Pre-Op Evaluation and Anesthesia Documentation Flashcards
Why do we pre-op interview?
Optimize the patient Gather an inventory Decrease morbidity and mortality Decrease DOS cancellations and delays Builds trust Standard of Care Documentation
Purpose of the Pre-Op Evaluation
evaluate current physical status and optimize the patient for surgery
Goals of Preoperative Interviewing
obtain medical history and surgical history
evaluate patient and determine the need for preop studies and/or speciality consultations
formulate and deliver safe anesthetic plan
minimize peri-operative morbidity and mortality
optimize patient safety and satisifaction
prevent surgical cancellation and delays
Standard 2
perform and document or verify documentation of a preanesthesia evaluation of the patient’s general health, allergies medication history preexisting conditions anesthesia history and any relevant diagnostic test. Perform and document or verify documentation of an anesthetic focused physical assessment to form anesthesia plan of care
Anesthesia Care Documentation (13)
Name and facility identification number of the patient
name of all anesthesia professionals involved in the patient’s care
immediate preanesthesia assessment and evaluation (ie change in health status, re-evaluation of NPO status)
anesthesia safety checks (supe, drugs, gas supply)
monitoring of the patient (oxygenation, ventilation, circulation, body temperature and skeletal muscle relaxation)
airway management
name, dosage, route and time of administration of drugs and anesthesia
techniques used and patient positioning
name and amounts of fluid (blood products, too)
IV techniques for insertion location
any complications adverse reactions problems during anesthesia
documentation in a timely and legible manner
AANA Stds for Nurse Anesthesia Practice
there may be patient specific circumstances that require modification of a standard. The CRNA must document modifications to these standards in the patient’s healthcare record, along with the reason for the modificiation
ASA Statement of Documentation of Anesthesia Care
-Patient Interview to assess: pateint and procedure identification anticipated disposition medical history (patients ability to give informed consent) surgical history anesthestic history current medications list Allergies/Adverse Drug Reactions NPO Status Documenting the presence of the periop plan for existing advance directives -Appropriate physical examination review of objective diagnostic data medica consultation when applicable assignment of ASA PS, + emergent status anesthetic plan ++ post and pain management documentation of informed consent appropriate premedication and prophylatic antibiotic adm
Principles of PreOp Evaluation
verify patient identity
verify and document the proposed surgical procedures and preoperative diagnosis
consider anesthetic implications
Essential Components of the Anesthesia Interview
BMI (height and weight) Allergies NPO instructions Medications Previous Anesthetic/Complications Family History of Malignant Hyperthermia Possibility of Pregnancy Systems Review Baseline Level of Cognition Airway Assessment
BMI Calculation
BMI (kg/m2)= weight (lbs)/height (inch)2] x703
Overweight BMI
> 25kg/m2
Obese BMI
> 30kg/m2
5 A’s
Allergies Ate Anesthesia History Airway Alert/Awake
Allergies
Exaggerated immune response or hypersensitivity
allergen and type of reaction
differentiate between side effects
Throat or tongue swelling, difficulty breathing= anaphylaxis
What caused the allergy? What was the reaction? What made it better? Where you hospitalized?
Ask about Allergies to:
drugs dyes contrast latex foods tape
Anesthetic Surgical Histories
Previous anesthetic/surgeries
types of surgery
type of anesthesia
date
complications
PONV
MH
difficult intuabation/ recall
prolonged wake up, unplanned post op intubation
Anesthetic implications from previous surgeries and complications
Past difficult intubations
receive letter from anesthesia following surgery
“difficult to place a breathing tube?
prolonged sore throat after surgery (>2 days post op)
significant weight gain since the previous surgery
Patient has fibroids?
Want to know where, bleeding and amount of blood loss?? N/V Adhesions have BP ready
ASU
ambulatory surgical unit
SDA
same day admission
History of Malignant Hyperthermia
Family History of MH? inherited myopathy (autosomal dominant) triggered by volatile anesthetics and depolarizing muscle relaxants leading to hypermetabolic state avoid triggers= TIVA patient or family member MH outcome (did the family member survive) genetic testing comleted?
Records
obtain pertinent records
-records associated with any previous anesthetic or surgical complications (recall, difficult intubation, or MH)
Other records of interest?
PACU, anesthesia, consultation, special testing (such as cardiac clearance, EKG PFTs and any other records that provide insight into patient status or previous complications
NPO
Nil per os
except medications and minimal water to swallow them, patients should refrain from eating or drinking according to current guidelines
Purpose of NPO guidelines
reduce risk of aspiration (high incidence of morbidity and mortality
aspiration= accidental inhalation of gastric contents into the lung-> chemical burn of the tracheobronchial tree and pulmonary parenchyma-> intense parenchymal inflammatory reation
Education importance of NPO instruction
Carbohydrate Drink
gatorade
Patients with longer gastric empyting
diabetes, recent injuries, obesity, abdominal complaints, gastroesophageal reflux disease, pregnant or recently delivered
Primary purpose of NPO
decrease aspiration risk
All emergency cases are considered
full stomach
Clear Liquid (water, black coffee, pulp free juice, carbonated beverages)
2 hour fast
Breast Milk
4 hour fast
Formula or cows milk, tea and coffee with milk, full liquids, light meal (low or nonfat) gum sweets (hard candy)
6 hour fast
Full meal, fried fatty foods
8 hours fast
Patient will full stomach
administer prokinetic, NG/OG to suction, blockers (pepsid), neutralize stomach acid
possible delay surgery
Selleck’s Manuever
attempts to protect against aspiration
straight down force on the cricoid cartiledge (BURP manuever)
compresses the esophageal lumen between the cricoid cartiledge and cervical spine
How much force for cricoid pressure?
30-40newtons, 3-4kg, 6.6-8.8lbs
Cricoid Pressure
decrease aspiration risk, not a guarantee
What do you want the gastric contents to be greater then
2.5
Burp Manuever
the displacement of the thyroid cartilage dorsally so as to abut the larynx against the bodies of the cervical vertebrae, 2 cm cephalad until mild resistance is met, and 0.5-2.0 cm laterally to the right
What is the difference between cricoid pressure and BURP?
The maneuver was termed BURP as an acronym for “backward-upward-rightward pressure” of the larynx. This procedure displaces the thyroid cartilage dorsally in such a way
that the larynx is pressed against cervical vertebrae’s body,
two centimeters in cephalic direction, until resistance appears. Subsequently, it should be displaced 0.5 cm -2.0 cm to the right
Physical Examination
heart/lung sounds breathing pattern bruising/scarring periperal pulses peripheral edema VS Mental status note sensory/motor deficits
Goal of Anesthesia
return patient to baseline status
Mallampati Class
Subjective assessment
ask the patient to look at you with chin elevated, mouth open wide and tongue sticking out
Have pain on both sides?
Which worse?
Mallampati Class 1
faucial pillars, hard plate, soft plate, and uvula
Mallampati Class 2
faucial pillars, soft palate, partial uvula
Mallampati Class 3
soft palate and base of uvula
Mallampati Class 4
hard palate only
Mouth Opening
Temporomanidibular joint
maxilla and mandible meet, ball and socket joint, used to chew talk yawn composed of muscles tendons and bones
TMJ disorders
teeth grinders, gum or fingernail chewers, malocclussion, stress- clench teeth, jaw trauma
TMJ
unable to displace tongue and not able to optimize laryngoscope or open mouth in general
Thyromental Distance
short implies visualization (intubation) may be difficult
anterior larynx, more acute angle, less space for tongue to be, compressed into by laryngoscope blade
Patil’s test
mandibular space, head fully extended from the mentum to the thyroid notch (upper edge of cartilage to chin)
Normal Thyromental Distance
3 fingerbreadths
Prayer Sign
subtle or overt joint contractures
decreased joint and cartiledge mobility
inability to place palms flat together suggests difficult intubation
cervical spine involvement results in limited atlanto-occipital joint motion= possible difficult intubation
Cervical Mobility
decrease cervical mobility prevents proper positioning for intubation (prevents optimal view of glottic opening)
ask the patient to move head side to side up and down
Neck Circumference
BMI >40kg/m2+ large neck (>45cm) = difficult intubation
Why bmi + enlarged neck?
upward pressure on neck tissue concentrated at neck
tissue mass + body mass @ concentration = difficult airway
Facial Hair
Difficult mask deal
disguise potential airway problems
Retrognathia
short thyromental distance
Female Patient
LMP
pregnancy
sexually active
Medications
Current medications
OTC, prescriptions, vitamins, minerals herbal supplements home remedies
which medicines hold/take DOS
Patient reliability to report medications
medications with potential for greater impact on anesthesic then others
How long?how often? dose?
Be Alert medications
anticoagulants anti-dysrhythmics antihypertensives beta blockers bronchodilators diuretics opioids vasodilators
TAKE medications prior to surgery
beta blockers GERD meds Ca+ channel blockers bronchodilators antiarrhythmics steroids diuretics antipsychotics thyroid medications
HOLD prior to surgery
oral hypoglycemics ACE inhibitors A2RBs (angiotension 2 blockers) diuretics herbal supplements
Per Surgeon’s order
anticoagulants
Procedures with blood loss
CBC
Age 50-60
EKG
Age >60
CBC and EKG
Cards disease
EKG Basic Chemistry
Pulmonary Disease
EKG
Cancer/Radiation Therapy
CBC EKG
Hepatic Disease/ Hepatitis
Pt/ptt, liver panel, ekg
Renal Disease
Pt/PTT basic chemistry profile, EKG
Bleeding Disorder
CBC, Pt/ptt, platelet function assay,
Diabetes
Basic chemistry, glucose DOS, EKG
Diuretic
BCP
Digoxin
BCP, EKG, Dig level
Steroid Use
BCP, glucose DOS
CNS disease
CBC, basic chem, glucose DOS, EKG
Cardiovascular Disease
HTN, angina, MI, CAD, valvular disease, syncope, CHF, edema/ dyspnea of cardiac origin, cardiac arrythmia
SOB
Hypertension
duration of disease excerise tolerance recent EKG medication regiemen- time on antihypertensives, patient compliance, well controlled on current therapy, provide instructions to take or hold meds on DOS document current medications
Cardiac Clearance w/ recent MI (within last 6 months)
6 months
Cardiac Clearance w. newly diagnosed CHF or CHF and exacerbations requiring hospitalization within the last 6 months
6 months
Cardiac Clearance with Aortic stenosis
12 months more recent if change in symptoms since last cardiology visit
