Questions

can you please write an observation paper on pre operation room. and please follow the rubric also i attach sample of my friend work please try to do as her

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My clinical rotation for this week is preoperation room. I saw many patients the floor was so busy in the morning. One of the case that I saw 64 years female, she came for Esophagogastroduoddenoscopy. She has history of HTN, hypothyroidism. Consent in, she took her medication for hypothoidism today and she is NPO midnight, and she stop asprin 14/09/2019. Her vital signs is TEM 97.2, pulse 79, BP 162/89, respiratory 20. O2 98%. The nurse ask pt about her name date of birth. And she ask about allergy, procedure and who is the doctor, also, when NPO, what medication she took and when the last time. Then she ask the pt to change dress. Then inserte the IV with the fluid. Bed in lower position and call light with pt.  Also take three consent from pt one for procedure one of anthesea and one for blood. Also ask pt to remove the jowlary and glass and dentior. And check the lab result if any abnormality and inform thr surgon and anethesea. Then give hand off report to OR nurse . note in the perioperation no time out only for some surgery.

My nursing diagnosis is

Fear and anxiety related to procedure as evidence by pt verbalize she is restless and not sleep two night and her Bp 162/89.

My goal is

Patien will able to report decrease anxiety and fear and blood decrease to normal level by 1122on 09/18/2019.

Intervention:

Explain the procedure to the pt, answer her questions, put her in comfortable position.

Goal met patent relax and she said feel better and anxiety decrease and I check her BP 128/80) this what i see and you can add more intervention and please follow each suction in rubric

 

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