Intro to History, pre-op assesment, lab, and chart review Flashcards
What are the components of a preoperative evaluation?
(11)
- Patient medical history (chart review and history)
- physical exam
- medications/allergies
- laboratory testing/diagnostic testing
- medical consultation (if indicated)
- assigning ASA physical status class
- NPO status (fasting status and risk of aspiration)
- formulation of plan (meds, equipment, position)
- discussion of plan (educate and decrease anxiety)
- informed consent
- documentation
what are the 6 purposes of preoperative evaluation?
- obtain pertinent medical history
- formulate plan of anesthetic care
- obtain informed consent
- patient education
- improve efficiency, reduce cost of perioperative care
- utilize operative experience to motivate patient to more optimal health status
What are the 3 main questions answered by the preoperative assessment?
- 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?
What is the optimal situation regarding a preoperative assessment?
- a pre-op clinic visit about 1 week before surgery
- patient interview and examination
- promotes patient teaching and anxiety reduction
- allows time to schedule appointments with medical consultants and complete required pre-op diagnostic testing
- obtain informed consent prior to operative day
Who requires early pre-op assessment?
- Angina, CHF, MI, CAD, poorly controlled HTN
- COPD/severe asthma, airway abnormalities, home O2 or ventilation
- IDDM, adrenal disease, active thyroid disease
- liver disease, ESRD
- massive obesity, symptomatic GERD
- severe kyphosis, spinal cord injury
What kind of information can you get off the OR schedule?
- Demographics- name, age, gender
- procedure and diagnosis
- length of procedure and position
- surgeon (s)
- type of anesthesia
What should you look at when doing chart review?
- Demographics- name, age, sex
- diagnosis/procedure
- surgical consent
- prior H&P (from surgeon or internist)
- nursing notes
- patient questionnaire
- lab results
- EKG, PFTS, X-ray, etc
- vital signs
- medication list
- allergies
What are the 4 parts of the pre-op interview?
- Introduce yourself
- Confirm patient ID, diagnosis and procedure
- Past medical history
- Past surgical history
How do you calculate BMI?
what is the scale of BMI?
Weight (kg) / height2 (m2)
< 25 = Normal
25-30 = overweight
30-35 = obese
35-40 = morbidly obese
How do you calculate ideal body weight?
male = 105 lb + 6 lb for every inch > 5ft
female = 105 lb + 5 lb for every inch > 5 ft
What is included in the physical exam?
(general systems)
- General impression
- airway
- heart lungs
- CNS/PNS
- vital signs
- surgical site
Physical Exam:
What do you assess while getting a general impression?
- height
- weight
- physical features
- mental status
- vital signs
Physical Exam:
How do you assess the airway?
- Mallampati classification
- thyromental distance
- head and neck movement
- neck circumference
- interincisor distance
- dentition
- relevant craniofacial deformities
- **looking for predictors of difficult airway management
Physical Exam:
How do you assess the heart?
- Auscultation
- rate
- rhythm
- murmors
- bruits
- extremity pulses
How do you assess the different valves?
- Aortic valve: 2nd-3rd Right sided interspace
- Pulmonic valve: 2nd-3rd Left sided interspace
- tricuspid valve: left sternal border
- mitral valve: apex
Physical Exam:
How do you assess the lungs?
- Inspection
- auscultation
- percussion
Physical exam:
How do you assess the neurologic/ musculoskeletal system?
- Extent of the neuro exam really depends on baseline deficits, disease or surgical procedure
- motor: gait, grip strength, ROM, ability to hold arms forward, etc
- Sensory: distinction of vibration, pain, light touch along dermatomes
- muscle reflexes
- cranial nerve abnormalities
- mental status
- speech
Physical Exam:
What are some other considerations?
- Surgical location
- IV access
- positioning
- monitoring needed
Why should you not go too crazy ordering labs?
- Lab tests are NOT great disease screening tools
- follow up of abnormal results is constly
- non-indicated tests increase risks for patients
- batteries of tests present medico-legal risk to providers
- excessive testing decreases facility efficiency and reduces resources available to care for others
How should you decide what lab tests to order?
- 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?
Sensitivity vs specificity
- sensitivity- true positive; you have the disease and the test is positive
- specifity- true negative; you don’t have the disease and the test is negative
What is the difference between:
minimally invasive
moderately invasive
highly invasive
- minimally invasive: little tissue trauma, minimal blood loss
- moderately invasive: modest disruption of normal physiology; anticipate some blood loss
- may need invasive monitors and/or ICU
- highly invasive- significant disruption of normal physiology
- commonly require transfusion and ICU care
What are the current ASA NPO status guidelines?
- 2 hrs for clear liquids all patients
- 4 hrs breast milk
- 6 hours formula or solids; light meal
- 8 hours heavy meal fried or fatty food, gum and candy
- **follow policy of the institution
What patients are considered an aspiration risk?
- extreme ages (<1 yr or >70 yr)
- ascites (ESLD)
- Collagen vascular disease, metabolic disorders (DM, obesity, ESRD, hypothyroid)
- Hiatal hernia/GERD/Esophageal surgery
- mechanical obstruction (pyloric stenosis)
- prematurity
- pregnancy
- neurologic diseases
- having eaten food or non-clear liquids
What are the ASA physical status classifications?
- I - normal, healthy patient; no systemic disease
- II - mild to moderate systemic disease, well controlled, no functional limitation; smoker
- III - severe systemic disease, functional limitation
- IV - severe systemic disease that is a constant threat to life
- 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
Who do you discuss the anesthetic plan with?
- supervising staff
- patient
- surgeon
- OR team
What should you tell the patient to help prepare them?
- Discuss choices of anesthetic technique
- consent- written and verbal
- Explain IV
- Describe use of local anesthetics, medications, fluids
- discuss airway management plan
- explain monitors- placement and purpose
- discuss postoperative recovery
- discuss pain management plan
What needs to be included with informed consent?
- Explanation of the planned anesthetic
- explanation of options available
- risks and benefits
- pt understanding and cooperation
- ***without consent, can be charged with assault and battery
- need consent from parents for minors
- signature of pt and witness
Patient preparation final checklist:
- IV/Fluid status
- pre-medication
- anesthetic plan
- labwork- results, labwork needed
- CKG, CXR, needed?
- use an old one for comparison
- blood products?
- check availability
- need for inhaler, steroid coverage, antibiotics, aspiration prophylaxis
What do you need to document for your pre-op evaluation?
- H&P
- informed consent
- NPO status
- medications
- allergies
- ASA physical status class
- pre-operative vital signs
- labs, tests, and consults
