Exam #3 Basic NUrsing

Prepare the postoperative room

If you transfer the patient to the surgical suite from a nursing unit in the hospital, you should prepare the room for the patient's return after surgery. Put clean linens on the bed and arrange the supplies and equipment you will need. Raise the bed to stretcher height and lock the wheels.

What is the benefit of leg excercises?

Increase Venous Return and prevent thrombophlebitis which increases the risk for DVT which increases the risk for PE and Death.

associated with a high degree of risk. For example, it may be associated with the potential for significant blood loss, involve vital organs, be a prolonged or complicated procedure, or have significant potential for postoperative complications.

Major surgery

often performed on an outpatient basis, involves little risk and usually has few complications. Examples include arthroscopy, breast biopsy, and inguinal hernia repair.

Minor Surgery

Physical assessment

If you identify risk factors from the nursing history, focus on these aspects during your brief head-to-toe physical assessment. For example, if the patient states they had a cough last week, perform a focused assessment of the ear, nose, throat, and lungs to determine how the cough may affect the patient's risk.

Examples of near events?

Surgery on the wrong body part Surgery on the wrong patient Wrong surgery on a patient Deep vein thrombosis (DVT) or pulmonary embolism (PE) after total knee or hip replacement Foreign body left in a patient after surgery (e.g., sponge, clip for draping) Surgical site infections after certain elective procedures (e.g., after bariatric surgery for obesity)

Preparing the Patient Through Teaching

Surgical events and sensations Pain management Physical activities: Deep breathing Coughing Incentive spirometry Leg exercises Turning in bed

•Useful for determining the risk for postoperative infection. ØExample: Incisions that enter the gastrointestinal (GI), respiratory, or genitourinary tracts have a higher risk for infection than does surgery of other body systems. ØHowever, if an organ ruptures or surgery is for repair a penetrating injury, the risk of infection is very high regardless of the body system involved.

by body system

Major and minor surgery

by degree of risk

Emergency surgery urgent surgery elective surgery

by degree of urgency

Uninfected; minimal inflammation; little risk of infection EX: Face-lift, cataract surgery, joint replacement, breast biopsy, tonsillectomy

clean wounds

Not infected, but carry high risk for infection ex:Surgery to repair trauma to open wounds, such as compound fractures; surgery in which a major break in surgical asepsis occurred

contaminated wounds

improve appearance

cosmetic surgery

the most common PACU emergency. It may occur as a result of secretion accumulation, obstruction by the tongue, laryngospasm (a sudden, violent contraction of the vocal cords), or laryngeal edema. Therefore, assessments made in the PACU include respiratory status (airway, pulse oximetry), cardiovascular status (blood pressure), temperature, central nervous system status (level of alertness, pupil response, movement, shivering, mental status-LOC), fluid status, wound status (if there is a large amount of fresh blood, do not remove dressing; instead reinforce), gastrointestinal status (nausea and vomiting), and general condition. These assessments initially are made every 10 to 15 minutes. Depending on facility.

respiratory obstruction

protects the healthcare agency and workers from later claims that the patient did not consent to have the procedure.

signed document

•depending on the surgery and facility, patients may be asked to shower or scrub the surgical site with soap or an antibacterial solution (e.g., 4% chlorhexadine gluconate, Betadine) the evening before surgery and the morning of the surgery. Studies demonstrate that this reduces bacterial colonization on the skin, but do not clearly prove that it reduces surgical infection.

skin preparation

•Includes the surgeon, surgical assistant, and scrub person. Before beginning the surgery, they perform a surgical scrub of the hands and arms, dry with sterile towels, and don sterile gowns and gloves.

sterile team

What are the intraoperative care

sterile team clean team anesthesia skin preparation positioning the client

Before a surgical procedure is performed, professional standards and the law require the surgeon to obtain the patient's informed consent. The signed consent form verifies that the surgeon and patient have communicated adequately about the surgery. Once signed and witnessed, the consent form is part of the patient's record and accompanies them to the operating room.

surgical consent

targets a specific tissue of the body. Produces loss of pain sensation at the desired site. It is typically used for minor procedures. However, after finishing a major surgery, the surgeon may infiltrate the operative area with local anesthetics to provide postoperative pain relief. Local anesthetics may be applied topically or injected. A _____ is applied directly to the skin and mucous membranes. Lidocaine and benzocaine are commonly used because they are rapidly absorbed and rapid acting.

topical or local anesthesia

Replaces malfunctioning body part, tissue, or organ Ex- kidney transplant

transplant surgery

Both preexisting wounds (e.g., from trauma) and the wounds (incisions) created by the surgical procedure can pose a risk for infection. Risk to the patient increases along with the risk for or presence of infection.

type of wound

How to obtain a signature

verify notify surgeon and delay if necessary document

Who are at greatest risk during surgical procedures?

very young and very old

Monitor ______ according to facility policy and report abnormalities to the physician and surgeon.

vital signs

Medications that cause surgical risk

ØAnticoagulants: precipitate hemorrhage ØDiuretics: electrolyte imbalances, respiratory depression from anesthesia ØTranquilizers: increase hypotensive effects of anesthetic agents ØAdrenal steroids: abrupt withdrawal may cause cardiovascular collapse ØAntibiotics in mycin group: respiratory paralysis when combined with certain muscle relaxants

transfer to the operative suite

ØPreoperative checklist and patient's chart: Must accompany the patient. ØValuables: Lock these up according to agency policy or have the patient's family keep them. ØGlasses, hearing aid: Occasionally, especially if the patient has a significant sensory deficit, the patient can wear their hearing aid or glasses to the surgical suite. You will need to arrange this in advance with the surgical staff or anesthesia team.

How to prevent wrong patient, wrong site, wrong surgery

ØUse a preoperative checklist to confirm that appropriate documents are available and the appropriate activities have been performed. ØVerify the patient's identity before the patient leaves the preoperative area. ØMark the surgical site before surgery. Use a permanent marker so that your marks will not be removed by the surgical skin prep and involve the patient in the marking process. ØTake a time-out with all team members before starting the procedure.

communication with the surgical team

Ørecieve a summary of the plan of care (e.g., a short briefing by the surgeon) and develop a shared understanding of the plan. ØSpeak up and be assertive with concerns about the procedure or decisions. ØAsk questions to clarify confusion. ØAcknowledge that they have heard and understood. ØAsk for and provide feedback (e.g., read back) on critical information. ØUse standard terminology. ØIdentify topics that should be discussed in preoperative teaching. ØDescribe the typical physical preparation of a client undergoing surgery.

How surgeries are classified?

•Body system •Purpose (e.g., palliation) •Degree of urgency (e.g., elective) •Degree of risk

Preoperative Screening test

•Complete blood count (CBC) •Urinalysis •Electrocardiogram (ECG) •Chest X-Ray CBC , Urinalysis and ECG -older than 50 years of age

What are cardiovascular complications in surgery

•Hemorrhage •Shock/Hypovolemia •Thrombophlebitis Pulmonary embolus

teaching effective coughing

•Place the patient in a semi-Fowler's position, leaning forward. •Provide a pillow or folded bath blanket to use in splinting the incision. •Ask the patient to: --•Inhale and exhale deeply and slowly through the nose three times. --•Take a deep breath and hold it for 3 seconds. --•"Hack" out for three short breaths. --•With mouth open, take a quick breath. --•Cough deeply once or twice. --•Take another deep breath. --•Repeat the exercise every 2 hours while awake

Consciousness returns in reverse order, with the usual pattern being: 1-5 Nurses in the PACU verbally reorient the patient by_____ and calling the patient by name. If the patient had spinal anesthesia, neurologic checks are done every

(1) unconsciousness, (2) response to touch and sounds, (3) drowsiness, (4) awake but not oriented, and (5) awake and oriented. gently touching and calling the patients name 15 minutes for the first hour.

What are the types of anesthesia

-General -Moderate sedation/analgesia -Regional -Topical and local anesthesia

What are the risk factors for infants?

-Limited ability to regulate temperature. -Immature immune, cardiovascular, liver, and renal systems. -Increased risk for infection. Increased risk for excess fluid volume, and deficient fluid volume. Even minor blood loss may represent a substantial portion of an infant's total blood. -Infants may have difficulty calming. -They are unable to understand what is happening, so you cannot use verbal reassurance and explanations to comfort them.

nursing care during preoperative phase focuses on?

-identifying existing health concerns -planning for intraoperative and postoperative needs -providing preoperative teaching

Individualized nursing diagnosis for preoperative patient

anxiety fear airway clearance impairment disturbed sleep pattern ineffective coping latex allergy reaction risk for latex allergy reaction knowledge deficit

leg excercises

1. Instruct the patient to lie supine in the bed. 2.Perform ankle circles. Instruct the patient to: a. Start with one foot in the dorsiflexed position. b. Slowly rotate the ankle clockwise. c. After three rotations, repeat the procedure in a counterclockwise direction. d. Repeat this exercise at least three times in each direction, then switch and exercise the other ankle. 3.Perform ankle pumps. Instruct the patient to: a. Start with one foot, leg extended. b. Point the toe until foot is plantar flexed. c. Pull the toes back toward the head until the foot is dorsiflexed; at the same time, press the back of the knee into the bed. d. Make sure the patient feels a pull, or a stretch, in the calf. e. Repeat the alternation between plantar and dorsiflexion several times. f. Repeat the cycle with the other foot. 4. Perform leg exercises. Instruct the patient to: a. Lie supine in the bed. b. Slowly begin bending the knee, sliding the sole of the foot along the bed until the knee is in a flexed position. c. Reverse the motion, extending the knee until the leg is once again flat on the bed. dRepeat several times. e. Repeat using the opposite leg.

Teaching patient to deep breathe

1. assist the patient to a fowler semi-fowler position ( allows for best chest expansion) 2. Assist the patient who will have a chest or abdominal incision to practice splinting the site with a folded blanket or pillow.(Counterpressure supports the incision and decreases pain.) 3. Teach the patient diaphragmatic/deep breathing. Tell the patient to: a. Place their hands anteriorly, along the lower end of the rib cage. The tips of the third fingers should touch at the midline. b. Slowly take a deep breath in through the nose. Tell the patient that they should feel the chest expanding as the diaphragm moves down. c. Hold the breath for 2 to 5 seconds. (Stimulates surfactant production and helps prevent alveolar collapse.) d. Slowly and completely exhale through the mouth. 4. Teach the patient to cough in conjunction with diaphragmatic breathing. Instruct the patient to: a. Complete two or three cycles of diaphragmatic breathing. b. On the next breath in, have the patient lean forward and cough rapidly, through an open mouth, using the muscles of the abdomen, thighs, and buttocks. Cough several times on that breath. (This information helps the patient to distinguish coughing from merely clearing the throat.) If the patient is too weak to perform this maneuver, have the patient inhale deeply, bend forward slightly, and perform three or four "huffs" against an open glottis to move secretions forward.

An older woman fell at home and fractured her hip. After being admitted to the hospital, the nurse knows that the patient is to be "stabilized" prior to having surgery. This surgery would be classified as:

A. Urgent: This patient will most likely have her surgery within the next 48 hr. It must be done to restore joint function

•anesthesiologist or a certified registered nurse anesthetist (CRNA) induces amnesia, analgesia, and muscle relaxation or paralysis with anesthesia. The role is to continuously monitor and evaluate the patient's responses to the anesthetic agent and the surgical procedure. CRNAs administer more than half of all anesthetics in the United States.

anesthesia

The nurse knows that the following should be given highest priority when receiving patient in the operating room: A.Assess level of consciousness. B.Verify patient identification and informed consent. C.Assess vital signs. Check for jewelry, glasses, and dentures.

B. The nurse is responsible for correctly identifying the patient and assuring that the informed consent is signed prior to the onset of the surgical procedure. The Joint Commission's 2016 National Patient Safety Goals applicable to surgery include improving the accuracy of patient identification as a major goal before starting procedures.

The nurse knows that the most important reason for controlling postoperative nausea/vomiting in the PACU is to: A.Prevent the patient from becoming dehydrated. B.Prevent potential airway issues. C.Prevent the surgical dressing from becoming soiled. D.Prevent the patient from becoming upset.

B.Prevent potential airway issues. RAtionale : The priority nursing intervention for the nurse in PACU is airway management. Controlling nausea and/or vomiting will prevent aspiration and ensure a patent airway.

Preoperative

Before surgery

Ablative diagnostic (exploratory ) surgery palliative surgery reconstructive surgery cosmetic surgery transplant surgery procurement surgery

By body system

Organizations that stressed patient safety

AORN (2020) The Joint comission (2020) National Quality Patners (NQP) leadership consortium (2020) The Institute for Healthcare Improvement

is a process of planning for future care in the event a person becomes unable to make his or her own decisions.

Advanced care planning

which are legal documents, allow patients to specify instructions for health care treatment should they be unable to communicate these wishes should they become unable to make self-directed decisions postoperatively.

Advanced directives

In which phase of the perioperative period would the patient be transferred to the OR bed?

Answer: B. Intraoperative phase Rationale: The intraoperative phase begins when the patient is transferred to the OR bed and lasts until transfer to the postoperative recovery area. The preoperative phase begins with the decision to perform surgery and lasts until the patient is transferred to the OR bed. The postoperative phase lasts from admission to the recovery area to complete recovery from surgery.

An appendectomy is considered which classification of surgery based on purpose?

B. Ablative Rationale: Ablative surgery is performed to remove a diseased part. Diagnostic surgery is performed to make or confirm a diagnosis. Palliative surgery is performed to relieve or reduce intensity of an illness. Reconstructive surgery is performed to restore function to tissue.

The nurse is completing a preoperative patient assessment. Which finding indicates the greatest risk for the development of a postoperative complication? A.The patient is 60 years old. B.The patient's blood pressure is 130/88 mm Hg. C.The patient does not understand the surgery. D.The patient has early stage Alzheimer's disease.

D.The patient has early stage Alzheimer's disease. The surgical experience may exacerbate any type of dementia. Even in the early stages, a patient with Alzheimer's disease may not be able to comprehend written or oral directions related to care. In cases of major surgery, the patient with dementia may pull at dressing, drains, and IV lines and be at increased risk for falls.

If the patient should experience a serious, life-threatening complication, such as intraoperative cardiac arrest, the family has previous knowledge of the patient's wishes regarding cessation of treatment, resuscitative efforts, or end-of-life decisions. It is important to discuss and document the exact wishes of the patient and family members before surgery, especially related to resuscitation (do-not-resuscitate [DNR]).

DNR

done to confirm or rule out a diagnosis. Examples include a biopsy, fine-needle aspiration, or invasive testing such as a cardiac catheterization.

Diagnostic (exploratory) surgery

is performed when surgery is the recommended course of action, but the condition is not time sensitive. The client may delay surgery to gather information, consider options, or organize care for the family.

Elective surgery

requires transport to the operating suite as soon as possible to preserve the patient's life or function.

Emergency surgery

•Incentive spirometry facilitates deep breathing, increases lung volume, and promotes coughing to clear mucus from the respiratory tree. The equipment varies in appearance, but all devices include a gauge to monitor the patient's progress visibly.

airway management

ØReduces length of hospital stay and cuts costs ØReduces stress for the patient ØMay require additional teaching and home care services for certain patients ØOlder patients, chronically ill patients, patients with no support system

Outpatient/Same-Day Surgery

Patients may be allergic to medications such as antibiotics (e.g., penicillin) and analgesics (e.g., codeine), tape, latex, and solutions used in surgery. Reactions range from unpleasant to life-threatening

allergies

What does a surgical consent form inlclude

The type of surgery being performed The name and qualifications of the person performing the surgery (e.g., Jason Esmar, MD) and the primary practitioner for the patient's care and treatment A statement that the risks and benefits of surgery, as well as reasonable alternatives, have been explained to the patient A statement of the relevant risks, benefits, and side effects of the alternatives The likelihood of achieving goals A statement that the patient has the right to refuse surgery or withdraw consent at any time When indicated, any limitations on the confidentiality of information about the patient

iis an inflammation of a vein associated with thrombus (blood clot) formation. Nursing interventions include notifying the surgeon, administering medications (e.g., anti-inflammatory agents, anticoagulants, analgesics), maintaining the patient on bed rest, and applying graduated compression stockings or intermittent pneumatic compression (IPC) devices as ordered.

Thrombophlebitis

is scheduled within 24 to 48 hr to alleviate symptoms, repair a body part, or restore function. Removal of a cancerous breast and internal fixation of a fracture are examples.

Urgent surgery

durable power of attorney

a legal agreement that allows an agent or representative of the patient to act on behalf of the patient

removal of a disease body part ex: cholestectomy / diabetics with diabetic neuropathy that develop gangrene of the toes and require an amputation

ablative surgery

postoperative

after surgery

Factors contributing to surgical risk

age, type of wound, preexisting conditions, mental status, medications, personal habits, allergies

•Intraoperative

during surgery

What is the purpose of deep breathing and coughing?

expand the lungs, improve ventilation, promote gas exchange, and help prevent atelectasis and pneumonia. Coughing after deep breathing mobilizes secretions, which keeps airways and alveoli open and provides greater surface area for gas exchange.

_______ produces rapid unconsciousness and loss of sensation. The anesthesiologist or nurse anesthetist administers inhaled and intravenous medications that depress the patient's central nervous system and relax the musculature. Muscle relaxants, paralyzing agents, narcotics, barbiturates, and inhaled gases are some of the agents used during general anesthesia.

general anesthesia

Evidence of infection, such as purulent drainage, necrotic tissue, or bacterial counts above 100,000 organisms per gram of tissue ex: A postoperative surgical incision of any type that has evidence of infection

infected wounds

helps protect patients from having a surgery they do not understand or want.

informed consennt

•begins when the patient is transferred to the OR bed until transfer to the postanesthesia care unit (PACU)

intraoperative

What are the risk factors for older adults?

less physiological reserve and often have comorbid conditions (other illness not related to the surgery). Many of the physiological changes of aging predispose older adults to increased risk. Among these changes are decreased kidney function, diminished immune function, decreased bone and lean body mass, increased peripheral vascular resistance, decreased cardiac output, decreased cough reflex, and increased time required for wound healing.

-where to write out what you do and do not want in terms of medical care if you are unable to speak for yourself. -ask you whether or not you want to receive life-prolonging treatments at the end of life. Such procedures typically include: transfusions of blood and blood products cardiopulmonary resuscitation (CPR) diagnostic tests Dialysis Tube feedings administration of drugs use of a respirator, and surgery.

living will

What are the two common forms of advance directive

living wills and durable power of attorney

•Certain herbal and alternative medications can: - increase the risk for cardiac dysrhythmias secondary to potassium loss; -interfere with metabolism of anesthetics because of their effects on the liver; -increase the potential for excessive bleeding; - decrease cerebral blood flow; cause hypertension; or increase the effects of opioids and sympathetic nervous system stimulants.

medications

•Patients with altered cognition, from either physical or mental illness, may be unable to comprehend preoperative instructions or give informed consent for surgical procedures. They may also require medications (e.g., antipsychotic agents) that interact with anesthetics and analgesics given in the perioperative period. Surgery and anesthesia may aggravate preexisting dementia, confusion, and disorientation.

mental status

involves intravenous administration of sedatives and analgesics to produce analgesia and a degree of amnesia that can be promptly reversed. The patient maintains cardiorespiratory function and can respond to verbal commands. Provides intravenous sedation and analgesia without producing unconsciousness. During conscious sedation, the patient may feel sleepy but is aware of their surroundings, can be easily aroused by touch or speech, and can talk with the surgical team. Because of the amnesic effect of many of the medications, the patient may not recall aspects of the procedure afterward. Conscious sedation is used for procedures such as bronchoscopy and cosmetic surgery.

moderate or conscious sedation/ analgesia

The first postoperative phase is often known as the post-anesthesia phase or the immediate postoperative phase. This phase begins when the client is transferred from the operating table to a bed (or gurney) for transport to the PACU. During this phase, the client is at high risk for respiratory and cardiovascular compromise. As a precaution, the anesthetist and the circulating nurse accompany the client and attend to their needs during transport to the PACU. They are also responsible for giving a comprehensive report to the PACU nurse

recovery from anesthesia

anesthetic agent injected near a nerve or nerve pathway or around operative site; it does not cause narcosis (sleepiness), but results in analgesia and reflex loss. C-section (spinal block; epidural). Prevents pain by interrupting nerve impulses to and from the area of the procedure. The patient remains alert but is numb in the involved area. Regional anesthesia may be administered by infiltration of the surgical site and surrounding tissue with local anesthetics, such as lidocaine or bupivacaine. These medications may also be injected into and around specific nerves to depress the sensory, motor, and/or sympathetic impulses of a limited area of the body

regional anesthesia

serious and costly errors resulting in severe consequences for the patient, and are mostly preventable.

near events

Meaning of PRN orders for medications Timing for best effect of medications Splinting incision

pain managment

is performed to relieve discomfort or other disease symptoms without producing a cure. Examples include nerve root destruction for chronic pain.

palliative surgery

•Substance abuse can increase surgical risk. -Smoking affects pulmonary function. -Long-term alcohol use contributes to liver disease, increasing the risk for bleeding. -Alcohol and other drugs interact with anesthetic agents and medications to create adverse effects. -Habitual substance abusers may have a cross-tolerance to anesthetic and analgesic agents, causing them to need higher than normal doses.

personal habits

Five variables determine the position of the patient in the operating room: the surgical site, access to the patient's airway, the need to monitor vital signs, comfort, and safety. A position that is ideal for accessing the surgical site may not be used if any of the other factors are compromised. If the patient has preexisting injuries or discomfort, factor this information into the decision about how to position. For example, a patient with chronic cervical spine pain may be positioned using a neck-roll.

positioning

reduce the risk of atelectasis, pneumonia, thrombophlebitis, and DVT.

postop physical activities : Deep-breathing exercises hyperventilate the alveoli and prevent them from collapsing again. Coughing helps remove retained mucus from the respiratory tract and usually is taught in conjunction with deep breathing. Because coughing is often painful, teach the patient how to splint the incision. IS-This device helps to increase lung volume and inflation of alveoli and facilitates venous return.- best results when patient is at a 45 degree angle or sitting up at 90 degrees. Leg exercises increase venous return through flexion and contraction of the quadriceps and gastrocnemius muscles. Turning in bed improves venous return, respiratory function, and intestinal peristalsis and prevents the unrelieved skin pressure that would occur if the patient were to remain in only one position.

lasts from admission to recovery room to complete recovery from surgery and last follow-up physician visit

postoperative

Many surgical clients have underlying acute or chronic disorders that increase surgical risk ex: acute conditions such as acute infections and upper respiratory tract infections Chronic Conditions - cardiovascular disease - chronic respiratory disorders -coagulation disorders -diabetes mellitus -liver disease -neurological disorders -nutritional disorders -renal disease

preexisting conditions

begins with decision to have surgery, lasts until patient is transferred to operating room or procedural bed

preoperative

Association of PeriOperative Registered Nurses (AORN)

prevention of injury and freedom from infection

related to transplant surgery ex: organ tissue is harvested from someone pronounced brain dead for transplantation to another person

procurement surgery

restore function ex: rotator cuff repair ( torn ligament)

reconstructive surgery

Preparing the Client

•Prepare skin: Surgical scrub: ​Depending on the surgery and facility, patients may be asked to shower or scrub the surgical site with soap or an antibacterial solution (e.g., 4% chlorhexadine gluconate, Betadine) the evening before surgery and the morning of the surgery. Studies demonstrate that this reduces bacterial colonization on the skin but do not clearly prove that it reduces surgical infection. •Bowel preparation: Enemas are used primarily for surgical procedures of the colon, not for all surgeries. To empty the colon of feces, patients are asked to consume a low-residue diet for several days before surgery and are given a regimen of medications and/or enemas to clear the bowel. Stress the importance of adhering to the regimen to limit the risk of contaminating the operative site with feces. •Facilitate an empty bladder: Indwelling catheters are not routinely inserted for surgery. Catheterization may be prescribed if it is important to keep the bladder empty during surgery, if fluid status is being carefully monitored, or if surgery is expected to last for a long period of time. •Preoperative medications: The anesthesiologist may prescribe preoperative medications to relax the patient, reduce respiratory secretions, or reduce the risk of vomiting and aspiration. If the surgery time is known, the medication is prescribed at a prearranged time. If not, it may be prescribed to give "on call." You will give the on-call medication when the surgical suite staff notifies you it is time to do so. •Antiembolism stockings are elastic stockings that compress the veins of the legs and increase venous return to the heart. They may be applied preoperatively to prevent venous pooling during surgery and decrease the risk of thrombus formation. Along with prophylactic medications (antithrombotics) antiembolism stockings aid in the prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE).

Postoperative care

•Recovery from anesthesia •Airway management •Vital signs/level of consciousness •Dressing assessment/drainage •Fluid therapy Pain control

Nursing History

•health history mental status, physical status, cultural and spiritual factors, allergies, access to social resources, coping strategies, alcohol and drug use, medications (including herbal products and over-the-counter medications), and knowledge and understanding of the surgery and anesthesia. It is also important to elicit patients' values and expressed needs.