________________
Postop VS: Temp _________ BP ______________ HR___________ RR_______________
What are two priority collaborative problems in the PACU for this client?
Identify three interventions for each.
Collaborative Problems
Interventions

What complications can you anticipate postoperatively based on review of the data recorded and the
medical and surgical stressors unique to this client? Explain the rationale for each.
Complication
Rationale

PERIOPERATIVE CARE PLAN