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Health Assessment > Intro > Flashcards

Intro Flashcards

0
Q

Preoperative Assessment Goals

A

-Optimize care, satisfaction and comfort
(important for quality of care; adverse effects are associated with inadequate evaluation)
-Minimize morbidity and mortality
-Minimize surgical delays or cancellations (by detecting problems early)
-Determine appropriate post-operative disposition (will they go to the ICU or go home?)
-Evaluate health status and determine if any further consultative, diagnostic investigations are needed
-Formulate most appropriate anesthetic plan
-optimize communication among members of the surgical and anesthetic teams
-evaluation should be efficient and cost-effective

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1
Q

Components of Preoperative Evaluation

A

mandated by joint commision – all patients requiring anesthesia for surgery undergo a preoperative evaluation by an anesthesia provider to be completed within 30 days prior to surgery and a reassessment 48 hours after surgery.

AANA and ASA publish standards of conduct for our practices and within that it is required we do an evaluation

  • Patient Hx (Chart review + Hx taking)
  • comorbidities, past meds, past surgeries..
  • Physical Exam
  • Laboratory Testing
  • interpret lab results already done or may need to order a new lab test and interpret it-anesthesia providers responsibility
  • Medical Consultation
  • ASA Physical Status Class
  • NPO status
  • Formulation Plan
  • Discussion of plan (educate and decrease anxiety)
  • Informed Consent
  • Documentation
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2
Q

3 main questions answered by the preoperative assessment

A
  • Is the patient in optimal health?
  • Could health problems or medications unexpectedly influence perioperative events?
  • Can, or should, the patients physical or mental condition be improved before surgery?
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3
Q

Where do we get the data?

A
  1. Patients medical history (medical record and patient interview)
  2. Physical examination
  3. Diagnostic Test (labs, etc.)
  4. Specialist Consultation/reports
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4
Q

Optimal Situation = Preoperative Clinic Visit ~ 1 week preop

A
  • Patient Interview
  • Physical examination
  • develop anesthetic plan
  • promotes patient teaching & anxiety reduction
  • allows time to schedule appointments with medical consultants and complete required preoperative diagnostic testing
  • obtain informed consent prior to operative day
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5
Q

Who requires Early Pre-Operative Assessment?

A

Angina, CHF, MI, CAD, poorly controlled HTN

COPD, severe asthma, airway abnormaltities, home o2 or vent

diabetes, adrenal dz, active thyroid dz

liver dz, end-stage renal dz

massive obesity, symptomatic GERD

severe kyphosis, spinal cord injury

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6
Q

OR Schedule

A
  • Demographics- name, age, sex
  • Procedure + diagnosis
  • Length of procedure + position
  • Surgeon
  • Type of Anesthesia
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7
Q

Chart Review

A
  • Demographics- name, age, sex
  • Diagnosis/Procedure
  • Surgical Consent
  • Prior H&P (from surgeon or internist)
  • Nursing notes
  • Patient questionnaire
  • Results of Laboratory Tests
  • EKG, PFTS, X-RAY, etc
  • Vital signs, pain score
  • medication list
  • allergies
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8
Q

If inpatient, may also look at:

A
  • progress notes
  • medication sheets
  • nursing notes
  • old anesthetic records
  • complications? look for malignant hyperthermia, airway difficulties, previous n/v
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9
Q

Preoperative Interview: 6 purposes

A

1) obtain pertinent medical hx
2) formulate plan of anesthetic care
3) obtain informed consent
4) patient education
5) improve efficiency, reduce cost of perioperative care
6) utilize operative experience to motivate patient to more optimal health status

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10
Q

Preoperative Interview

A
  • Introduce anesthesia provider to patient and/or family
  • Confirm pt ID, diagnosis, and procedure (surgical site)
  • open-ended questions
  • general to specific
  • organized and systematic
  • layperson terminology
  • individualized
  • control environment (+/- family members present, interpreters, good lighting, respectful, “unrushed”)

-look for co-exisiting dz

  • medications
  • allergies including latex, including type of rxn
  • prescriptive-d/c for surgery? taken this am?
  • OTC (ASA, NSAIDS)
  • herbals
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11
Q

The preoperative history:

A
  • previous anesthetics + surgeries
  • complications, family hx complications, OB deliveries
  • exercise tolerance
  • sleep apnea hx
  • ETOH abuse
  • drug abuse
  • tobacco use
  • females- last menstrual period
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12
Q

Physical Exam: General Impression

A

GENERAL IMPRESSION:

  • height
  • weight
  • physical features
  • mental status
  • vital signs
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13
Q

Physical Exam: Airway

A
  • Mallampati Classification
  • Thyromental distance
  • Head and neck movement
  • Neck circumference
  • Interincisor distance
  • Dentition
  • Relevant craniofacial deformities
  • *LOOKING FOR PREDICTORS OF A DIFFICULT AIRWAY
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14
Q

Physical Exam: Heart

A

Ausculatation

  • rate
  • rhythm
  • murmurs
  • bruits (carotid)
  • extremity pulses
  • extremity edema
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15
Q

Physical Exam: Lungs

A

Inspection
Auscultation
Percussion
Palpation

16
Q

Physical Exam: Neurologic System

A

Extent of neuro exam depends on baseline deficits, dz or procedure

motor- gait, grip strength, ability to hold arms forward
sensory- distinction of vibration, pain, light touch along dermatomes
muscle reflexes- deep, superficial, and pathologic
cranial nerve abnormalities
mental status
speech

17
Q

Physical Exam: Musculoskeletal System and Obesity

A

Gait, ROM, and deficits

Obesity: 20% over ideal body weight
IBW (M)= 105 lb +6lb for each inch > 5 ft.
IBW (F)= 100 lb + 5lb for each inch > 5 ft.

Body mass index of 30- 39.9 kg/m2

18
Q

Physical Exam: Other

A

Surgical site (confirm!)
IV
Position
Monitoring

19
Q

Goals of preoperative/preprocedure lab testing:

A

reduce anesthetic morbidity
increase quality of periooperative care
decrease cost of perioperative care
return patient to desirable functioning

20
Q

lab tests

A
  • lab tests are NOT good dz screening tools
  • follow up of “abnormal” results is costly
  • nonindicated test increase risks for patients
  • batteries of tests present medicolegal risk to providers
  • excessive testing decreases facility efficiency and reduces resources available to care for others
21
Q

The Litmus Test

A

Will the results of this “test” change my management of this anesthetic?

Will the results of this “test” improve this patient’s outcome?

22
Q

Questions to ask about labs/tests

A

Is the test needed to confirm a suspicion?
Is the suspected abnormality linked to morbidity?
Is there a higher than average likelihood of an abnormality?
Will a positive or negative result affect the case management in any way?

23
Q

Predictive Value

Sensitivity vs Specificity

A

Sensitivity : if a lab test test is sensitive than it will make the lab result positive in a patient that has the disease

Specificity: it will be negative in a patient without the disease

24
Q

What kind of surgery are we doing?

A

Testing partially selected based on invasiveness of proceudre

Minimally Invasive:
little tissue trauma, minimal blood loss

Moderately Invasive:
modest disruption of normal physiology, some blood loss and may need invasive monitors and or ICU

Highly Invasive:
significant disruption of normal physiology and commonly requires transfusion and ICU care

25
Q

What lab/tests when?

A

Instiutional Policy

Current expert organization guidelines (ACC/AHA guidelines)

Anesthesia provider judgment

Take into consideration: 
H&H
Chemistry
Coags
LFTS
Renal Function Test
UA
Pregnany Test
EKG
Chest Xray
Pulmonary Function Tests

ex: women of childbearing age may need to have pregnant test before surgery

26
Q

Consults?

A

Controversial
Avoid the terms “cleared for surgery” or “cardiac clearance”
Ask yourself: Does peri-op management of a patient’s disease process go beyond your comfort level? *ex: do you need advice from an expert consultant on the patient’s care that could change or guide your management?

27
Q

ASA Status

A

To classify the physical condition of the patient requiring anesthesia and surgery

  • reflection of preoperative status
  • ASA is independent of the operative procedure and surgical risk
  • subjective communication tool used between anesthesia providers institutions etc.
28
Q

ASA Physical Status Classification

A

I- normal, healthy patient; no systemic disease; excludes young baby and extreme elderly

II- mild to moderate systemic disease, well controlled, no functional limitation
ex: controlled HTN, controlled DM, smoker with no chronic pulmonary dz, mild obesity, and pregnancy

III- severe systemic dz, functional limitation , no imminent danger of death
ex: controlled CHF, stable angina, old heart attack, poorly controlled HTN, morbid obesity, chronic renal failure

IV- severe systemic dz that is a constant threat to life ; poorly controlled or at the end stage of dz, risk of death
ex:symptomatic COPD, unstable angina, symptomatic CHF, liver or kidney failure

V- moribund patient, not expected to survive with or without the surgical procedure

VI- patient declared brain dead whose organs are being harvested for donation

E- emergency operation required

29
Q

NPO Status

A

Based on current asa guidelines that balance risk factors of fasting with pulmonary aspiration risk

  • 2 hours for clear liquids all patient
  • 4 hours breast milk
  • 6 hours formula or solids; light meal
  • 8 hours heavy meal fried or fatty food, gum and candy

Follow the institutions policy however! *note: some clinicans remain skeptical and use more conservative guidelines NPO 6-8 hours

30
Q

Aspiration Risk Patients

A

Some patients considered an aspiration risk no matter what their NPO status is
No seperate guidelines available
Even if a patient has not had anything to eat or drink; there gastric tract may not be emptying

  1. age extremes 70 years
  2. ascites (ESLD)
  3. collagen vascular dz, metabolic disorders (DM, obesity, ESRD, hypothyroid)
  4. hiatal hernia/GERD/esophageal surgery
  5. mechanical obstruction (pyloric stenosis)
  6. prematurity
  7. pregnancy
  8. neurologic dz
31
Q

Formulate Anesthetic Plan

A
  • Type of Anesthesia
  • Drugs
  • Monitors
  • Airway (such as instrumentation)
  • Positioning
  • Intraoperative Mointoring
  • Postoperative care
32
Q

Patient Preparation: Information the Patient requires from an anesthesia professional:

A
  • Discuss choices of anesthetic technique (consent) verbal & written consent
  • explain IV catheter
  • describe use of local anesthetics, meds such as adverse effects, fluids
  • discuss airway management plan
  • explain monitors-placement, purpose
  • discuss postoperative recovery (where are they going? will they be intubated)
  • discuss pain management plan
  • explain process of transport to OR
  • postoperative- PACU, pain relief, airway
  • possible outcomes- sore throat, blood transfusion, facial swelling, nasal packing, etc.
33
Q

Informed Consent

A

informs patient and is a legal document!

  • explanation of the planned anesthetic
  • explanation of options available
  • risks and benefits
  • pt understanding & cooperation
  • without consent- assault and battery
  • minors- consent from parents or guardian
  • signature of pt and witness
34
Q

Confirm Schedule with OR team

A
  • Time, length procedure
  • Anatomical location
  • position
  • xray needed?
  • additional meds?
  • procedure
  • or table position
35
Q

Final Pre-Operative Check List

A
  • IV/Fluid Status
  • Pre medication
  • Anesthetic Plan
  • Labwork- results, labwork needed?
  • EKG, CXR,needed? use old for comparison
  • Blood products? -availability and need
  • need for inhaler, steroid coverage, antibiotics, aspiration prophylaxis
36
Q

DOCUMENT DOCUMENT DOCUMENT

A 
H&P (review of systems)
informed consent
npo status
meds
allergies
asa physical status class
pre operative vital signs
labs, tests, and consults
37
Q

Risks and Benefits : What qualifies as what you should tell them?

A

court uses two standards to determine if hte pt has been given enough explanation during informed consent

1) reasonable practioner- what practioner deems important
2) prudent patient standard- what would the prudent pt need to know to make an intelligent decision?

38
Q

Time

A

need to keep preoperative assessment to 10 minutes or it can be costly

Health Assessment (4 decks)

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