8 - Anesthesia Records

Question 1

T/F: Anesthesia records are not legal documents.

Answer 1

False

Question 2

What can you use to write on an anesthesia record?

Answer 2

Blue or black ink only; NO PENCILS

Question 3

How should you record drugs that are given to the patient?

Answer 3

Use full drug name (no trade names or abbreviations);

Amount patient received in mgs and route/time of administration

Question 4

How should time be written on the record?

Answer 4

Military time

Question 5

What should you note after 10-15 minutes of giving the premed?

Answer 5

The effect it is having on the patient

Question 6

When would you consider a premed to have had “profound” effect?

Answer 6

When you can intubate the patient with no additional drugs

Question 7

The anesthesia record timeline should begin on a ___ minute value.

Answer 7

15

Question 8

How is the starting 15 minute value on the record determined?

Answer 8

In relevance to when the 1st parameters are recorded;

EX: If your first set of readings are at 10:25, the timeline should begin on the 10:15 value and the 1st recordings would be on the second line from 10:15 = 10:25

Question 9

What values should be recorded every 15 minutes?

Answer 9

Temp, SpO₂, EtCO₂, O₂ L/min

Question 10

When should fluid volumes be recorded and how?

Answer 10

At the end of a 15 min time period as the volume given during that time.

EX: The volume recorded at 10:15 is the amount that was given between 10:00 and 10:15

Question 11

What is recorded in the top row of boxes in the “Fluids” section?

Answer 11

The amount given during that 15 min time period

Question 12

What is recorded in the bottom row of boxes in the “Fluids” section?

Answer 12

Used to keep a running total of the fluids administered so far

Question 13

When during a 15 min time period should temp, SpO₂, EtCO₂, and O₂ flow be recorded?

Answer 13

Can be recorded at any time during that period, but similarly each time (i.e. the beginning, middle, or end of the period each time)

Question 14

Other than in the time period boxes, where should the total amount of fluids administered be written and when?

Answer 14

It should be recorded to the right where indicated; recorded after fluid administration has been discontinued.

(green circle in picture)

Question 15

How often should the [] of inhalant be recorded and how? When is this done?

Answer 15

Every 5 min in a bar graph format (shade in the vaporizer setting between the 2 time periods);

This is recorded when the next time period is reached (EX: at 10:25 the vaporizer setting is shaded in from 10:20 to 10:25)

Question 16

What scale should be used when recording inhalant []?

Answer 16

0-3% (as indicated on the left of the record sheet)

Question 17

What is EXP %, where can this value be found, and how often is it recorded?

Answer 17

EXP % = expired % of inhalant anesthetic;

Found on the multiparameter monitor;

Recorded every 15 min

Question 18

How often are HR, RR, and BP measured? When should these readings begin?

Answer 18

Every 5 min;

Starts as soon as the monitor is attached

Question 19

T/F: It is not important to indicate the type of BP monitor used

Answer 19

False; it must be indicated on the record

Question 20

When using a doppler, only the _____ BP is measured. When using an oscillometric unit, _____ measurements are recorded, which include _____, _____, and _____.

Answer 20

systolic, all 3, systolic, diastolic, mean

Question 21

How are remarks noted on the anesthetic record and what are some examples?

Answer 21

The remark is assigned a number and the info is entered on the record in the remark area. The corresponding number is placed under the time the event occurred in the remark numbers/codes section;

EX: events, drugs/meds administered, BP unit stopped working, fluid bolus was administered

Question 22

What are remark codes and where are they written?

Answer 22

They are common remarks that are used on many anesthesia records and are assigned a symbol;

Symbols are placed in the remark numbers/codes section under the time they occurred

Question 23

What is recorded in the procedure 1 box?

Answer 23

Start of procedure (time incision is made) and end of procedure (time last suture is placed)

Question 24

Where should you record any meds administered after the procedure is over? What details should be included?

Answer 24

In post-op meds box (green box);

Time, drug name, amount in mgs, route

Question 25

When should your last temp, HR, RR, and SpO₂ readings be taken?

Answer 25

After the patient is extubated

Question 26

What are the most common complications experienced during anesthesia?

Answer 26

Hypotension and hypothermia

Question 27

What should you do if the HR values are not similar in the ECG and SpO₂ sections of the monitor?

Answer 27

Count a HR manually

Question 28

Where is RR found on the monitor? How else can you take a RR?

Answer 28

In the CO₂ section; can also manually count the RR

Question 29

What is the NIBP section of the monitor and what does it tell you?

Answer 29

Non-Invasive Blood Pressure;

Gives you values taken with oscillometry

Question 30

What will we be using to measure BP in cats and what value is recorded? Why?

Answer 30

Using a doppler because cats are too small fot NIBP - measure systolic P only

Question 31

What is SpO₂?

Answer 31

Measure of the Hgb saturation of oxygen in the patient

Question 32

What is EtCO₂ measuring? What is it a reflection of?

Answer 32

End tidal CO₂ - measures amount of CO₂ exhaled by the patient;

Reflects alveolar [] of CO₂ in the lungs

Question 33

What does EXP % reflect?

Answer 33

[] of inhalant anesthetic in the alveoli

Question 34

Where is EXP % found?

Answer 34

In the gas section on the monitor