Discussion: Risk Assessment

Discussion: Risk Assessment

Discussion: Risk Assessment

You have been asked to clear a patient for an elective procedure. You are seeing the patient in the preoperative clinic. Respond to the following and support your summary and recommendations plan with a minimum of two APRN-approved scholarly resources.

Discuss the areas of concern you would review.

Develop a patient presentation as you may have experienced in clinical practice or practicum hours and detail the process and workup performed.

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Risk Assessment

As an APRN in the preoperative clinic, when evaluating a patient for an elective procedure, there are several areas of concern that I would review to ensure the patient is suitable for the surgery. These areas include the patient’s medical history, current medications, allergies, physical examination findings, and any relevant diagnostic tests or investigations. Firstly, I would thoroughly review the patient’s medical history, focusing on chronic conditions such as diabetes, hypertension, cardiovascular disease, or respiratory infections. These conditions can increase the risk of complications during and after surgery. Additionally, I would inquire about any previous surgical procedures and their outcomes.

Patient Presentation

John a 55 -year old Male presents to the preoperative clinic for evaluation pending an elective herniorrhaphy secondary to an inguinal hernia. He has no complaints at the moment. He has a past medical history of hypertension, dyslipidemia, and type 2 diabetes mellitus, all of which are well-controlled with medications. He denies any significant family history of cardiovascular diseases or surgical complications. His surgical history includes an appendicectomy performed 10 years ago without any complications. He has no known allergies (Gritsenko et al,.2020).He is currently on Lisinopril 10 mg daily for hypertension, Atorvastatin 20 mg daily for dyslipidemia and Metformin 1000 mg twice daily for diabetes mellitus.

John’s vital signs are within normal limits. His blood pressure is 130/80 mmHg, heart rate is 72 beats per minute, respiratory rate is 16 breaths per minute, and temperature is 98.6°F. His cardiovascular and respiratory examinations are unremarkable. Abdominal examination reveals no tenderness, masses, or organomegaly. There are no signs of peripheral edema or clubbing.

The pre-operative workup included hematological tests, biochemistry investigations and even radiological investigations. A full hemogram revealed normal blood components with a basic metabolic panel showing normal renal function. ALipid profile showed total cholesterol of 180 mg/dL, LDL levels of 110 mg/dL, HDL at50 mg/dL, triglycerides 120 mg/dL and HbA1c of 6.5% indicating well-controlled diabetes. Chest X-ray showed clear lung fields with no evidence of active pathology. Electrocardiogram showed normal sinus rhythm with no evidence of ischemia or arrhythmias. Pulmonary function tests were within normal limits with forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1).

References

Gritsenko, K., Helander, E., Webb, M. P. K., Okeagu, C. N., Hyatali, F., Renschler, J. S., Anzalone, F., Cornett, E. M., Urman, R. D., & Kaye, A. D. (2020). Preoperative frailty assessment combined with prehabilitation and nutrition strategies: Emerging concepts and clinical outcomes. Best practice & research. Clinical anaesthesiology, 34(2), 199–212. https://doi.org/10.1016/j.bpa.2020.04.008

Nidadavolu, L. S., Ehrlich, A. L., Sieber, F. E., & Oh, E. S. (2020). Preoperative Evaluation of the Frail Patient. Anesthesia and analgesia, 130(6), 1493–1503. https://doi.org/10.1213/ANE.0000000000004735