醫務術前評估詞彙
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醫務術前評估詞彙：
Preoperative Assessment術前評估
Assessment and Implementation評估實施
Standard Protocol.採用標準護理程序
rmine if the client has any communication impairment and if the client is mentally competent.測定病人存在溝通障礙，心智是否健全。
ss the client's understanding of the intended surgery and anesthesia.評估病人是否瞭解即將進行的手術及麻醉。
in a nursing history：獲取護理史
ition leading to surgery 需手術的病情
B. The need for isolation precautions. 隔離需要
nic illnesses. 慢性疾病
menstrual period (for female clients in childbearing years)。 末次月經(育齡期女性病人)
ious hospitalizations. 既往住院史
cation history， including prescription and over-the-counter (OTC)， and date/time of last doses. 用藥史，包括處方與非處方藥，末次用藥日期/時間
ious experience with surgery and anesthesia.既往手術及麻醉史
ly history of complications from surgery or anesthesia. 家庭手術或麻醉併發症史
rgies to medications or food， including specific questions about natural rubber latex.藥物或食物過敏史，包括天然橡膠特種過敏反應
ical impairment. 身體受損情況
theses and implants (e.g.， dentures， hearing aid， pacemaker， internal defibrillator， hip prosthesis)假體和移植(如義齒、助聽器、起搏器、除顫器、人工髖關節)
ing， alcohol， and drug use. 吸菸、飲酒和吸毒史
pation 職業
ss client's weight， height， and vital signs.評估病人體重、身高和生命體徵。
ss client's respiratory status， including character and rate of respirations， oxygen saturation， ability to breathe lying flat， and chest x-ray report.評估病人呼吸系統狀況，包括呼吸特徵與速度，氧飽和度，平臥呼吸能力及胸片。
ss client's circulatory status， including apical pulse， electrocardiogram (ECG) report， and peripheral pulses.評估病人循環系統狀況，包括心尖搏動、心電圖和周圍脈搏。
rmine client's neurological status， including level of consciousness (LOC)。測定病人神經學狀況，包括神志清醒程度。
ss client's musculoskeletal system，including range of motion (ROM) of joints.評估病人肌骨骼系統，包括關節活動度。
ine client's skin; identify any breaks in skin integrity and determine level of hydration.檢查病人皮膚，確認皮膚完整性受損情況，確定水合程度。
ss client's emotional status， including level of anxiety， coping ability， and family support.評估病人情緒狀況，包括焦慮程度、應對能力和家庭支援。
ew the results of laboratory tests， including complete blood count (CBC)， electrolytes， urinalysis， and other diagnostic tests.審查化驗報告，包括全血計數、電解質、尿檢和其他診斷試驗。
if client has an advanced directive.詢問病人是否得到事先說明。
tify the time of client's last intake of food or drink.確認病人上次攝食與飲水時間。
Completion Protocol.採用護理完成標準程序。
Evaluation評價
ew records to determine if necessary information has been assessed.複查記錄，確定必需項目是否得到評估。
uate client's ability to cooperate.評價病人合作能力。
Identify Unexpected Outcomes and Nursing Interventions確認意外結果與護理措施
Record and Report記錄與報告
g agency format (preoperative checklist)， complete all essential information.採用機構表格(術前目錄單)，填寫全部重要信息。
rt abnormal laboratory values and other concerns to the surgeon or anesthesiologist.向手術醫生或麻醉師報告異常化驗值及其他問題。
