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NURA-606-01 Advanced Health Assessment > Lecture 1: PreOp Assessment AL > Flashcards

Lecture 1: PreOp Assessment AL Flashcards

1
Q

Why is the preop assessment performed?

Regulatory Requirements:

A

 AANA Standard of Care (see document)
https://www.aana.com/docs/default-source/practice-aana-com-web-documents(all)/standards-for-nurse-anesthesia-practice.pdf

 American Society of Anesthesiologists - mandated

 The Joint Commission on Accreditation of Healthcare Organizations - mandated

 Centers for Medicaid and Medicare-reimbursement

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2
Q

AANA Standard of Care:

A

Standard 1: Patient’s Rights
Standard 2: Preanesthesia Patient Assessment and Evaluation
Standard 3: Plan for Anesthesia Care
Standard 4: Informed Consent for Anesthesia Care and Related Services
Standard 5: Documentation
Standard 6: Equipment
Standard 7: Anesthesia Plan Implementation and Management
Standard 8: Patient Positioning
Standard 9: Monitoring, Alarms
Standard 10: Infection Control and Prevention
Standard 11: Transfer of Care
Standard 12: Quality Improvement Process
Standard 13: Wellness
Standard 14: A Culture of Safety

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3
Q

AANA Standard of Care

Standard 9: Monitoring, Alarms

A 
Oxygenation 
Ventilation 
Cardiovascular
Thermoregulation
Neuromuscular
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4
Q

Goals of Preoperative Evaluation:

***oral

A

 reduce patient risk and morbidity a/w surgery and anesthesia
 prepare the patient medically and psychologically
 promote efficiency
 reduce costs

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5
Q

Components of Preoperative Evaluation:

A

 Patient medical history (chart review + history taking)  Physical exam
 Medications/ Allergies
 Laboratory testing/ Diagnostic testing
 Medical consultation (if indicated)
 ASA-Physical Status assignment
 NPO status (fasting status and aspiration risk)
 Formulation of anesthetic plan
 Discussion of plan (educate and decrease anxiety)
 Informed consent
 Documentation

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6
Q

Where is this assessment performed?

Preoperative Evals/Assessment:

A

Presurgical testing centers (early testing)

Hospitals

  1. OR settings
  2. critical care units
  3. specialty departments

Outpatient centers

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7
Q

When is the Preop Eval performed?

Optimal Situation =

A

Preoperative Clinic Visit ~ 1 week preop
 Patient interview
 Physical examination
 Develop anesthetic plan
 Promotes patient teaching & anxiety reduction
 Allows time to schedule appointments with medical consultants and complete required pre-operative diagnostic testing
 Obtain informed consent prior to operative day

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8
Q

Who Requires Early Preoperative Assessment?

A

Examples:
 Angina, CHF, MI, CAD, poorly controlled HTN
 COPD/severe asthma, airway abnormalities, home O2 or ventilation
 IDDM, adrenal disease, active thyroid disease
 Liver disease, end-stage renal disease
 Morbid obesity, symptomatic GERD
 Severe kyphosis, spinal cord injury

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9
Q

OR Schedule:

A 
 Demographics- name, age, gender
 Procedure + diagnosis
 Length of procedure + position
 Surgeon(s)
 Type of anesthesia (double check)
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10
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 
 Medication List 
 Allergies
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11
Q

Do NOT forget about the…..?

A

Patient

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12
Q

If inpatient, may also look at:

A 
 progress notes
 medication administration records
 nursing notes
 consult notes
 test results
 ***old anesthesia records (complications noted?)
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13
Q

Are there additional benefits of the preop assessment?

A

YES! Make pt feel comfy!

Establishment trusting relationship!

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14
Q

Preoperative Interview:

A

 Introduction- title (SRNA, CRNA, MDA) & role
 Confirmation- pt. ID, dx, procedure (surgical site)
 Education- type of anesthetic, IV insertion, urinary cath, airway instrumentation, monitors, postop care
 Establishment- trusting relationship

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15
Q

The Preoperative Interview: History

A 
Review of systems (subjective!):
▪ CNS/NM
▪ Cardiac
▪ ENT
▪ Pulm
▪ Vascular/HTN
▪ Endocrine
▪ GI/hepatic
▪ Renal
▪ Hematologic
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16
Q

The Preoperative Interview: Medications

A

Allergies

  • **what happened
  • including latex type rxn

Prescription meds

  • DC’d? When?
  • Taken this AM?

OTC (ASA, NSAIDs)

Herbals (2 weeks!)

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17
Q

Preoperative management of Medications (BOX 31.15):
1. Antihypertensives medications

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Continue on the day of surgery,

EXCEPT for ACEIs and ARBs

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18
Q

Preoperative management of Medications (BOX 31.15):
2. Cardiac medications (e.g. BBs, digoxin)

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Continue on the day of surgery

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19
Q

Preoperative management of Medications (BOX 31.15):
3. Antidepressants, anxiolytics, and other psychiatric medications

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Continue on the day of surgery

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20
Q

Preoperative management of Medications (BOX 31.15):
4. Thyroid medications

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Continue on the day of surgery

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21
Q

Preoperative management of Medications (BOX 31.15):
5. Oral contraceptive pills

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Continue on the day of surgery

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22
Q

Preoperative management of Medications (BOX 31.15):
6. Eye drops

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Continue on the day of surgery

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23
Q

Preoperative management of Medications (BOX 31.15):
7. Heartburn or reflux medications

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Continue on the day of surgery

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24
Q

Preoperative management of Medications (BOX 31.15):
8. Opioid medications

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Continue on the day of surgery

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25
Q

Preoperative management of Medications (BOX 31.15):
9. Anticonvulsant medications

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Continue on the day of surgery

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26
Q

Preoperative management of Medications (BOX 31.15):
10. Asthma medications

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Continue on the day of surgery

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27
Q

Preoperative management of Medications (BOX 31.15):
11. Corticosteroids (oral and inhaled)

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Continue on the day of surgery

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28
Q

Preoperative management of Medications (BOX 31.15):
12. Statins

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Continue on the day of surgery

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29
Q

Preoperative management of Medications (BOX 31.15):
13. Aspirin

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Continue aspirin in pts w/ prior percutaneous coronary intervention, high-grade IHD/CAD, and significant CVD. Otherwise, discontinue aspirin 3 DAYS before surgery.

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30
Q

Preoperative management of Medications (BOX 31.15):
14.1 P2Y12 inhibitors…Antiplatelet medications (e.g. clopidogrel, ticagrelor, prasugrel, ticlopidine)

Patients having cataract surgery w/ topical or general anesthesia:

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Patients having cataract surgery w/ topical or general anesthesia do not need to stop taking thienopyridines.

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31
Q

Preoperative management of Medications (BOX 31.15):
14.2 P2Y12 inhibitors…Antiplatelet medications (e.g. clopidogrel, ticagrelor, prasugrel, ticlopidine)

If reversal of platelet inhibition is necessary:

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

If reversal of platelet inhibition is necessary, the time interval for discontinuing these medications before surgery is:

5-7 days for clopidogrel and ticagrelor,
7-10 days for prasugrel, and
10 days for ticlopidine.

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32
Q

Preoperative management of Medications (BOX 31.15):
14.3 P2Y12 inhibitors…Antiplatelet medications (e.g. clopidogrel, ticagrelor, prasugrel, ticlopidine)

Pts with stents:

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Do NOT discontinue P2Y12 inhibitors in pts who have drug-eluting stents until they have completed 6 mo of dual antiplatelet therapy, unless pts, surgeons, and cardiologists have discussed the risks of discontinuation.

The same applies to pts w/ bare metal stents until they have completed 1 month of dual antiplatelet therapy.

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33
Q

Preoperative management of Medications (BOX 31.15):
15.1 Insulin (short-acting…. e.g. regular)

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

For ALL pts, discontinue ALL short-acting (e.g. regular) insulin on day of surgery (unless insulin is administered by cutaneous pump).

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34
Q

Preoperative management of Medications (BOX 31.15):
15.2 Type 2 Diabetes

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Pts with type 2 diabetes should take none or up to one half of their dose of long-acting or combination (e.g. 70/30 preparations) insulin on the day of surgery.

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35
Q

Preoperative management of Medications (BOX 31.15):
15.3 Type 1 Diabetes

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Pts with type 1 diabetes should take a small amount (usually one third) of their usual long-acting insulin dose on the day of surgery.

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36
Q

Preoperative management of Medications (BOX 31.15):
15.4 Insulin pump

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Pt with an insulin pump should continue their basal rate only.

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37
Q

Preoperative management of Medications (BOX 31.15):
16. Topical medications (e.g. creams and ointments)

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Discontinue on the day of surgery

38
Q

Preoperative management of Medications (BOX 31.15):
17. Non-insulin antidiabetic medications

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Discontinue on the day of surgery (exception: SGLT2 inhibitors should be discontinued 24 hours before elective surgery)

39
Q

Preoperative management of Medications (BOX 31.15):
18. Diuretics

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Discontinue on the day of surgery (exception: thiazide diuretics taken for hypertension, which should be continued on the day of surgery)

40
Q

Preoperative management of Medications (BOX 31.15):
19. Sildenafil (Viagra) or similar drugs

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Discontinue 24 hrs before surgery

41
Q

Preoperative management of Medications (BOX 31.15):
20. COX-2 inhibitors

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Continue on the day of surgery unless the surgeon is concerned about bone healing

42
Q

Preoperative management of Medications (BOX 31.15):
21. NSAIDs

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Discontinue 48 hrs before the day of surgery

43
Q

Preoperative management of Medications (BOX 31.15):
22. Warfarin (Coumadin)

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Discontinue 5 days before surgery,

EXCEPT for pts having cataract surgery w/o a bulbar block.

44
Q

Preoperative management of Medications (BOX 31.15):
23. MAOIs

*instruct pts to take these medications with a small sip of water, even if fasting, unless stated otherwise

A

Continue these medications and adjust the anesthesia plan accordingly.

45
Q

The Preoperative Interview

A

Past surgical hx (including previous anesthetics):

  • complications
  • family hx complications
  • obstetrical deliveries
Other:
ETOH use?
Drug abuse?
Tobacco use?
Females - LMP?
Pain?
NPO status
Height/weight
46
Q

The Preop Interview: Physical Exam

A

 General Impression, mental status (document!)
 Airway-regardless of plan (ALWAYS)
 Heart (ALWAYS)
 Lungs (ALWAYS)
 CNS/PNS
 Vital signs (current by NA or RN, document)
 Height/weight (current by NA or RN, document)

47
Q

Mallampati Classification

A 
PUSH = 
Pillars
Uvula
Soft Palate
Hard Palate
I = PUSH
II = USH
III = SH
IV = H
48
Q

“Although by itself, the Mallampati class has a low____ positive predictive value in identifying patients who are difficult to intubate. Therefore a _____________ approach to predicting intubation difficulty has proven to be more helpful”

A

“Although by itself, the Mallampati class has a low positive predictive value in identifying patients who are difficult to intubate. Therefore a multifactorial approach to predicting intubation difficulty has proven to be more helpful”

49
Q

Additional difficult airway predictive tests (also review slide 35):

A
  1. thyromental distance: <6.5cm or 3 fingers
  2. interincisor distance: <3cm or 2-3 fingers
  3. Atlanto-occipital function: <23deg, average 35deg
  4. mandibular protrusion test (ULBT)
  5. hyomental distance (mandibulohyoid): <4cm or 2 fingers
  6. neck circumference (>16cm
50
Q

Mandibular protrusion test(ULBT)

A

Class A: Lowers past uppers (bite upper lip)
Class B: Lowers equal uppers
Class C: Lowers cannot reach uppers (bad)

51
Q

Size of Neck Average neck size:

A

male = 15- 16 inches (38-40 cm)
women = 13-14 inches (33-35 cm)
17 inches or > 40 cm neck size – 5% chance of difficult airway *Increases 1.3% for every 1 cm increase in neck size

52
Q

Physical Exam: Prayer Sign

A

Joint stiffening ~ airway stiffening?

53
Q

Physical Exam: Heart

A 
 Auscultation 
 Rate 
 Rhythm 
 Murmurs 
 Bruits (carotid) 
 Extremity pulses
 APTM
54
Q

Physical Exam: CV

A

Bruits (carotid)
Extremity pulses
Extremity edema

55
Q

Physical Exam: Lungs

A

 Inspection
 Auscultation
 Percussion
 Palpation

56
Q

Physical Exam: Neurologic/ Musculoskeletal System

*Extent of neuro exam really depends on baseline deficits, disease or surgical procedure

A

 Motor – gait, grip strength, ROM, ability to hold arms forward, etc.
 Sensory – distinction of vibration, pain, light touch along dermatomes
 Muscle reflexes – deep, superficial, and pathologic
 Cranial nerve abnormalities
 Mental status
 Speech

57
Q

End Target Organ Damage

A

Eye ball vessels
CXR Cardiomegaly
Wide QRS
Proteinuria

58
Q

“2012 ASA Practice Advisory for Preanesthesia Evaluation states that:

A

routine preoperative tests do not make an important contribution to preanesthetic evaluation of an asymptomatic patient” (Hata & Hata, 2017)

59
Q

Preop testing should be SELECTIVELY ordered based on:

SELECTIVE testing:

A

Preop testing should be SELECTIVELY ordered based on:

  • patient’s medical history and physical exam
  • planned surgery
  • expected intraoperative blood loss

SELECTIVE testing:
expedites patient care
reduces healthcare cost
improves delivery of perioperative meds

60
Q

More tests are better, right?

Will the results change the INTRAOPERATIVE management of this patient? If so, then…..

A

WRONG!

TEST!!!

61
Q

Factors that contribute to nonselective ordering:
• Surgeons and PCPs— often no diagnostic focus
anesthesia providers “require them”
• Routine screening for disease states
• Diagnostic baseline
• Personal habit
• Medicolegal necessity “not to miss anything”

A

• Surgeons and PCPs— often no diagnostic focus
anesthesia providers “require them”
• Routine screening for disease states
• Diagnostic baseline
• Personal habit
• Medicolegal necessity “not to miss anything”

  • the more we test the more we are liable for
62
Q

Pretesting is partially based on invasiveness of surgery:

❑ Minimally Invasive (skin lesion excision)

A

little tissue trauma, minimal blood loss (<500 mL)

63
Q

Pretesting is partially based on invasiveness of surgery:

❑ Moderately Invasive (inguinal hernia, tonsillectomy, knee arthro)

A

modest disruption of normal physiology

anticipate some blood loss (500-1500 mL)

may need invasive monitors and/or ICU

64
Q

Pretesting is partially based on invasiveness of surgery:

❑ Highly Invasive (vascular sx, TURP, TJR, rad neck dissect, lung)

A

significant disruption of normal physiology

blood loss >1500 mL

commonly require transfusion and ICU care

65
Q

What labs/tests and when?

A 
What labs/tests and when?
 Institutional policy
 Current expert organization guidelines i.e. ACC/AHA guidelines 
 Anesthesia provider judgment
 Table 31.18
66
Q

What labs/tests and when?

Table 31.18: HF

A

EKG

CXR (consider)

67
Q

What labs/tests and when?

Table 31.18: HTN

A

EKG
CXR (consider)
Electrolytes
Creatinine

68
Q

What labs/tests and when?

Table 31.18: Chronic AFib

A

EKG

Drug Levels

69
Q

What labs/tests and when?

Table 31.18: COPD

A

EKG
CXR (consider)
CBC
Drug Levels

70
Q

What labs/tests and when?

Table 31.18: Diabetes mellitus

A

EKG
Electrolytes
Creatinine
Glucose

71
Q

What labs/tests and when?

Table 31.18: Renal Disease

A

CBC
Electrolytes
Creatinine

72
Q

What labs/tests and when?

Table 31.18: Morbid obesity

A

EKG
CXR (consider)
Glucose

73
Q 
CXR?
 Assessment of perioperative risk = ?
 Therefore, should or should  not be ordered routinely
 Decision based on? 
 Indications = ?
A

questionable

should NOT

based on abnormalities identified during
the preop assessment (ie, rales, SOB
intercostal retractions, deviated trachea)

severe COPD, suspected pulmonary edema, pneumonia, susp mediastinal masses or PE

74
Q

What about CXR in smokers?

A

if Significant smoking history = 20 pack years

20 pack yrs = 2 packs / day X 10 years

75
Q

RECOMMENDATIONS for PREOP 12 LEAD ELECTROCARDIOGRAM:
 CLASS IIA RECOMMENDATION
 Class IIB
 Class III

A

 CLASS IIA RECOMMENDATION: It is Reasonable to Perform the Procedure for patients with IHD, significant arrhythmia, PAD, CVD, or significant structural heart disease (except if undergoing low-risk surgical procedures)
 Class IIB: The Procedure may be Considered for asymptomatic pts w/o known coronary heart ds, except for those undergoing low-risk surgical procedures
 Class III: The Procedure Should Not Be Performed Because it is Not Helpful for asymptomatic patients undergoing low-risk surgical procedures

76
Q

Consults?
Avoid the terms:
Ask specific questions:

A

Avoid the terms: “cleared for surgery” or “cardiac clearance”
Ask specific questions: “Is this patient able to undergo robotic prostatectomy?”

77
Q

NPO Status:
Based on CURRENT ASA guidelines that balance risk factors of fasting with pulmonary aspiration risk
 _ hours for clear liquids all patients
 _ hours breast milk
 _ hours formula or solids; light meal
 _ hours heavy meal fried or fatty food
Follow your institutions policy however!
* note: some clinicians remain skeptical and use more conservative guidelines NPO 6-8 hours etc.

A

 2 hours for clear liquids all patients
 4 hours breast milk
 6 hours formula or solids; light meal
 8 hours heavy meal fried or fatty food

78
Q

Other NPO Status considerations:

A
  • Age extremes <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 drinks
  • HIV/Lipodystrophy
79
Q

ASA Physical Status Classification
I- normal, healthy patient; no systemic disease
II- mild systemic disease, well controlled, no functional limitation
III- severe systemic disease, functional limitations
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

A

I- normal, healthy patient; no systemic disease
II- mild systemic disease, well controlled, no functional limitation
III- severe systemic disease, functional limitations
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 (added to any above)

I- you aint got shit
II- you got shit but its controlled
III- you got shit and it aint controlled
IV- you got shit that bout to kill ya
V- if yo shit makes it w/ or w/or surgery, I be like wow
VI- yo shit going to someone else

80
Q

ASA PS Class Examples: II

A

II- mild systemic disease, well controlled, no functional limitation

Current smoker 
social drinker
preggers 
obese (30< BMI<40) 
well-controlled DM/HTN 
mild lung disease
81
Q

ASA PS Class Examples: III

A

III- severe systemic disease, functional limitations

One or more moderate to severe diseases
poorly-controlled DM/HTN
COPD
morbid obesity (BMI>40)
active hepatitis
alcohol dependence or abuse
implanted pacer
moderate EF reduction
ESRD undergoing regular dialysis
premature infant
PCA < 60 weeks
Hx (>3mo) of MI, CVA, TIA, or CAD/stents
82
Q

ASA PS Class Examples: IV

A

IV- severe systemic disease that is a constant threat to life

Hx (<3mo) of MI, CVA, TIA, or CAD/stents
ongoing cardiac ischemia or severe value dysfunction
severe EF reduction
sepsis
DIC
ARD or ESRD not undergoing regular dialysis

83
Q

ASA PS Class Examples: V

A

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

ruptured abd/thoracic aneurysm
massive trauma
intracranial bleed with mass effect
ischemic bowl in the face of significant pathology or
multi organ/system dysfunction
84
Q

How long is a typical preoperative anesthetic assessment on a same day surgery patient?

A

10 min?

85
Q

How many care plans do we need at minimum?

A

A & B

A = ET and GA
B = back up plan
86
Q

Formulate Anesthetic Plan:

A 
Preoperative care
Intraoperative care
 Type of Anesthesia 
 Drugs 
 Monitors 
 Airway 
 Positioning 
 Intraoperative monitoring
Postoperative care
87
Q

Anesthesia Plan Components:

A 
 Drug plan/ anesthetic technique
 Airway plan
 Ventilation plan
 Fluid plan/ IV access plan
 Monitoring plan
 Positioning plan
 Other considerations
88
Q

The Anesthetic Plan will be influenced by:

A 
 Current physical status 
 History and physical assessment 
 Co-existing diseases 
 Airway assessment/ Difficult airway? 
 Previous anesthesia complications 
 Family history of anesthesia problems 
 Planned surgery
89
Q

Choices of Anesthetic Technique:

A 
Initiation of the anesthetic technique may include 
 General 
 Regional 
 Combined General/Regional 
 MAC 
 Local
90
Q

Intraoperative Fluid Requirements (review slide 83):

A 
Maintenance
Fluid deficit
Blood loss
Evaporative loss (3rd space loss)
***Goal-direct fluid management
91
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, medications, fluids
 Discuss airway management plan
 Explain monitors- placement, purpose
 Discuss postoperative recovery
 Discuss pain management plan

92
Q

Informed Consent:

A 
Informed Consent:
 Explanation of the planned anesthetic
 Explanation of options available
 Risks and Benefits
 Pt. understanding &amp; cooperation
 Without consent – Assault and Battery
 Minors – consent from parents or guardian
 Signature of pt. &amp; witness

NURA-606-01 Advanced Health Assessment (9 decks)

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