Intro to Charting/ Pre-op Eval

Question 1

Goals of pre-operative evaluation?

Answer 1

1.) assesing risk of coexisting diseases, midfying risks, addressing pt’s concerns, and discussing options for anesthesia care

Question 2

3 pillars of documentation

Answer 2

legibility, consistency, accuracy

Question 3

Consider the following case:
A 47 year old woman with biliary colic and well controlled asthma requires anesthesia for laparoscopic cholecystectomy.. What will be administered during the PRE-OPERATIVE phase?

Answer 3

1. ) midazolam, 1-2 mg IV to reduce anxiety

2. ) albuterol, two puffs, to prevent bronchospam

Question 4

What monitors should you check for?

Answer 4

1. ) EKG
2. ) blood pressure/ cuff
3. ) pulse oximeter probe
4. ) capnography monitor
5. ) temperature probe

Question 5

How do you prepare ephedrine? Include steps in dilution technique.

Answer 5

1. )Draw out 1 ml of Ephedrine from 50mg/ml vial in 10 ml syringe
2. ) Add 9 ml of normal saline

Question 6

What should be assessed during the patient interview?

Answer 6

1. ) pt and procedure info
2. ) verification of admission status
3. ) admission status
4. ) anesthetic hx
5. ) meds/allergy hx
6. ) NPO status

Question 7

What is the time limit before a provider has to re-assess the patient from the initial pre-op assessment to the time the patient arrives for sx?

Answer 7

48 hour period

Question 8

What are all the components of the pre-anesthesia evaluation?

Answer 8

1. ) patient interview
2. ) Physical exam including vital signs and documentation of airway assessment
3. ) Review of objective diagnostic data and medical records
4. ) medical consultations when applicable
5. ) ASA physical status, including emergent status when applicable
6. ) Formulation of anesthetic plans & discussion of risks and benefits of the plan (including discharge issues when indicated) w/ the pt or pt’s legal representative or escort
7. ) Documentation of informed consent
8. ) appropriate premedication and prophylactic antibiotic administrations (if indicated)

Question 9

What must be done immediately upon entering the OR?

Answer 9

pt’s vitals must be taken and documented

Question 10

What should be documented during intraoperative care?

Answer 10

1. ) reverify NPO status; Check of equipment, drugs and gas supply
2. ) Monitor the pt (record vital signs, and use of non-routine monitors)
3. ) doses of drugs and agents used, times and routes of administration and any adverse reactions
4. ) type and amts of IV fluids used, including blood and blood products and times fo administration
5. ) the techniques used and patient positions
6. ) IV/ intravascular lines and airway devices that are inserted including technique for insertion and location
7. ) Unusual events during the administration of anesthesia
8. ) the status of pt at the conclusion of anesthesia

Question 11

What needs to be included for IV documentation?

Answer 11

amount, type and duration

Question 12

Which of the following is CONTINUALLY evaluated during all anesthetics? (4)

Answer 12

oxygenation, ventilation, circulation, and temperature

Question 13

How do you assess oxygenation?

Answer 13

pulse oximeter, end tidal O2, and color

Question 14

How do you assess ventilation? (3)

Answer 14

chest rise, check breathing bag, and auscultation of breath sounds

Question 15

How do you check if ETT tube is inserted correctly?

Answer 15

end tidal CO2

Question 16

How do you assess circulation?

Answer 16

1. ) EKG (continuous)
2. ) Blood pressure and heart rate
3. ) palpation of pulse, auscultation of heart sounds, intraarterial pressure, pulse oximetry

Question 17

What factors might change body temperature? (6)

Answer 17

1. ) length of surgery >30 minutes
2. ) heat loss due to exposure
3. ) increased fluid requirements
4. ) thin, fragile pt
5. ) cardiovascular disease
6. ) Blood transfusion

Question 18

What temperature are fluids kept?

Answer 18

68 degrees Fahrenheit

Question 19

What must be included for medication charting? (4)

Answer 19

1. ) drug given
2. ) amount (specify mcg, mg)
3. ) Route
4. ) Charted under correct time

Question 20

What are the national patient safety goals? (7)

Answer 20

1. ) identify pts correctly
2. ) improve staff communication
3. ) Use medicines safely
4. ) use alarms safely
5. ) Identify patient safety risks
6. ) prevent infection
7. ) prevent mistakes in sx

Question 21

What are the four areas of national focus for CMS core measures?

Answer 21

1. ) heart failure
2. ) acute MI
3. ) pneumonia
4. ) surgical care improvement project (SCIP)

Question 22

Surgery patients on beta blocker therapy prior to arrival and received a beta blocker during the perioperative period will be given what SCIP designation?

Answer 22

SCIP Card 2

Question 23

Prophylactic antibiotic received within one hour prior to sx incision is given what SCIP designation?

Answer 23

SCIP Inf -1

Question 24

Examples of unusual events?

Answer 24

bronchospasm, laryngospasm, change in EKGs

include time, how managed, no opinionated info!

Question 25

What order must charting a drug follow?

Answer 25

1. ) drug
2. ) Dose
3. ) Route (IV, IM, subQ)
4. ) Time

Question 26

What should you always write before drugs in the OR record?

Answer 26

write vitals

Question 27

What 8 things should be checked at end of case?

Answer 27

1. ) correct date
2. ) start time/end time
3. ) abx w/ correct dose/ time
4. ) AA signature
5. ) Sevo turned off, O2 flows up
6. ) PACU vitals
7. ) fluid/ EBL/ urine totals
8. ) opioid dose adds up with waste sheet

Question 28

What 7 things need to be on face sheet?

Answer 28

1. ) date
2. ) procedure
3. ) initials of anesthesia providers
4. ) type of anesthesia
5. ) ASA
6. ) surgeon
7. ) start time and end time

Question 29

What sheets do we NOT fill out??

Answer 29

sheet 6 quality assurance sheet, sheet 7 physician order sheet, and sheet 8 patient’s medication list