Considerations in History and Physical Assessment of the Plastic, Cosmetic, and Reconstructive Surgery Patient

Special Considerations in History and Physical Assessment of the Plastic, Cosmetic, and Reconstructive Surgery Patient



Andrea Fassiotto, RN


Murray Calloway County Hospital, 803 Poplar Street, Murray, KY 42071, USA


E-mail address: afassiotto@murrayhospital.org



Abstract


One of the most important tasks of the perioperative nurse is to obtain a thorough history and physical assessment before surgery. The nurse should be able to assess the patient, obtain a history of the patient, and observe for any potential problems.



Keywords


• Patient history • Assessment • Plastic surgery • Reconstructive surgery


One of the most important tasks of the perioperative nurse is to obtain a thorough history and physical assessment before surgery. This task is the first line of defense for safeguarding the surgical patients against potential complications. Many patients do not realize how their past medical and surgical history affects each future procedure, therefore it is critical to assess the patient for an accurate history. The nurse should be able to assess the patient, obtain a history of the patient, and observe for any potential problems.


The advent of electronic medical records (EMRs) has made this task much easier on nurses and patients alike. Patients who have been seen in your facility before will already have their records in the system. The history will just need to be reviewed and any updates made. For patients who have never visited your facility, it will make it easier to do a consistent interview, and their information will be in the system for any subsequent visits. However, not all facilities have EMRs at present, and paper files are still being kept. Whichever system your surgery center uses, remember to keep all records confidential in accordance with the HIPPA (US Health Insurance Portability and Accountability Act).



Building patient trust for optimal care


When obtaining a history and performing a physical examination, it is important to establish a rapport with the patient. Make sure she is comfortable, and provide for privacy. Minimize distractions, and make eye contact with your patients to reassure them that you are listening to what they say.


Does the patient have any religious or cultural beliefs that would affect her care? Some cultures are more private than others or regard eye contact as being rude. In addition, members of the Jehovah’s Witness religion do not accept any blood products. Most facilities will require patients to sign a release of responsibility if they need a transfusion but refuse it.


Most of us have a routine when we are obtaining a history and performing a physical assessment. We also make many system observations at once when we initially meet our patient. How many times have you noticed patients’ pain, nausea, or nervousness as soon as they walked in?



Create a consistent, systematic approach


A systematic approach to doing the history and physical assessment works best. Take each body system individually, asking patients questions regarding each system. Some nurses do their assessment and history together, others ask questions first and then move on to the assessment. Whichever technique you use, consistency is the key. When you use the same technique with each patient, you are less likely to overlook the key points of your assessment.


The integumentary system is a good place to start. Patients’ skin can tell us a great deal about their overall well-being. Does she have any rash, cut, or bruis or any skin condition such as psoriasis? Has she ever had a wound that would not heal, an infection caused by methicillin-resistant Staphylococcus aureus, or a vancomycin-resistant infection? Ask the patient to show you any unusual skin conditions.


Has she had any history of any neurologic disorder? Ask the patient about headaches, including migraines. Does she have any history of seizures? If so, are they well controlled? When was the last one? Are the seizures petit or grand mal? Is the patient alert and oriented to person, place, and time? Does she have any slurred speech? Does the patient answer questions in a timely manner?

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Apr 2, 2016 | Posted by in Reconstructive surgery | Comments Off on Considerations in History and Physical Assessment of the Plastic, Cosmetic, and Reconstructive Surgery Patient

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