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health assessment > spring 2014 > Flashcards

spring 2014 Flashcards

0
Q

what is answered by the pre-op assessment

A
  • is the pt in optimal health
  • can, or should, the pts physical or mental condition be improved before surgery
  • risk assessment: does pt have any health problems or use any meds that could unexpectedly influence peri-operative events?
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1
Q

Goal for Preop assessment

A
  • Optimize care, satisfaction, and comfort
  • minimize morbidity and mortality
  • minimize surgical delays or cancellations
  • determine appropriate post-op disposition
  • evaluate health status and determine if any further consultative, diagnostic investigations are needed
  • formulate most appropriate anesthetic plan
  • Optimize communication among members of the surgical and anesthetic teams
    evaluation should be efficient and cost-effective
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2
Q

how do anesthesia providers get the most useful data

A

pt medical history- includes medical record and pt interview

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3
Q

what are we looking for with pre-op assessment

A
  • previous surgical history and family anesthetic history
  • medication history
  • difficult airway
  • disease state of pt (severity, impact on activities, current and recent exacerbations, stability, treatments and interventions)
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4
Q

preop eval includes

A
  • pt history
  • physical exam
  • labs
  • medical consults
  • ASA class
  • formulate plan
  • discuss plan
  • informed consent
  • documentation
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5
Q

pt history: sources

A
  • pt/parent/family
  • or schedule
  • pt chart
  • surgeon/specialist consutants/physicians
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6
Q

confirm schedule with or team and assertain

A
  • time;length of procedure
  • anatomical location
  • position
  • xray needed?
  • procedure (s)
  • Or table position
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7
Q

the OR schedule will tell you

A

Demographics- name , age, sex

  • procedure
  • surgeon (s)
  • type of anesthesia
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8
Q

chart review

A
  • demographics
  • diagnosis/procedure
  • consent
  • prior h&P
  • labs
  • EKG, PFTs, xray
  • vital signs
  • medication allergies
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9
Q

Inpts specifically check ? in chart

A
  • progress notes
  • medication sheets
  • nursing notes
  • old anesthetic records
  • complications?
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10
Q

preop interview- 6 purposes

A
  • obtain pertinent medical history
  • formulate anesthetic plan
  • obtain informed consent
  • pt edu
  • improve efficiency, reduce cost of periop care
  • utilize operative experience to motivate pt to more optimal health status
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11
Q

take a good history

A
  • confirm findings from chart review
  • open-ended questions
  • general to specific
  • organized and systematic
  • layperson terminology
  • individulized
  • control environment
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12
Q

NPO

A

2 hrs for clear liquids for all pts
4hr breast milk
6 hr formula or solids; light meal
8 hrs heavy meal- fried/fatty- GUM/CANDY

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13
Q

history (steps on how to take and what to include)

A
  • introduce self
  • confirmation of pt
  • co-existing diseases
  • meds- allergies
  • previous anesthetic (surgeries
  • exercise tolerance
  • sleep apenal hx
  • etoh abuse?
  • drug abuse/ tobacco use?
  • lmp?
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14
Q

who is an aspiration risk?

A
  • Age extremes 70
  • Ascities
  • collagen vascular disease, metabolic dx (DM/obese/ESRD/hypoth
  • Hiatal hernia/GERD/ Esophageal surgery
  • mechanical obstruction (pyloric stenosis)
  • prematurity
  • preggers
  • neurologic dx
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15
Q

the physical

A 
general impression
airway
heart 
lungs
cns/pns
surgical site
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16
Q

what you need to get from the surgeon

A
  • procedure
  • position
  • special considerations
  • confirm abnormal findings
  • labs
  • blood ordered
  • abx?
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17
Q

general impression

A

height/weight-
physical features
neuro status
vs

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18
Q

neuro specific

A
  • ** depends on baseline***
  • motor- gait, grip strength, ability to hold arms forward ect
  • sensory
  • muscle reflexes
  • CN abnormalities
  • mental status
  • speech
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19
Q

obesity def and formula

A

30% over ideal body weight

m- IBW= 105+6lb for each inch over 5 feet
w- IBW= 100+5lb for each inch over 5 feet

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20
Q

airway exam

A
  • mallampati class
  • thyromental distance
  • head and neck movement
  • neck circumference
  • interincisor distance
  • dentation
  • relevant craniofacial deformities
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22
Q

heart/cv

A

auscultate- RRMBE(extremity pulses)- rate rhyth,murmur, bruit and ext

bruits, extremity pulses and edema

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23
Q

lungs

A

inspection
auscultation
percussion
palpation

cyanosis, clubbing, accessory muscles- work of breathing

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24
Q

other parts of the physical exam

A

surgical site

  • iv
  • position
  • monitoring
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25
Q

sensitivity r/t labs

A

be positive in the patient with a disease

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25
Q

types of surgery

A

minimal
moderately invasive
highly invasive

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26
Q

specificity r/t labs

A

to be negative in the pat without disease

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27
Q

asa status

A

to classify the physical condition of the pt requiring anesthesia and surgery

  • independent of the procedure and surgical risk
  • subjective communication tool
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28
Q

ASA1

A

normal healthy pt; no systemic disease

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29
Q

ASA 2

A

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

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30
Q

ASA3

A

sever systemic disease, functional limitation

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31
Q

ASA4

A

severe systemic disease that is a constant threat to life

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32
Q

ASA 5

A

moribund pt, not expected to survive with or without the surgical procedure

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33
Q

ASA6

A

pt declared brain dead whose organs are being harvested for donation

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34
Q

E

A

emergency operation required

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35
Q

Parts to Formulate Anesthetic plan

A 
type of anesthesia
drugs
monitors
airway
positioning
intraop monitoring
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36
Q

pt prep/edu

A
  • discuss choices of anesthetic technique(consent)
  • explain iv
  • descrive use of local anesthetics, meds. fluids
  • discuss airway management
  • explain monitors
  • process to the or
  • pacu care
  • possible outcomes- sore throat ect
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37
Q

what to document

A 
H&P
INformed consent
NPO status
Allergies
ASA
Pre-op VS
- Labs/tests/ consults
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38
Q

why do we do an airway eval for every pt

A
  • to PREDICT ease or difficulty of airway management
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39
Q

what do we take into consideration for preop airway

A
  • type of surgery
  • type of anesthetic
  • safety factors (positioning)
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40
Q

review airway structures

A

nose— fx, septal deviation, bleeding bc very vascular, sinuses* caution
pharynx—- teeth, tounge, hard, soft palate- shape of these,
larynx-
trachea- deviated? visualize it?

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41
Q

why intubate

A
  • airway protection (aspiration, secretions (blood, saliva, foreign objects= laryngospasm, edema
  • maintain patent airway
  • provide positive pressure ventilation
  • maintain adequate oxygenation
  • deliver predicable FiO2
  • Provided positive end-expiratory pressure
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42
Q

indications for a mask case

A
  • no instrumentation of the airway required
  • difficult airway not present
  • surgeon does not need access to the head/neck
  • no airway bleeding/secretions
  • short duration
  • no table position changes
  • have to be able to get a good seal and be able to overcome obstruction with airway/chin lift
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43
Q

airway assesment history

A
  • had general anesthetic before? y/n difficult?
  • were you awake for an intubation
  • severe sore throat/dental injury?
  • co-existing diseases?
  • surgical history that could effect airway?
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44
Q

co-morbidities

A
  • lesions of larynex
  • thyroid disease
  • cancer
  • cerd
  • diabetes
  • sleep apnea- obesity
  • genetic disorders
  • RA
  • musculoskeletal
  • scleroderma
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46
Q

sugeries that will effect airway

A
  • tracheostomy/scar
  • nex dissection
  • UVPP (uvulo palytopharengeal plasty )
  • Cervical neck instrumentation
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47
Q

physical exam (2 part)

A
  • general appearance (head, neck- size circum and length, presence of heavy facial hair)
    Mouth (lips, gums, tissues)
  • Teeth (length of incisors, condition of teeth (missing protrusion, overbite), relationship of upper incisors to lower incisors, dentures/bridges out)
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47
Q

normal mouth opening

A

4cm or > 2 FB

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48
Q

what’s the neck size cut off for too large?

A

16in or 40 cm– women
17in man
>60cm

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49
Q

physcial exam

A

look at the size and mobility of tongue

  • size and shape of mandible ‘ maxilary overgrowth
  • assess for TMJ
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50
Q

Thyromental distance definition

A

distance from mandible to prominence of thyroid cartilage (tyro-mental)

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51
Q

thyromental distance #

A

6.5cm (50mm) or 3 FB

53
Q

Normal Hyoidmental distance #

A

2 FB

54
Q

assess preop

A

cervical ROM

55
Q

what joint is key for head movement

A

atlanto-occipital joint

56
Q

must also include in an good airway assessment

A

breath sounds

57
Q

Mandibular protrusion test graded by

A 
CLASS A:
class b and c
58
Q

Class A for mandibular protrusion Test (MPT)

A

lower incisiors can be protruded anterior to the upper incisiors

59
Q

CLASS B (MPT)

A

the lower incisors can be brought edge to edge with upper incisors

60
Q

CLASS C (MPT)

A

lower incisors cannot be brought edge to edge with upper incisors

61
Q

dental assessment

A
  • poor dentition
  • loose teeth
  • chipped teeth
  • capped
  • removable brideges
  • dentures
62
Q

Top right back tooth is #

A

1

63
Q

Top right front tooth is #

A

8

64
Q

Top left tooth is #

A

9

65
Q

back left tooth is #

A

16

66
Q

bottom left tooth is #

A

17

67
Q

bottom right tooth is #

A

32

68
Q

mallampati definition

A

is a prediction of what you will see at the cord level based on the size of the tongue

69
Q

how do a mallampati exam

A
  • pt sitting head neutral

- open mouth as wide as possible and stick out tongue

70
Q

class one see

A

entire uvula, pillars, fauces, soft and hard palate

71
Q

class 2

A

see tongue is covering the tip of the uvula

72
Q

class 3

A

see the hard and soft palate

73
Q

class 4

A

hard palate only

74
Q

strong predictor of difficult airway

A
  • obesity
  • decreased head and neck movement
  • decreased jaw movement
  • receding mandible
  • “buck teeth”
  • mallimpati
  • short neck
75
Q

when do most difficult airway issues happen

A

66% induction

1-7% of people will be difficult intuabtions- in general!

76
Q

if you can bag your pt what pathway are you in

A

nonemergent pathway

77
Q

can you use a fiberoptic after a couple of attempts

A

no you’ll have blood or secretions in the airway and wont beable to see

78
Q

awake intubation end pts

A

succeed, fail (cancel case, consider other option, surgical airway)

79
Q

what do you need for an airway set up

A
  • laryngoscope
  • blades 2 types
  • oral/nasal airways several sizes
  • tongue depressor
  • ET tube 2 sizes
  • Stylet
  • Syringe
  • Suction
  • ambu-bag
  • Lma
80
Q

difficult airway cart

A
  • et tubes
  • et guides
  • laryngoscop blades
  • supraglottic airway – combitube
  • retrograde intubation eq
  • fiveroptic intubation equip
  • surgical airway stuff
  • exhaled co2 detector
81
Q

what do you document?

A

preop– dental, c-ROM, Mallampati class, TM distance, mouth opening

  • Post intubation—– visualization, trauma, equipment used, hemodynamic or respiratory changes
  • post-extubation— loose teeth intact, airway patency, adjuncts airway maneuvers used
82
Q

why do we care about positioning

A
  • pt safety
  • comfort
  • surgical exposure and/or surgical access
  • *can cause undesirable physiological changes and injuries
83
Q

describe the OR table

A

Length 80.7 in
wt limit 136kg (270lb)
newer wt lim 270kg (600lbs)

84
Q

where is the center of gravity for the OR table

A

over the post

85
Q

how do you transfer a pt to the OR table

A
  • stretcher along side OR table ___ LOCK BOTH
  • OR table has a draw sheet
  • staff members on stretcher side and bed side
  • pt trsfers self or moved by staff (watch extrem and h/neck aligned with spine
  • then apply safety strap
86
Q

most common operative positions

A
  • supine/dorsal decubitus position (trendelenburg/rT)#1
  • Lithotomy
  • prone or ventral decubitus position
  • lateral decubitus
  • sitting
87
Q

Supine

A

access to airway and arms (iv/monitors)

less physiologic changes

88
Q

supine pillow placement under head y?

A
  • proper sniffing position
  • avoids dorsal extension and lateral flection of neck (brachial plex inj)
  • doughnut - avoids alopecia
  • no eye pressure
89
Q

what do we do with the draw sheet under the pt?

A

tuck it under the pt - not the mattress

90
Q

Supine arm conciderations

A
    • properly secured to or table with sheet/arm board
  • abd <90 degrees, avoids stretch brachial plexus
  • padded
  • safety straps
  • hands supinated!!!!! or palms to the side of the leg
91
Q

Supine lower ext consideration

A

heels not hanging over bed and PADDED

  • *pillow under knees/slight flextion of hips and knees
  • no crossed feet/legs
  • devices on to increase venous return and decrease risk DVT
  • safety strap
92
Q

how do nerves get injured

A
  • stretching
  • compression
  • kinking
  • ischemia
  • transection
93
Q

risk factors for nerve injury

A
  • position
  • prolonged surgery
  • technique (GA)
  • Preexisting diseases (obese, Diabeties)
94
Q

Stretching is the most common cause of _________ injury and give examples

A

Brachieal plex

  • arm +- board falls off table,
  • neck extention/ turned to side
  • arm board extended/abd greater 90
  • cardiac retractors
95
Q

how does the pt feel with a brachial plex inj

A
  • electric shocks/burn
  • numb or weak arm
  • no or weak motor control of shoulder/elbow
  • pain
96
Q

how to inj the radial nerve

A

compression lateral aspect of the humerus against- surgical retractors, ether screen, mismatched arm board, repeat bp inflation

====WRIST DROP, weakness in ABD of thumb and numbness 1,2, and ring fingers

97
Q

ulnar nerve damage

A

THE MOST COMMON POST OP PN INJ (more common in men and very muscular ppl)

  • compression of nerve in cubital tunnel— btw olecranon and medial epicondyle of humerus
  • stretch inj too.
98
Q

ulnar nerve inj looks like

A

CLAW HAND

  • cant ABD or oppose 5th finger
  • weak grip ulnar side of fist
  • loss sensation PALMAR 4/5 fingers
  • atrophy of intrinsic muscle of hand
99
Q

how to decrease ulnar nerve injury

A
  • pad arm boards
  • avoid downward compression by strap
  • assure surgical personnel do not compress pts arm
  • place bp cuff proximally so that it does not impose on ulnar groove or cubital tunnel
  • avoid prolonged FLEXION of elbow
100
Q

Supine CV changes

A

minimal

initally- increased venous return to heart (increase preload, SV, CO)
which activates baroreceptors which decrease sympathetic outflow and increase parasympathetic impulses= COMPENSATORY DECREASES IN HR AND PVR

reduced venous drainage from lower extremities

101
Q

what is a possible complication of supine position and obese folks, preggers, ascites

A

ivc compression syndrome

so do left lateral position if better tolerated

102
Q

Vent changes supine

A

FRC decreases +/- 800ml (r/t cephalad displacement of the diaphram and compression of lung bases)

muscle relaxants further reduce lung volumes
- loss of chest wall muscle tone—- reduce oppos

103
Q

Hyoidmental distance definition

A

Distance from hyoid to mandible

104
Q

normal hyoidmental distance

A

2 FB

105
Q

what joint should be concerned about with head ROM

A

atlanto-oxcipital joint

106
Q

last part of airway assessment

A

LISTEN TO B. BREATH SOUNDS

107
Q

mandibular protrusion test ranked how

A

class A/B/c

108
Q

Class A is—

A

normal- the person’s lower incisors can protrude anterior to upper incisors

109
Q

Class B-

A

lower incisors meet the upper incisors

110
Q

class c-

A

the lower incisors cannot be brought to the edge of the upper incisors

111
Q

dental assessment includes

A 
dentition
lose teeth
chipped teeth
caps
removable bridges
dentures
112
Q

mallimpati

A

prediction of what will see at the cords related to the size of the tongue
do not as ah
head in neutral position

113
Q

what axis line up in sniffing position

A

the oral, pharyngeal and laryngeal

114
Q

what are some strong predictors of diff airway

A 
obesity
decreased head and neck move
decreased jaw mvt
receding mandible
"buck teeth"
115
Q

what is the % difficult intubation

A

1-7%

116
Q

when do most of the diff intubations occur

A

induction

117
Q

when is it not an option to use a fiberoptic scope

A

after a couple of attempts because there is going to be blood and secretions now in the airway

118
Q

when do you move to the emergency pathway

A

when you can’t bag the pt

119
Q

first thing u do when you realize that you are in the emergency pathway

A

call for help

120
Q

nonemergency pathway def

A

mask ventilation is adequate

121
Q

initial intubation fails- what are the options

A

awake patient, call for help, or return to spontaneous ventilation

122
Q

for a difficult airway 2 options to proceed

A

awake or reg intubation

123
Q

with success confirm ett placement

A
  • etco2
  • b chest rise
  • breath sounds
  • color change
124
Q

airway set up

A
  • laryngealscope
  • 2 blades
  • 2 ett sizes (with stylets and syringes)
  • lma
  • tongue depressor
  • suction
  • ambu bag
  • ## oral/nasal airways
125
Q

don’t for get about diff airway cart

A

fiberoptic stuff, jet vent, retrograde equip, co2 detector, surgical airway

126
Q

document preintubation

A

dental exam, cROM, mallimpati class, Tm distance, mouth opening

127
Q

document post intubation

A

vizulaized, trauma, equipment used, hemodynamic or resp changes

128
Q

doc post extubation

A

loose teeth intact, airway patency, adjunct airways used

129
Q

final pre op checklist for patient prep

A 
iv/fluids
premeditated
anesthetic plan
lab/ekg
blood products?
need for inhaler/steroid/abx?

health assessment (4 decks)

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