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Student __________________________________________________ Date ________________________

Instructor_________________________________________________ Date ________________________

Skills Performance Checklist 28.1 Preoperative Assessment

S U NP Comments

PLANNING

1. Identified expected outcomes. _____ _____ _____ __________________________

2. Provided necessary information to nursing assistive _____ _____ _____ __________________________

personnel.

3. Gathered necessary equipment. _____ _____ _____ __________________________

IMPLEMENTATION _____ _____ _____ __________________________

1. Identified patient using two identifiers. _____ _____ _____ __________________________

2. Determined if patient has communication _____ _____ _____ __________________________

impairments.

3. Assessed patient’s understanding of intended surgery _____ _____ _____ __________________________

and anesthesia, had patient describe in own words,

and asked patient/family about expectations of

surgery and care.

4. Asked if patient has advance directive. _____ _____ _____ __________________________

5. Collected nursing history and identif ed risk factors. _____ _____ _____ __________________________

a. Condition leading to surgery. _____ _____ _____ __________________________

b. Chronic illnesses and associated risks. _____ _____ _____ __________________________

c. Last menstrual period if applicable. _____ _____ _____ __________________________

d. Previous hospitalizations. _____ _____ _____ __________________________

e. Medication history. _____ _____ _____ __________________________

f. Previous experience with surgery and anesthesia. _____ _____ _____ __________________________

g. Family history of complications from surgery or _____ _____ _____ __________________________

Copyright © 2016, by Mosby, an imprint of Elsevier Inc.

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Skills Performance Checklists

anesthesia.

h. Allergies to medications, food, or tape. _____ _____ _____ __________________________

i. Physical impairment. _____ _____ _____ __________________________

j. Prostheses and implants. _____ _____ _____ __________________________

k. Smoking, alcohol, and drug use. _____ _____ _____ __________________________

l. Occupation. _____ _____ _____ __________________________

6. Assessed patient’s weight, height, and vital signs. _____ _____ _____ __________________________

7. Assessed patient’s respiratory status. _____ _____ _____ __________________________

8. Evaluated patient’s circulatory status. _____ _____ _____ __________________________

9. Determined patient’s neurological status. _____ _____ _____ __________________________

10. Evaluated patient’s musculoskeletal system. _____ _____ _____ __________________________

11. Examined patient’s skin, identif ed breaks in skin _____ _____ _____ __________________________

integrity, and determined level of hydration.

12. Evaluated patient’s emotional status. _____ _____ _____ __________________________

13. Reviewed results of laboratory tests. _____ _____ _____ __________________________

14. Completed GI assessment; identified time of _____ _____ _____ __________________________

patient’s last intake of food and drink.

EVALUATION

1. Determined if patient information is complete and _____ _____ _____ __________________________

validated unclear information with family.

2. Evaluated patient’s ability to cooperate. _____ _____ _____ __________________________

3. Asked patient to explain why he or she is having _____ _____ _____ __________________________

surgery.

4. Identified unexpected outcomes. _____ _____ _____ __________________________

RECORDING AND REPORTING

1. Documented f ndings in the preoperative notes. _____ _____ _____ __________________________

2. Reported abnormal laboratory values or other _____ _____ _____ __________________________

Copyright © 2016, by Mosby, an imprint of Elsevier Inc.

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Skills Performance Checklists

concerns to surgeon and anesthesiologist.

3. Documented evaluation of patient learning. _____ _____ _____ __________________________

Copyright © 2016, by Mosby, an imprint of Elsevier Inc.