Intro to History, pre-op assesment, lab, and chart review Flashcards
1
Q
What are the components of a preoperative evaluation?
(11)
A
- 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
2
Q
what are the 6 purposes of preoperative evaluation?
A
- 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
3
Q
What are the 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?
4
Q
What is the optimal situation regarding a preoperative assessment?
A
- 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
5
Q
Who requires early pre-op assessment?
A
- 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
6
Q
What kind of information can you get off the OR schedule?
A
- Demographics- name, age, gender
- procedure and diagnosis
- length of procedure and position
- surgeon (s)
- type of anesthesia
7
Q
What should you look at when doing chart review?
A
- 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
8
Q
What are the 4 parts of the pre-op interview?
A
- Introduce yourself
- Confirm patient ID, diagnosis and procedure
- Past medical history
- Past surgical history
9
Q
How do you calculate BMI?
what is the scale of BMI?
A
Weight (kg) / height2 (m2)
< 25 = Normal
25-30 = overweight
30-35 = obese
35-40 = morbidly obese
10
Q
How do you calculate ideal body weight?
A
male = 105 lb + 6 lb for every inch > 5ft
female = 105 lb + 5 lb for every inch > 5 ft
11
Q
What is included in the physical exam?
(general systems)
A
- General impression
- airway
- heart lungs
- CNS/PNS
- vital signs
- surgical site
12
Q
Physical Exam:
What do you assess while getting a general impression?
A
- height
- weight
- physical features
- mental status
- vital signs
13
Q
Physical Exam:
How do you assess the airway?
A
- Mallampati classification
- thyromental distance
- head and neck movement
- neck circumference
- interincisor distance
- dentition
- relevant craniofacial deformities
- **looking for predictors of difficult airway management
14
Q
Physical Exam:
How do you assess the heart?
A
- Auscultation
- rate
- rhythm
- murmors
- bruits
- extremity pulses
15
Q
How do you assess the different valves?
A
- Aortic valve: 2nd-3rd Right sided interspace
- Pulmonic valve: 2nd-3rd Left sided interspace
- tricuspid valve: left sternal border
- mitral valve: apex
16
Q
Physical Exam:
How do you assess the lungs?
A
- Inspection
- auscultation
- percussion
17
Q
Physical exam:
How do you assess the neurologic/ musculoskeletal system?
A
- 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
18
Q
Physical Exam:
What are some other considerations?
A
- Surgical location
- IV access
- positioning
- monitoring needed
19
Q
Why should you not go too crazy ordering labs?
A
- 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
20
Q
How should you decide what lab tests to order?
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?
21
Q
Sensitivity vs specificity
A
- 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
22
Q
What is the difference between:
minimally invasive
moderately invasive
highly invasive
A
- 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
23
Q
What are the current ASA NPO status guidelines?
A
- 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
24
Q
What patients are considered an aspiration risk?
A
- 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
25
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
26
Who do you discuss the anesthetic plan with?
* supervising staff
* patient
* surgeon
* OR team
27
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
28
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
29
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
30
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
