Standards of Care for Perioperative Nursing
Standard I: Assessment
The perioperative nurse collects patient health data.
- The priority of data collection is determined by the patient's immediate condition or needs, and the relationship to the proposed laser intervention. Pertinent data include, but are not limited to, current medical diagnoses and therapies; physical status and physiological responses; psychosocial status of the patient; cultural, spiritual, and lifestyle information; the individual understanding, perceptions, and expectations of the laser surgery or treatment; previous responses to illness, hospitalizations, and surgical, therapeutic, or diagnostic procedures; and results of diagnostic studies.
- Pertinent data are collected using appropriate assessment techniques.
- Data collection involves the patient, significant others, and health care providers when appropriate. It may be accomplished through diverse means, such as interview, review of records, assessment, and/or consultation.
- Data collection is systematic and ongoing.
- Relevant data are documented in a retrievable form.
Standard II: Diagnosis
The perioperative nurse analyzes the assessment data in determining diagnoses.
- Interpretive statement: Nursing diagnoses are concise statements about actual, or high risk for, health problems/clinical conditions that are amenable to nursing intervention.
- Diagnoses result from analysis and interpretation of data about the patient's problems, needs, and health status.
- Diagnoses are derived from the assessment data.
- Diagnoses are validated with the patient, significant others, and health care providers, when possible.
- Diagnoses are documented in a manner that facilitates the determination of expected outcomes and plan of care.
Standard III: Outcome Identification
The perioperative nurse identifies expected outcomes unique to the patient.
- Outcomes are derived from the diagnoses and are mutually formulated with the patient, significant others, and health care providers, when possible.
- The patient's present and potential physical capabilities and behavioral patterns are congruent with the expected outcomes from the laser surgery or treatment.
- Outcomes are attainable with consideration of the patient's capabilities and material resources.
- Outcomes are documented as measurable goals and include a time estimate for attainment.
- Outcomes are prioritized.
- Outcomes provide direction for continuity of care.
Standards IV: Planning
The perioperative nurse develops a plan of care that prescribes interventions to attain expected outcomes.
- The plan of care reflects current nursing practice in laser technology.
- The plan of care is individualized to the patient's condition and needs.
- The plan of care is developed with the patient, significant others, and health care providers, when appropriate.
- The plan of care specifies nursing diagnoses and a logical sequence of interventions needed to achieve the outcomes.
- The plan of care provides for continuity of care.
- The plan of care is documented and communicated to appropriate people.
Standard V: Implementation
The perioperative nurse implements the interventions identified in the plan of care.
- Interventions are consistent with the established plan of care.
- Implementation of the plan of care is an ongoing process and is based on the patient's response.
- Interventions reflect the rights and desires of the patient and significant others.
- Interventions are implemented in a safe and appropriate manner.
- Interventions may be assigned or delegated as appropriate.
- Interventions are documented and communicated as appropriate to promote continuity of care.
Standard VI: Evaluation
The perioperative nurse evaluates the patient's progress toward attainment of outcomes.
- Evaluation of the effectiveness of interventions is systematic and ongoing.
- The patient's responses to interventions are documented and retrievable.
- The effectiveness of interventions are evaluated in relation to outcomes.
- Ongoing assessment data are used to revise diagnoses, outcomes, and the plan of care, as needed.
- Revisions in diagnoses, outcomes, and the plan of care are documented.
- The patient, significant others, and health care providers are involved in the evaluation process, when appropriate.