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N928 - Basic Principles > Pre-Op Assessment & Documentation > Flashcards

Pre-Op Assessment & Documentation Flashcards

1
Q

Purpose of the pre-op assessment

A
  1. evaluate current physical status
  2. optimize the patient for surgery
  3. Minimize Perioperative Morbidity & Mortality
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2
Q

Goals of pre-op evaluation (6)

A
  1. OBTAIN medical & surgical history
  2. EVALUATE pt & determine need for pre-op studies or consultations
  3. FORMULATE anesthetic plan
    (to)
  4. MINIMIZE perioperative morbidity & mortality
  5. OPTIMIZE pt safety and satisfaction
  6. PREVENT surgical cancellations & delays
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3
Q

AANA Standard #2

A

Preanesthesia patient assessment and evaluation

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4
Q

AANA Standard #3

A

Plan for Anesthesia care

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5
Q

AANA Standard #4

A

Informed consent for anesthesia care & relevant services

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6
Q

AANA Standard #5

A

Documentation

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7
Q

AANA Standard #6

A

Equipment

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8
Q

AANA Anesthesia Care Documentation includes (13)

A
  1. Name & MRN
  2. Name of all anesthesia providers involved
  3. Immediate pre-op anesthesia assessment & evaluation
  4. Anesthesia safety checks (AGM, drug supply, gas supply, monitors)
  5. Monitoring of the patient (oxygenation, ventilation, circulation, body temperature, skeletal muscle relaxation)
  6. Airway management techniques
  7. Name, dose, route & time of drugs & anesthetics
  8. Patient positioning (who positioned, type of devices used)
  9. Name and amount of IV fluid or blood products
  10. IV lines inserted (technique / location)
  11. Complications / Rxn / Problems
  12. Status of patient at end of anesthesia
  13. Document in a timely and legible manner
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9
Q

Modification to AANA standard

A

MUST BE DOCUMENTED

the modification & why

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10
Q

ASA Preanesthesia Standard (6)

A
  1. Review medical record
  2. Interview & examine pt [discuss Hx, including anesthesia & medical experience and therapies]
  3. Order / Review pertinent labs, tests, or consultations
  4. Order appropriate pre-op medications
  5. Ensure consent is obtained
  6. Document in the chart the above has been performed
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11
Q

Principles of pre-op evaluation

A
  1. Verify pt identity (name, DOB, surgeon, surgery, laterality)
  2. Verify and document proposed surgical procedure and preoperative diagnosis
  3. Consider anesthetic implications
    * *RESPECT PRIVACY
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12
Q

Pre-op Interview Clinic

A

1-2wks before, clinic or phone
* if optimization / pre-arrangement is needed, anticipate

  • MUST still VERIFY INFORMATION DOS
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13
Q

Essential Components

A
  1. BMI
  2. Allergies
  3. NPO status
  4. Medications
  5. Previous anesthesia complications
  6. Family history of MH
  7. possibility of pregnancy
  8. systems review
  9. Baseline cognition
  10. AIRWAY ASSESSMENT
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14
Q

5 As

A 
Ate (NPO status, GERD?, Aspiration risk?)
Allergies
Anesthesia history
Airway
Alert (neuro)
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15
Q

BMI

A

[ lbs / (inches^2) ] x 703

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16
Q

lbs → kg

A

half of lbs

subtract first or first 2 digits

120lbs → 60 → (-6) = 54kg
300 lbs → 150 → (-15) = 135kg

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17
Q

Normal BMI

A

18.5 - 24.99 kg/m^2

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18
Q

Overweight BMI

A

25-29.99 kg/m^2

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19
Q

Obese BMI

A

> 30

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20
Q

Allergies

A

What allergen?
Type of reaction? = was it a side effect vs rxn?
Throat / tongue swelling, difficulty breathing = anaphylaxis

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21
Q

Specifically ask about allergies to:

A 
Drugs
Dyes
Contrast
Latex
Foods
Tape
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22
Q

Surgical history

A 
What kind of surgery?
When?
Why?
Type of anesthesia?
Complications [PONV, MH, awareness, prolonged wakeup / unplanned admission]
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23
Q

Recall is defined as

A

Awareness under general anesthesia

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24
Q

Anesthesia history

A 
difficult intubation?
letter or medical alert bracelet.
sore throat > 48hours after surgery
significant weight change since last surgery
MANY surgeries (visual s/s; chart)
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25
Q

Malignant Hyperthermia

A 
Inherited myopathy
Volatile anesthetics or depolarizing NMB → hypermetabolic state
AVOID TRIGGERS = TIVA
pt or family hx MH
What was the outcome?
Genetic testing completed?
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26
Q

Anesthetic implications of repeated surgery

A
  • scars / adhesions
  • airway damage / patency
  • Allergies
  • Anxiety
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27
Q

Reason for NPO guidelines

nil per os

A

reduce the risk for aspiration (Morb&Mort)

Asp → chemical burn of tracheobronchial tree and pum parenchyema → INTENSE parenchymal inflammatory reaction

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28
Q

NPO Recommendations & who they are for

A

For HEALTHY, “NORMAL” individuals

2H clear liquid (water, black coffee, tea, pulp-free juice, carbonated beverages)
4H Breastmilk
6H “light meal” low or non-fat - formula, cows milk, tea/coffee with creamer, full liquids, gum, hard candy
8H Full meal, fried, fatty food

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29
Q

Factors that increase risk of aspiration

A

“Full stomach” or non-compliance with NPO
Increased intra-abdominal pressure
Diabetes (especially uncontrolled)
Pregnancy
Obesity, SBO, Ascites, GERD (especially uncontrolled)
TRAUMA (SNS stimulation = ↓ gastric motility)
Bulimia

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30
Q

baseline physical exam for comparison later (8)

A 
vital signs
heart/lung sounds
breathing pattern
peripheral pulses
peripheral edema
bruising/scaring
BASELINE SENSORY/MOTOR DEFICITS
MENTAL STATE
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31
Q

mental state assessment

A

awake, alert, oriented, demented, confused, combative, mental retardation (MR)

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32
Q

GOAL OF ANESTHESIA

A

RETURN PATIENT TO BASELINE STATUS (same or better than before)

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33
Q

Airway visual assessment

A

Identification of structures (hard & soft p, tonsils, faucial pillars, uvula, dentition, upper lip bite test, thyromental distance, sternomental? distance, neck circumference, mobility/ROM, interincisor distance)

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34
Q

Airway “tests”

A

Mallampati Class (I, II, III, IV & the oh so rare 0)
- 3 & 4 greater chance of difficult airway; dependent upon patient cooperation
Inter-incisor (3 finger breadths)
Thyromental distance; BAD <6cm, GOOD 3 fingers >7cm
Sternomental Distance; BAD <13cm, GOOD >14cm
Neck circumference; GOOD <45cm & BMI <40
Upper lip bite; Class 1, 2, 3 (whole lip, half lip, no lip bite)
Prayer Sign/Table top test; ↓ joint/cartilage mobility (atlanto-occipital joint involvement = ↓ ROM
Dentition; malnourished, drug abuse
Cervical mobility/ROM

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35
Q

TMJ

A

ball and socket joint; mandible & maxilla
muscles, tendons, bones
Disorders: teeth grinding, nail biting, gum chewing, malocclusion, stress-clenched teeth, jaw trauma

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36
Q

Patil’s Test

A

Thyromental distance, head fully extended.
upper edge of thyroid to mentum;
short distance implies visualization during intubation may be difficult
- more anterior larynx
- more acute angle
- less space to displace/ compress tongue

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37
Q

cervical spine mobility / sniffing position

A

oral - pharyngeal - laryngeal axis alignment.

allows view of glottic opening

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38
Q

dentition

A

loose, chipped, cracked, broken, removable
DOCUMENT
any crowns, implants, devices, removable objects?

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39
Q

Neck circumference indicative of difficult intubation

A

> 45cm

BMI >40

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40
Q

difficult mask ventilation prediction

A 
Mask seal
Obesity
Age >55yr
No teeth
Stiff lungs
Beard
Obesity
No teeth
Elderly (>55 yr)
Snores
Facial hair
ROM 
Over 55 yr
Zzz (OSA / snore)
Edentulous
Neck surgery / trauma / radiation
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41
Q

difficult intubation pneumonic

A 
Look for pathology
Evaluate 3-3-2 rule
Mallampati classification
Obstruction
Neck mobility (pain or tight?)

Look @ face/neck (mass, injury, bleed)
Evaluate (ROM, thickness, circumf, surgical Hx)
Thyromental distance
Incisors; opening; 3 fingers
Teeth (chips, cracks, loose, missing, dentures, braces)
Grade, Mallampati
Overbite (oral space, TMJ, tonsillar hypertrophy, abscess, mandibular compliance)

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42
Q

facial hair can do 2 things

A
  1. difficult to get mask seal

2. disguise potential difficult airway

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43
Q

female patients

A

possibility of pregnancy;

last menstural period

44
Q

Medication Hx / current medications

Question which ones? (8)

A 
OTC / Rx, vitamins, minerals, herbals, home remedies
why? how long? how often? last dose?
Pursue questioning on the following:
Anticoagulants
Anti-dysrhythmias
Anti-hypertensives
Beta-blockers
Bronchodilators
Diuretics
Opioids
Vasodilators
45
Q

medications to TAKE DOS

A 
beta blockers
GERD meds
Ca+ channel blockers
bronchodilators
antiarrhythmias
steroids
diuretics (if for HF)
antipsychotics
thyroid medications
46
Q

medications to HOLD DOS

A 
oral hypoglycemics
ACE inhibitors (PROFOUND hypotension)
A2RB
Diuretics (as long as its not for HF)
Herbal supplements

-per surgeon’s order
anticoagulants

47
Q

Cardiovascular pre-op assessment

A

HTN, angina, CAD, MI, valvular dz, syncope, CHF, edema, dyspnea, arrhythmias

LISTEN to heart

48
Q

Hx HTN

A

duration of dz
EXERCISE TOLERANCE (METS)
recent EKG

Medication?
how long, compliance, controlled?
DOCUMENT current meds

49
Q

single best indicator of cardiopulmonary function

A

Exercise Tolerance

50
Q

Angina / CAD / MI

A

Exercise Tolerance
s/s, precipitating factors, last chest pain, date of MI
METHODS OF RELIEF
INTERVENTIONS, if any?
EKG, ECHO, cardiac cath, most recent cardiologist visit, cardiac clearance

51
Q

cardiac clearance

A

Recent (w/n 6 mo) MI = 6 months
Newly diagnosed CHF or CHF w/ hospitalization w/n 6 mo = 6 months
Aortic Stenosis = 12 mo or more recent if change in symptoms

52
Q

Risk of 2nd MI is highest w/n

A

6mo of MI

53
Q

Valvular Dz

A

Do they take ATB for dental work?

stenosis or regurgitation
- need recent or comparative EKG, ECHO, cardiology notes/consults/clearance

54
Q

syncope & cardiac arrthymias

A

causes, if known
last episode, any treatment?

CONSIDER CIRCULATION BLOCK
-review notes / past & current EKG

do they have a pacemaker or AICD (magnet)

55
Q

arrythmias

A

type
intermittent or continuous
interventions or current medical management?
anticoagulants or antiarrhythmic?

56
Q

congestive heart failure

A

current status, controlled?
recent weight gain / pedal edema?
dyspnea or difficulty lying flat - do you sleep sitting up?
last hospitalization
recent changes in management
current EKG & ECHO with documented EJECTION FRACTION
take diuretics DOS

57
Q

respiratory

A 
Asthma / COPD / chronic bronchitis / emphysema
Recent URI / cough or cold
Pneumonia
Tuberculosis
OSA / snore
Tobacco use / Vape
58
Q

Asthma

A

Frequency / Last attack
Triggers / hospitalizations?
Ever been intubated or ICU?
Treatment regimen; controlled or uncontrolled?
Meds, dose, route, last dose rescue, frequency of use
current or past oral steroid use
Antibiotic treatment
Pediatrics
- changes in activity, lethargy, appetite, fluid intake

59
Q

Emphysema

A

Home oxygen use?
Inhaler / Nebulizer / Corticosteroid use

Pulmonology reports / PFTs / ABGs / CXR

60
Q

Tuberculosis

A 
INH therapy **CHECK LFTs**
symptomatic vs latent [productive cough, chest pain, fatigue, loss of appetite/weight, fever, chills, night sweats]
New onset / worsening of symptoms
Isoniazid (INH) therapy
CXR if symptomatic
61
Q

OSA

A

*bring CPAP or BIPAP with you

Document settings

62
Q

Tobacco use

A

per day, type, years,
Pack year = # years x packs per day
or
(#cig per day x years smoked) / 20

FORMER SMOKERS; same information, quit date

63
Q

Nervous

A

Stroke / TIA
Seizures
Headache
Neuropathy

64
Q

Stroke / TIA

A 
Date of occurrence
Cerebral blood flow studies
Carotid doppler
Angiogram
*RESIDUAL DEFICITS*?
- hemiparesis, dysphagia, visual disturbances
DOCUMENT
65
Q

Headaches

A 
frequency
type
triggers / relief
debilitating?
have you seen a neurologist?
medications?
66
Q

Seizures

A

Hx , type, last, frequency, cause, MEDICATIONS, CHECK BLOOD LEVELS OF MEDS
TAKE MEDS DOS

67
Q

Neuropathy

A

Unique positioning needs
Choice of anesthetic do not block a limb with neuropathy
PROVIDES BASELINE
site of neuropathy, type
- numbness, tingling, pain, loss of sensation, “pins & needles”, “goes to sleep”

in fingers/ toes? one side or both?
DOCUMENT

68
Q

GI : GERD

A

recognize patients at risk for aspiration
*High incidence of GERD associated with?

Ask about: Meds, OTC/RX, controlled/uncontrolled, factors and frequency of reflux, DYSPHAGIA?,
TAKE GERD MEDS DOS

RSI = 30-40 Newtons cricoid pressure = 6.6-8.8 lbs = 3-4 kg

69
Q

Hiatal Hernia

A

heartburn, regurgitation, nausea
severity?
treatment?

70
Q

Bowel obstruction

A

date of obstruction
surgical intervention? past or present ostomy?
Crohn’s? IBS?

71
Q

Endocrine

A

Diabetes

Thyroid Dz

72
Q

Diabetes

A

RSI
Meds? controlled vs uncontrolled?
HgbA1c

73
Q

Thyroid : Hyperthyroidism

A

weight loss, ↑ HR (need B blocker?), heat sensitivity, nervousness, irritability, tremors, anxiety, muscle weakness
U-thyroid? check pulse

74
Q

Thyroid: Hypothyroidism

A

weight gain, cold intolerance, fatigue, depression, dry skin, muscle cramps

*ASSESS GOITERS & encroachment upon airway

75
Q

Autoimmune: Rheumatoid Arthritis (RA)

A

inflammation, pain, stridor, hoarseness, dysphagia, painful speech, steroid use

POSSIBLE CERVICAL SPINE INSTABILITY
atlantoaxial instability = GET FLEXION / EXTENSION FILM; looking for atlantoaxial SUBLUXATION

*potentially difficult airway d/t TMJ dz, ↓ C-spine mobility, ↓ arytenoid joint mobility

76
Q

Musculoskeletal

A

SUX is bad news bears
Muscular Dystrophies = progressive weakening & atrophy
MS, MG, myopathy, fibromyalgia, myotonias, obestity, Sjogrens syndrome

77
Q

Hepatic

A

What dz? Bruise or bleed? Protein level?
Coag [Pt/Ptt]
LFT [AST/ALT]

Hepatitis: type, date, treatment
Jaundice: origin [ETOH vs unknown]
Cirrhosis: scaring → impaired fxn
Alcohol: frequency, types, amount
*consider coagulation studies & EKG
78
Q

Renal

A

Last dialysis? How much did they take off? Weight gain?
Acute vs Chronic failure
ESRD - dialysis?
*lytes / renal panel / EKG / Pt/Ptt / LFTs

79
Q

Alcohol / Drugs

A

What, amount, frequency, last dose, route, duration of use

  • Acute intoxication = ↓ dosages
  • Chronic use = ↑ dosages
80
Q

Hematological / Coagulation

A

Hx anemia, coagulopathies, ITP/TTP/HUS, DVT, PE, sickle cell, anticoagulant use, transfusion history, bleeding tendency

81
Q

MISC in pre-op

A

Hx malignancy
Hx psychiatric illness / dementia / alzheimers
Hx infectious dz / HIV / AIDS / Herpes

82
Q

Anesthetic Plan includes (5)

A 
Type of anesthesia
Airway device
Type of induction
Medications
Monitoring modalities / special equipment
83
Q

ASA Physical Status

A

1 - normal healthy
2 - mild systemic dz
3 - severe systemic dz
4 - severe systemic dz that is a constant threat to life
5 - moribund patient not expected to survive without surgery
6 - declared brain-dead; anticipating organ procurement (donor)
E - EMERGNCY (add to any of the above)

84
Q

EMERGENCY CASE

A 
consent, if possible
consider "FULL STOMACH"
anticipate possible equipment needs
medication considerations
blood products available?
is additional help available?
85
Q

Informed consent

A

Discuss anesthetic plan, alternatives, risks, potential complications.
Answer questions
Obtain written consent

STANDARD #4

86
Q

What to document?

A
  • Verified identity
  • invasive procedures
  • techniques used
  • special eq used (doppler / ultrasound)
  • ventilation modes
  • incision
  • inducation
  • intubation
  • extubation
  • verified surgical procedure
  • AGM check
  • Times (in/out of room, atbx)
  • transport time & location
  • patient status
  • collaborative efforts & communication (Dr. X notified of 500mL blood loss)
  • name of individuals who perform a given procedure
87
Q

If the patient has neuropathy, do NOT

A

place neuraxial block to that extremity

88
Q

Cultural considerations

A
  • acceptance of blood products
  • confirm AND/DNR status: usually suspended while in the OR
  • religious tokens
89
Q

Assess pain ideology

A

“you’re the headliner, I’m just the backup”

How do you perceive pain? What are your pain goals → Some discomfort is likely - b/c surgery. How can you communicate discomfort to us?

90
Q

Blood Transfusion

A

Acceptance

History

91
Q

Major CV Risks

A

Unstable coronary syndromes, acute/recent MI w/ ischemic risk, unstable/severe angina, decomp HF, significant / symptomatic / uncontrolled arrhythmias, high grade AV block, severe valvular dz

92
Q

Intermediate CV Risks

A

Mild angina, Hx MI, pathological Q waves, compensated HF, DM (insulin dependent), renal insufficiency

93
Q

Minor CV Risks

A

Age, abnormal EKG (LVH, LBBB, ST-T abormalities), non sinus rhythm, low functional capacity, Hx stroke, uncontrolled HTN

94
Q

METs

A

1 MET - cannot care for self fully
4 MET - 1 flight of stairs
>10 MET - strenuous sports (football, skiing, basketball, swimming)

95
Q

Surgery:
High Risk
>5% Cardiac risk

A

emergent operations (especially in elderly), aortic/major vasculature, peripheral vascular, prolonged surgery with major fluid loss/shifts

96
Q

Surgery:
Intermediate Risk
<5% cardiac risk

A

carotid endarterectomy, head/necck, intraperitoneal, intrathoracic, orthopedic, prostate

97
Q

Surgery:
Low Risk
<1% cardiac risk

A

endoscopic, superficial, cataract, breast surgery

98
Q

ASA 1

A

Healthy, non-smoker, minimal ETOH use, normal BMI

99
Q

ASA 2

A

Mild systemic dz
PREGNANCY
smoker, social alcohol drinker, obesity, well controlled DM/HTN, mild lung dz

100
Q

ASA 3

A

Severe systemic dz
substantive functional limitations
1 or more moderate dz:
Uncon DM/HTN, COPD, BMI>40, active hepatitis, alcohol dependence, pacemaker, moderate ↓ EF%, ESRD, dialysis,
Within the last 3 months [MI, CVA, TIA, CAD/stents]

101
Q

ASA 4

A

Severe systemic dz that is a CONSTANT threat to life:
RECENT <3mo [MI, TIA, CVA, CAD/stents], ongoing cardiac ischemia, valve dysfunction, severe ↓ EF%, shock, sepsis, DIC, ARD or ESRD w/o regular dialysis

102
Q

ASA 5

A

Moribund patient who will not survive without surgery.
Ruptured abd/throac aneurysm, massive trauma, intracranial bleed w/ mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction.

103
Q

ASA 6

A

Declared brain-dead patient whose organs are being removed for donor purposes.

104
Q

Time sensitive surgery

A

stable, but required intervention; w/n days to weeks

[tendon/nerve injuries, cancer procedures]

105
Q

Urgent surgery

A

condition threatens life, limb, organ; w/n 6-24 hours

[perf bowel, compound fx, eye injury]

106
Q

Emergent surgery

A

life, limb, organ-saving; w/n 6 hours

[ruptured aortic aneurysm, major trauma to thorax/abdomen, acute increase in ICP]

N928 - Basic Principles (22 decks)

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