Individualized Physical Assessments

Guidelines:

• Proper documentation of patient condition pre and post-op
• Identification of adverse assessment findings
• Plan of care specific to patients condition

Considerations:

• Pressure ulcers
• Jewelry/Scars/tattoos
• Bruising
• Burns
  • Bovie
• Possible interventions
  • A-Line
  • Foley
• Mouth opening
  • Teeth
• Flexibility
• Any nerve pain/tingling/weakness
  • critical comparison

Nurse’s role:

• Documentation
• Communication
• Identification
  • Assessment is continuous
• Pre-op baseline assessment
• Induction assessment
• Emergence assessment
  • Burns
  • Cuts
  • Bruises
  • Redness
  • Reactions

Pitfalls:

• Improper baseline completed
• Nurse turnover with bad report
• Anesthesia turnover
• “f/u primary care”is not treatment plan
• Improper nursing expectation
  • PACU has septo/rhino who continues to bleed – how much is normal!?

Examples:

• 86M left sided weakness in PACU
  • History? (compare to pre-op)
  • Family? (compare to patient’s norm)
  • Consults & CT (if doubt, act)
• Drain foley balloon, red discharge (notify physician, leave in place as is if possible, anticipate urology consult or need for further operative time/anesthesia)
• Routine assessment finds bruising behind the ears intra-operatively

Linchpins (Key Points):

• Proper identification and documentation of patient condition can be vital to proper
  treatment