Biomaterial Database

Perioperative documentation. Integrating nursing diagnoses on the patient record. 1987

V Stanfield

Community Memorial Hospital, Monomonee Falls, Wis.

The perioperative record maintains accurate communication between the OR and the postoperative care nurse. For example, the nurse can easily verify the type and placement of a drain by checking the area labeled "Potential for infection." The check-off format also makes the information consistent and easy-to-read, and the nurse does not have to decipher any handwriting. Another advantage of this format is that it is easy to retrieve data for nursing research. It is also suitable for computerization.

UI	MeSH Term	Description	Entries
D007430	Intraoperative Care	Patient care procedures performed during the operation that are ancillary to the actual surgery. It includes monitoring, fluid therapy, medication, transfusion, anesthesia, radiography, and laboratory tests.	Care, Intraoperative
D009730	Nursing Assessment	Evaluation of the nature and extent of nursing problems presented by a patient for the purpose of patient care planning.	Nursing Protocols,Assessment, Nursing,Protocols, Nursing,Assessments, Nursing,Nursing Assessments,Nursing Protocol,Protocol, Nursing
D009733	Nursing Diagnosis	Conclusions derived from the nursing assessment that establish a health status profile for the patient and from which nursing interventions may be ordered.	Diagnosis, Nursing,Diagnoses, Nursing,Nursing Diagnoses
D009737	Nursing Records	Data recorded by nurses concerning the nursing care given to the patient, including judgment of the patient's progress.	Records, Nursing,Nursing Record,Record, Nursing
D009871	Operating Room Nursing	The functions of the professional nurse in the operating room.	Nursing, Operating Room
D010351	Patient Discharge	The administrative process of discharging the patient, alive or dead, from hospitals or other health facilities.	Discharge Planning,Discharge Plannings,Discharge, Patient,Discharges, Patient,Patient Discharges,Planning, Discharge,Plannings, Discharge
D011300	Preoperative Care	Care given during the period prior to undergoing surgery when psychological and physical preparations are made according to the special needs of the individual patient. This period spans the time between admission to the hospital to the time the surgery begins. (From Dictionary of Health Services Management, 2d ed)	Care, Preoperative,Preoperative Procedure,Preoperative Procedures,Procedure, Preoperative,Procedures, Preoperative
D006801	Humans	Members of the species Homo sapiens.	Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man