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
