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NURA 606 Adv Health Assessment > Intro to Hx Taking, Pre op Eval, Lab Testing & Chart Review > Flashcards

Intro to Hx Taking, Pre op Eval, Lab Testing & Chart Review Flashcards

1
Q

components of the pre op evaluation

A
  1. detailed pt hx (chart review + hx taking) - ROS
  2. physical and airway exam
  3. medications/allergies
  4. lab testing/diagnostic testing
  5. previous surgeries
  6. medical consultation (if indicated)
  7. ASA status
  8. NPO status (fasting status and aspiration risk)
  9. anesthetic plan
  10. discussion of plan (educate and decrease anxiety)
  11. informed consent
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2
Q

Where is the pre op eval performed?

A

presurgical testing centers (early testing)

hospitals

  • OR settings (holding)
  • critical care units
  • specialty departments

outpatient centers

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3
Q

Pre op eval clinics:

A

1 week prior to surgery

  • pt interview
  • physical exam
  • medical records to be acquired and collated
  • promotes pt teaching and anxiety reduction
  • allows time to schedule appts with medical consultants and complete required pre operative diagnostic testing/interventions
  • abnormalities addressed immediately
  • obtain informed consent prior to operative day
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4
Q

Early pre op assessment: populations that would benefit

A

Includes, but not limited to:

  • angina, CHF, MI, CAD, poorly controlled HTN
  • COPD/severe asthma, airway abnormalities, home 02 or ventilation
  • IDDM, adrenal disease, active thyroid disease
  • liver disease, ESRD
  • morbid obesity, symptomatic GERD
  • severe kyphosis, spinal cord injury
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5
Q

Chart Review:

A
  • demographics - name, age, sex
  • diagnosis/procedure
  • surgical consent
  • prior H&P (from surgeon or internist)
  • prior anesthetics records
  • nursing notes
  • patient questionnaire
  • results of lab tests
  • EKG, PFTs, XRay, etc.
  • vital signs (when)
  • medication list
  • allergies
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6
Q

Past Anesthetic Hx

A

Complications

  • difficult airway
  • slow wake up
  • MH

family history complications
-MH

Obstetrical deliveries

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7
Q

Physical exam: components

A
  • general assessment: appearance
  • disposition
  • cognition/mental status
  • record of VS/day of
  • airway exam
  • auscultation - CV/Pulm
  • neuro exam
  • peripheral veins
  • examine site for RA (regional anesthesia)
  • examine surgical site
  • AICD/pacemaker (other)
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8
Q

Physical Exam: Airway

A

anesthesia perspective - most important aspect of physical exam

  • mallampati score
  • dentition
  • neck mobility (ROM, how far can lift your chin?)
  • neck circumference
  • neck length
  • thyromental distance
  • mandibular protrusion (bite your upper lip)
  • mouth opening (mallampati, fingerbreadth test)
  • pertinent deformities (ROM, radiation, tumors, head and neck sx)
  • airway pathology
  • facial hair
  • past surgical hx
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9
Q

Difficult mask ventilation

A
  • age >55
  • OSA/snoring
  • edentulous
  • facial hair
  • BMI>26
  • neck circumference
  • Mallampati 3 or 4
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10
Q

Difficult DL

A
  • h/o difficult airway
  • OSA
  • congenital abnormaliies
  • obesity
  • cervical spine dx
  • non reassuring airway exam findings
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11
Q

Physical Exam: CV

A

VS (rate, rhythm, BP)

Auscultation (murmurs, abnormal heart tones, carotid bruits)

Inspection

  • peripheral pulses (consider sick pt or if need for a line)
  • IV access (consider access and if need for central line)
  • JVD
  • peripheral edema
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12
Q

Physical Exam: Resp

A

VS (RR, spo2)

Auscultation (wheezing, dec breath sounds, abn breath sounds)

Inspection (cyanosis, clubbing, accessory muscle use, resp effort, res pattern)

need for post op CPAP or vent support??

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13
Q

Physical Exam: Neuro/MS

A

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

surgical positioning - limitations

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14
Q

Exercise Tolerance: purpose

A

cardiopulm fitness or functional capacity

predictor or cardiac risk & need for further testing

quantified by METs - estimated energy requirement for various activities (metabolic equivalents)

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15
Q

1 MET - 3 MET: activity

A

self care

eating, dressing, or using the toilet

walking indoors and around the house

walking one to two blocks on level ground at 2 to 3 mph

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16
Q

4 MET - 9 MET: activity

A

light housework (dusting, washing dishes)

climbing a flight of stairs or walking up a hill

walking on level ground at 4mph

running a short distance

heavy housework (scrubbing floors, moving heavy furniture)

moderate recreational activities (golf, dancing, doubles tennis, throwing a baseball or football)

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17
Q

> 10 METs

A

strenuous sports

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18
Q

Johns Hopkins Surgery Risk Classification System: Category 1

A

minimal risk

minimally invasive

little or no blood loss

still consider that SURGICAL RISK may be minimal, but overall risk could be high

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19
Q

Johns Hopkins Surgery Risk Classification System: Category 2

A

mild risk

minimal to moderately invasive

EBL not exceeding 500 ml

20
Q

Johns Hopkins Surgery Risk Classification System: Category 3

A

moderate risk

moderate to significantly invasive

EBL 500-1500 ml

21
Q

Johns Hopkins Surgery Risk Classification System: Category 4

A

major risk

highly invasive

EBL > 1500 ml

22
Q

Johns Hopkins Surgery Risk Classification System: Category 5

A

critical risk

highly invasive

EBL>1500 ml

Post op ICU, life saving procedure

23
Q

ASA + surgical risk = ?

A

overall perioperative risk!!

24
Q

What is ASA status?

A

perioperative risk assessment (does not consider risks inherent to operative procedure)

informs clinical decision making:

  • enhanced levels of monitoring
  • less invasive treatment options
  • interventions to reduce risk

correlation of ASA scores and M&M, complications

LIMITATION: clinician subjectivity

25
Q

ASA I

A

normal, healthy patient; no systemic disease

26
Q

ASA II

A

mild to moderate systemic disease, well controlled, no functional limitation

HTN, DM - well controlled, perform ADLs

27
Q

ASA III

A

SEVERE SYSTEMIC DISEASE

functional limitations - interventions outside of medication (i.e. home O2)

28
Q

ASA IV

A

SEVERE SYSTEMIC DISEASE that is a constant threat to life

29
Q

ASA V

A

morbund patient, not expected to survive with or without the surgical procedure

30
Q

ASA VI

A

patient declared brain dead whose organs are being harvested for donation

31
Q

ASA: addition of “E”

A

emergency operation required

CAN BE ADDED TO ANY ASA STATUS

32
Q

Pregnancy Testing Considerations

A
  • consider premenopausal women of childbearing age
  • surgical considerations (harm to fetus):
  • –direct injury
  • –reduced blood flow
  • –teratogenic agents

-sensitive subject, don’t force the pt

Full discussion of risks, benefits, alternatives - DOCUMENT

33
Q

CBC, HGB, HCT: considerations and NICE guidelines

A

proposed sx

potential blood loss

clinical indications: hematologic dx, CKD, chronic liver dx, anticoag therapy, etc.

NICE guidelines: ASA 3 or 4 intermediate procedures, all patients having major procedures

34
Q

Electrolytes & Glucose: considerations

A

clinical indications for electrolytes: CKD, cirrhosis, certian meds, DM, type of sx, dialysis

clinical indications for glucose: DM, steroid use, cirrhosis

35
Q

Renal function: considerations and NICE guidelines

A

Assess tubular function & GFR

clinical indications: DM, HTN, dehydration, known renal dx, h/o transplant, etc

NICE guidelines:
-Routine in ASA 3 or 4 having intermediate procedure & ASA 2, 3 or 4 having major procedure

-Risk for AKI: ASA 3 or 4 having minor procedure, ASA 2 for intermediate

36
Q

Liver Function: considerations

A

Hx of liver injury & exam findings

Clinical Indications: hepatitis, jaundice, cirrhosis, portal HTN, bleeding disorders, etc.

37
Q

Coagulation Profile: considerations and NICE guidelines

A

routine testing not indicated unless known or suspected coagulopathy

clinical indications: bleeding disorder, hepatic dx, anticoagulant use

NICE guidelines: ASA 3 or 4: intermediate, major, complex procedures; known anticoagulant meds or chronic liver disease

38
Q

Urinalysis: considerations

A

no indication for routine use

clinical indications: suspected UTI, unexplained fever or chills

acute drug toxicity

39
Q

T&S/T&C: considerations

A

decision is usually guided by institutional policy (surgical blood order schedule) - reduce unnecessary blood orders ($$)

clinical indications: suspect blood transfusion

40
Q

ECG: clinical indications and NICE guidelines

A

no indication for routine use

clinical indications: h/o IHD, HTN, DM, HF, CP, syncope, DOE, etc.

2014 ESC/ESA guidelines: risk factors for IHD, CVD, sig arrhythmia, or symptomatic; intermediate/high risk surgery

NICE guidelines: ASA 3 or 4, intermediate procedure; ASA 2, 3 or 4, major procedures

41
Q

Chest xray: clinical indications

A

no indication for routine use

clinical indications: advanced COPD, bullous lung disease, suspected pulmonary edema, suspected pulmonary edema, suspected PNA, suspected mediastinal mass, suspicious findings on exam

patients undergoing thoracic, upper abdominal, AAA sx

42
Q

ECHO: clinical indications

A

no indication for routine use

clinical indications: heart murmur and symptomatic, S&S of HF, unexplained dyspnea; clinical stable, ventricular dysfunction not tested in previous year

43
Q

PFTs: clinical indications

A

considered for type and invasiveness of surgery (CABG, lung resection

clinical indications: severe asthma, symptomatic COPD, scoliosis, restrictive lung dx

44
Q

NPO status: CURRENT ASA guidelines for 2, 4, 6, 8 hours

A

balance risk factors of fasting with pulmonary aspiration risk

2 hours: clear liquids; all patients
4 hours: breast milk
6 hours: formula or solids; light meal
8 hours: heavy meal, fried or fatty food, candy, gum (controversial; some say it promotes gastric emptying, some say it promotes HCl production)

Consider: difficult airway & co-morbidities

45
Q

Populations with potential aspiration risk

A

No separate guidelines currently available up to clinician judgment/institution)

  1. age extremes <1 yr or >70 yr
  2. ascites (ESLD)
  3. collagen vascular disease, metabolic disorders (DM, obesity, ESRD, hypothyroid)
  4. hiatal hernia/GERD/esophageal sx
    - -how bad? How do you sleep @ night?
  5. mechanical obstruction (pyloric stenosis)
  6. prematurity (extreme of age)
  7. pregnancy
  8. neurologic diseases
  9. having eating food or non-clear drinks
    - -Be CLEAR with how you ask!!
46
Q

Continue meds day of procedure EXCEPT:

A
  • ACEIs and ARBs
  • ASA: stop 3 days prior unless perc. coronary intervention, high grade IHD, sig CVD
  • P2Y12 inhibitors: stop 5-10 day prior unless drug-eluding stent (6 month dual antiplatelet therapy) & bare metal stents (1 month dual antiplatelet therapy)
  • discuss risk w/ surgeon/cardiologist*

-short acting insulin; none or 1/2 dose of long-acting insulin day of *** insulin pump - basal rate only

  • topical
  • non insulin anti-diabetic meds
  • diuretics
  • sildenafil or similar
  • NSAIDS: 48 hour
  • Warfarin: 5 days prior

NURA 606 Adv Health Assessment (9 decks)

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