8 - Anesthesia Records Flashcards
T/F: Anesthesia records are not legal documents.
False
What can you use to write on an anesthesia record?
Blue or black ink only; NO PENCILS
How should you record drugs that are given to the patient?
Use full drug name (no trade names or abbreviations);
Amount patient received in mgs and route/time of administration
How should time be written on the record?
Military time
What should you note after 10-15 minutes of giving the premed?
The effect it is having on the patient
When would you consider a premed to have had “profound” effect?
When you can intubate the patient with no additional drugs
The anesthesia record timeline should begin on a ___ minute value.
15
How is the starting 15 minute value on the record determined?
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
What values should be recorded every 15 minutes?
Temp, SpO2, EtCO2, O2 L/min
When should fluid volumes be recorded and how?
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
What is recorded in the top row of boxes in the “Fluids” section?
The amount given during that 15 min time period
What is recorded in the bottom row of boxes in the “Fluids” section?
Used to keep a running total of the fluids administered so far
When during a 15 min time period should temp, SpO2, EtCO2, and O2 flow be recorded?
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)
Other than in the time period boxes, where should the total amount of fluids administered be written and when?
It should be recorded to the right where indicated; recorded after fluid administration has been discontinued.
(green circle in picture)
How often should the [] of inhalant be recorded and how? When is this done?
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)
What scale should be used when recording inhalant []?
0-3% (as indicated on the left of the record sheet)
What is EXP %, where can this value be found, and how often is it recorded?
EXP % = expired % of inhalant anesthetic;
Found on the multiparameter monitor;
Recorded every 15 min
How often are HR, RR, and BP measured? When should these readings begin?
Every 5 min;
Starts as soon as the monitor is attached
T/F: It is not important to indicate the type of BP monitor used
False; it must be indicated on the record
When using a doppler, only the _____ BP is measured. When using an oscillometric unit, _____ measurements are recorded, which include _____, _____, and _____.
systolic, all 3, systolic, diastolic, mean
How are remarks noted on the anesthetic record and what are some examples?
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
What are remark codes and where are they written?
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
What is recorded in the procedure 1 box?
Start of procedure (time incision is made) and end of procedure (time last suture is placed)
Where should you record any meds administered after the procedure is over? What details should be included?
In post-op meds box (green box);
Time, drug name, amount in mgs, route
When should your last temp, HR, RR, and SpO2 readings be taken?
After the patient is extubated
What are the most common complications experienced during anesthesia?
Hypotension and hypothermia
What should you do if the HR values are not similar in the ECG and SpO2 sections of the monitor?
Count a HR manually
Where is RR found on the monitor? How else can you take a RR?
In the CO2 section; can also manually count the RR
What is the NIBP section of the monitor and what does it tell you?
Non-Invasive Blood Pressure;
Gives you values taken with oscillometry
What will we be using to measure BP in cats and what value is recorded? Why?
Using a doppler because cats are too small fot NIBP - measure systolic P only
What is SpO2?
Measure of the Hgb saturation of oxygen in the patient
What is EtCO2 measuring? What is it a reflection of?
End tidal CO2 - measures amount of CO2 exhaled by the patient;
Reflects alveolar [] of CO2 in the lungs
What does EXP % reflect?
[] of inhalant anesthetic in the alveoli
Where is EXP % found?
In the gas section on the monitor
