| Preoperative Assessment  | 术�评估  |
| Assessment and Implementation  | 评估实施  |
| 1. Use Standard Protocol.  | é‡‡ç”¨æ ‡å‡†æŠ¤ç�†ç¨‹åº�  |
| 2. Determine if the client has any communication impairment and if the client is mentally competent.  | 测定病人å˜åœ¨æ²Ÿé€šéšœç¢�,心智是å�¦å�¥å…¨ã€‚  |
| 3. Assess the client's understanding of the intended surgery and anesthesia.  | 评估病人是�了解�将进行的手术�麻醉。  |
| 4. Obtain a nursing history:  | 获�护��  |
| A. Condition leading to surgery  | 需手术的病情  |
| B. The need for isolation precautions.  | 隔离需�  |
| C. Chronic illnesses.  | 慢性疾病  |
| D. Last menstrual period (for female clients in childbearing years).  | 末次月�(育龄期女性病人)  |
| E. Previous hospitalizations.  | 既往�院�  |
| F. Medication history, including prescription and over-the-counter (OTC), and date/time of last doses.  | 用��,包括处方与�处方�,末次用�日期/时间  |
| G. Previous experience with surgery and anesthesia.  | 既往手术�麻醉�  |
| H. Family history of complications from surgery or anesthesia.  | å®¶åºæ‰‹æœ¯æˆ–麻醉并å�‘ç—‡å�²ã€€ |
| I. Allergies to medications or food, including specific questions about natural rubber latex.  | �物或食物过��,包括天然橡胶特�过��应  |
| J. Physical impairment.  | 身体��情况  |
| K. Prostheses and implants (e.g., dentures, hearing aid, pacemaker, internal defibrillator, hip prosthesis)  | �体和移�(如义齿�助�器�起�器�除颤器�人工髋关节)  |
| L. Smoking, alcohol, and drug use.  | �烟�饮酒和�毒�  |
| M. Occupation  | �业  |
| 5. Assess client's weight, height, and vital signs.  | 评估病人体��身高和生命体�。  |
| 6. Assess client's respiratory status, including character and rate of respirations, oxygen saturation, ability to breathe lying flat, and chest x-ray report.  | 评估病人呼�系统状况,包括呼�特�与速度,氧饱和度,平�呼�能力�胸片。  |
| 7. Assess client's circulatory status, including apical pulse, electrocardiogram (ECG) report, and peripheral pulses.  | 评估病人循环系统状况,包括心尖�动�心电图和周围脉�。  |
| 8. Determine client's neurological status, including level of consciousness (LOC).  | 测定病人神ç»�å¦çŠ¶å†µï¼ŒåŒ…æ‹¬ç¥žå¿—æ¸…é†’ç¨‹åº¦ã€‚ã€€ |
| 9. Assess client's musculoskeletal system, including range of motion (ROM) of joints.  | 评估病人肌骨骼系统,包括关节活动度。  |
| 10. Examine client's skin; identify any breaks in skin integrity and determine level of hydration.  | 检查病人皮肤,确认皮肤完整性��情况,确定水�程度。  |
| 11. Assess client's emotional status, including level of anxiety, coping ability, and family support.  | 评估病人情绪状况,包括焦虑程度ã€�åº”å¯¹èƒ½åŠ›å’Œå®¶åºæ”¯æ�´ã€‚  |
| 12. Review the results of laboratory tests, including complete blood count (CBC), electrolytes, urinalysis, and other diagnostic tests.  | 审查化验报告,包括全血计数ã€�电解质ã€�尿检和其他诊æ–试验。  |
| 13. Ask if client has an advanced directive.  | 询问病人是�得到事先说明。  |
| 14. Identify the time of client's last intake of food or drink.  | 确认病人上次摄食与饮水时间。  |
| 15. Use Completion Protocol.  | 采用护ç�†å®Œæˆ�æ ‡å‡†ç¨‹åº�。  |
| Evaluation  | 评价  |
| 1. Review records to determine if necessary information has been assessed.  | �查记录,确定必需项目是�得到评估。  |
| 2. Evaluate client's ability to cooperate.  | 评价病人�作能力。  |
| Identify Unexpected Outcomes and Nursing Interventions  | 确认�外结果与护�措施  |
| Record and Report  | 记录与报告  |
| 1. Using agency format (preoperative checklist), complete all essential information.  | é‡‡ç”¨æœºæž„è¡¨æ ¼ï¼ˆæœ¯å‰�目录å�•),填写全部é‡�è¦�ä¿¡æ�¯ã€‚  |
| 2. Report abnormal laboratory values and other concerns to the surgeon or anesthesiologist.  | �手术医生或麻醉师报告异常化验值�其他问题。  |