Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Health Assessment > Flashcards for Midterm Exam > Flashcards

Flashcards for Midterm Exam

1
Q

Labs and Diagnostic Testing: CBC, H&H

A

Consider:

  • Proposed surgery
  • Potential blood loss
  • Clinical indications: hematologic dx, chronic kidney/liver dz, anticoagulants, etc.
  • NICE guidelines: ASA-PS 3 or 4 intermediate procedures, all pts having major procedures
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Lab and Diagnostic Testing: Electrolytes

A

Clinical indications for electrolytes:

  1. chronic kidney dx
  2. cirrhosis
  3. certain meds
  4. DM
  5. dialysis
  6. type of surgery
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Lab and Diagnostic Testing: Glucose

A
  • Clinical indications for glucose: DM, steroid use, cirrhosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Lab and Diagnostic Testing: Renal Function

A
  • Assess tubular function & GFR
  • Clinical indications: HTN, DM, dehydration, renal dx, h/o transplant, etc.
  • NICE guidelines:
    • Routine: ASA 3 or 4 having intermediate procedure & ASA 2, 3, or 4 having major procedure
    • Risk for AKI: ASA 3 or 4 having minor procedure, ASA 2 for intermediate
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Lab and Diagnostic Testing: Liver Function

A
  • History of liver injury & exam findings
  • Clinical indications: hepatitis, jaundice, cirrhosis, portal HTN, bleeding disorders, etc.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Lab and Diagnostic Testing: Coagulation Profile

A
  • Routine testing not indicated unless known or suspected coagulopathy
  • Clinical indications: bleeding disorder, anticoag meds, liver dx
  • NICE guidelines: ASA 3 or 4; intermediate, major, complex procedures; anticoag meds or chronic liver dz
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Lab and Diagnostic Testing: Urinalysis

A
  • No indication for routine use
  • Clinical indications: suspected UTI, unexplained fever or chills
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Lab and Diagnostic Testing: T&S, T&C

A
  • Decision usually guided by institution policy (surgical blood order schedule)- reduce unnecessary blood order$
  • Clinical indications: suspect blood transfusion
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Lab and Diagnostic Testing: ECG

A
  • No indication for routine use
  • Clinical indications: h/o IHD, HTN, DM, HF, CP, syncope, DOE, etc.
  • 2014 ESC/ ESA guidelines: risk factors for IHD, CVD, sig. arrhythmia, or symptomatic; intermediate/ high risk surgery
  • NICE guidelines: ASA 3 or 4 intermediate procedure; ASA 2, 3, or 4 major procedures
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Lab and Diagnostic Testing: Chest X-ray

A
  • No indication for routine use
  • Clinical indications: advanced COPD; bullous lung disease; suspected: pulmonary edema, pneumonia, mediastinal mass; suspicious findings on exam
  • Patients undergoing thoracic, upper abdominal, AAA surgery
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Lab and Diagnostic Testing: ECHO

A
  • No indication for routine use
  • Clinical indications: heart murmur and symptomatic, S&S of HF, unexplained dyspnea
  • Clinically stable, ventricular dysfunction not tested in previous year
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Lab and Diagnostic Testing: PFT’s

A
  • Considered for type and invasiveness of surgery (CABG, lung resection)
  • Clinical indications:
    1. severe asthma
    2. symptomatic COPD
    3. scoliosis
    4. restrictive lung dx
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Patients considered “Aspiration Risk”

A
  1. Age extremes <1 or >70
  2. Prematurity
  3. Pregnancy
  4. Ascites (ESLD)
  5. Neurologic dz
  6. Collagen vascular dz, metabolic disorders (DM, obesity, ESRD, hypothyroid)
  7. Hiatal Hernia/GERD/Esophageal surgery
  8. Mechanical obstruction (pyloric stenosis)
  9. Having eaten food or non-clear drinks
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Continue meds day of surgery except…

A
  • ACEIs and ARBs
  • ASA: stop 3 days prior unless PCI, high-grade IHD, sig. CVD
  • P2Y12 inhibitors: stop 5-10 days prior unless drug-eluting stent (6-month dual antiplatelet therapy) & bare metal stents (1-month dual antiplatelet therapy) *** Discuss risk w/ surgeon/ cardiologist
  • Warfarin: stop 5 days prior
  • NSAIDS: 48 hrs prior
  • Short-acting insulin; none or ½ dose of long-acting insulin day of *** insulin pump- basal rate only
  • Non-insulin antidiabetic meds (metformin →lactic acidosis)
  • Topical
  • Diuretics
  • Sildenafil or similar
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Cardiovascular Assessment
Renal Failure

A
  1. ↑CO – compensation for ↓ O2 carrying capacity
  2. HTN – Na+ retention, RAAS activation
  3. LVH common
  4. CHF w/ pulmonary edema after limits of compensation reached
  5. Deposition of Ca++ - in conduction system & on heart valves
  6. Arrhythmias – electrolyte imbalances
  7. Uremic pericarditis – can be asymptomatic, chest pain, tamponade, usually 2◦ to inadequate dialysis
  8. Accelerated CAD, PVD
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Fluid Balance Assessment
Renal Failure

A

•Fluid overload VS intravascular depletion s/p dialysis/ aggressive diuretic therapy

  1. Body weight
  2. VS (orthostatic hypotension & tachycardia)
  3. Atrial filling pressures
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Pulmonary Assessment
Renal Failure

A
  • ↑ MV to compensate for metabolic acidosis
  • ↑ pulmonary extravascular water = interstitial edema = widened alveolar/arterial O2 gradient
  • “Butterfly wings” on CXR 2⚬ to ↑ permeability of alveolar capillary membrane (edema even with normal PCWP)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Endocrine Assessment

Renal Failure

A
  • Peripheral resistance to insulin = poor glucose tolerance
  • Hyperparathyroidism = prone to fractures
  • Abnormal lipid metabolism = accelerated atherosclerosis
  • Kidneys do not degrade hormones and proteins normally = increased circulating PTH, insulin, glucagon, GH, LH, PL
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Normal Na+

A

135-145 meq/L

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Normal K+

A

3.5-5 meq/L

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Normal Cl-

A

95-105 meq/L

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Normal HCO3-

A

Venous: 19-25 meq/L

Arterial: 22-26 meq/L

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Normal Ca++

A

4.5-5.5 meq/L

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Normal Phosphate

A

2.4-4.7 mg/dL

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Normal Mg+

A

1.5-2.5 meq/L

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Normal Serum Osmolality

A

280-300 mOsm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Labs/Test Abnormalities common w/ renal failure

A
  1. Assess adequacy of dialysis
  2. Metabolic acidosis with high AG
  3. Hyperkalemia (hypok w/ dialysis)
  4. Hyperglycemia (if insulin resistant)
  5. Hypermagnesemia
  6. Hyponatremia (hyper is rare)
  7. Hypocalcemia (unclear etiology)
  8. Hypoalbuminemia (esp. w/ dialysis)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Hyperkalemia EKG findings

A

Tall T waves

ST depression

Wide QRS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Hypokalemia ECG findings

A

Peaked or flattened T waves

Prolonged PR & QT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Hypocalcemia ECG findings

A

Prolonged QT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Assessment of Muscle Strength: elbow flexion & extension

A

elbow flexion = C5, C6

elbow extension = C6, C7, C8

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Assessment of Muscle Strength: Grip

A

C7, C8, T1

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Assessment of Muscle Strength: Finger ABduction

A

C8, T1, ulnar nerve

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Assessment of Muscle Strength: Opposition of thumb

A

C8, T1, median nerve

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Assessment of Muscle Strength: hip flexion & adduction

A

L2-L4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Assessment of Muscle Strength: Hip ABduction

A

L4, L5, S1

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Assessment of Muscle Strength: Hip extension

A

S1

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Assessment of Muscle Strength: Knee extension

A

L2-L4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Assessment of Muscle Strength: Knee flexion

A

L4, L5, S1, S2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Assessment of Muscle Strength: Dorsiflexion

A

L4, L5

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Assessment of Muscle Strength: Plantar flexion

A

S1

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

List of MAOI’s

A
  • Phenelzine
  • Isocarboxazid
  • Selegiline
  • Brofaromine
  • Befloxatone
  • Iproniazid
  • Moclobemide
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Interferon B

A

Disease modifying therapy/ immunomodulator for MS

Side Effects: flu-like symptoms, hepatotoxicity, myelosuppression, depression

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Dimethyl Fumarate

A

Disease modifying therapy/ immunomodulator for MS

Side Effects: GI discomfort, infections

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Glatiramer Acetate

A

Disease modifying therapy/ immunomodulator for MS

Side Effects: well tolerated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

Natalizumab

A

Disease modifying therapy/ immunomodulator for MS

Side Effects: Leukoencephalopathy, hepatotoxicity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Fingolomid

A

Disease modifying therapy/ immunomodulator for MS

Side Effects: bradycardia, hepatoxicity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Teriflumonide

A

Disease modifying therapy/ immunomodulator for MS

Side Effects: neutropenia, hepatotoxicity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Mitoxantrone

A

Immunosuppresant drug for MS

Side Effects: severe myelosuppression and cardiac toxicity– reduced EF–heart failure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Drugs that affect coagulation status (SLE)

A
  1. Ibuprofen
  2. Indomethacin
  3. ASA
  4. Cox-2 Inhibitors
  5. DVT preventative therapy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Leads that correspond to inferior wall (RCA)

A

II, III, avF

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Leads that correspond to lateral wall (circumflex branch of LCA)

A

I, avL, V5-V6

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

Leads that correspond to anterior wall (LCA)

A

V3-V4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Leads that correspond to septal wall (left descending coronary artery)

A

V1-V2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

V1 placement

A

+ electrode placed directly over R atrium; corresponds to septal wall (LAD)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

V2 placement

A

+ electrode placed just anterior to the AV node; corresponds to septal wall (LAD)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

V3 & V4 placement

A

+ electrode placed over ventricular septum; corresponds to anterior wall (LAD)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

V5 & V6 placement

A

+ electrodes placed over lateral surface of L ventricle; corresponds to lateral wall of heart (circumflex)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

Causes of left axis deviation

A
  • LBBB
  • Chronic HTN
  • Aortic stenosis
  • Aortic insufficiency
  • Mitral regurgitation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

Causes of right axis deviation

A
  1. PE
  2. Pulm HTN
  3. COPD
  4. Cor pulmonale
  5. Acute bronchospasm
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

Right ventricular hypertrophy

A

Large R wave in V1 and gets progressively smaller in V2, V3, V4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

Left ventricular hypertrophy

A

Large S wave in V1 and larger R wave in V5

  • Depth (in mm) of S in V1, plus height of R in V5 if >35 mm = LVH
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

Ischemia

A

T wave inversion or ST segment depression

64
Q

T wave inversion or ST segment depression

A

Ischemia

65
Q

Injury

A

ST segment elevation (>1 mm)

66
Q

ST segment elevation (>1 mm)

A

Injury

67
Q

Infarction (old MI)

A

Q waves which are >1 small box or 1/3 size of QRS

68
Q

Q waves which are >1 small box or 1/3 size of QRS

A

Infarction (old MI)

69
Q

ASA I

A

Normal, healthy pt; no systemic dz

70
Q

ASA II

A

Mild to moderate systemic dz, well-controlled, no functional limitations

71
Q

ASA III

A

Severe systemic dz, functional limitation

72
Q

ASA IV

A

Severe systemic dz that is a constant threat to life

73
Q

ASA V

A

Moribund pt, not expected to survive (+/- surgery)

74
Q

ASA VI

A

Pt declared brain dead; harvesting organs for donation

75
Q

GI/Liver Assessment

Renal Failure

A
  • 10-30% pts develop GI hemorrhage
  • High incidence of Hep B&C (multiple transfusions)
  • Anorexia, N/V
  • Ascites w/ dialysis
  • Hypersecretion of gastric acid + delayed emptying (autonomic neuropathy)
76
Q

Renal Failure: Impact on Drugs

A

Effects altered due to:

  • Anemia
  • Decreased serum protein
  • Fluid retention = change Vd for MR’s
  • Electrolyte abnormalities = pts more prone to dig toxicity
  • Abnormal cell membrane activity

Drugs eliminated by the kidneys unchanged are CONTRAINDICATED

  • Gallamine, phenobarbital, LMWH

***LMWH is cleared by the kidneys and NOT removed during dialysis = prolonged duration and r/f bleeding!

77
Q

Renal Function Tests for GFR

A
  1. Blood Urea Nitrogen (10-20 mg/dL)
  2. Plasma creatinine (0.7-1.5 mg/dL)
    • GFR can decreased 50% without rise in plasma creatinine. Not accurate indicator, especially in elderly
  3. Creatinine clearance** (110-150 mL/min)
78
Q
  • Chronic Kidney Disease (CKD) =
  • Chronic Renal Failure (CRF) =
  • ESRD =
  • Acute Kidney Injury (AKI) =
A

Chronic Kidney Disease (CKD) = GFR < 60 mL/min/1.73m2 for 3 months

Chronic Renal Failure (CRF) = GFR 15 mL/min/1.73m2

ESRD = Loss of renal function for 3 months or more (Diabetes accounts for ½ of cases & HTN for ¼. Polycystic 10%-genetic autosomal dominant)

Acute Kidney Injury (AKI) = Sudden decreased function/UOP

79
Q

What situations requires dialysis?

A
  1. Oliguria
  2. Fluid overload
  3. Hyperkalemia
  4. Severe acidosis
  5. Metabolic encephalopathy
  6. Pericarditis
  7. Coagulopathy
  8. Refractory GI symptoms
  9. Drug toxicity
80
Q

What is hemodialysis

A
  • Diffusion of solutes between blood and dialysis solution remove metabolic wastes and restore buffers to the blood
  • Need vascular access
    • AV fistula = cephalic vein anastomosed to radial artery
    • Jugular or femoral vein for emergency access
81
Q

Dialysis and meds

A
  • General rule: scheduled doses of drugs are administered after dialysis
  • Low-molecular weight, water-soluble, non-protein bound drugs are readily cleared by dialysis
82
Q

Neuro Assessment: Renal Failure

Neuro Assessment s/p Dialysis

A
  • Uremic Encephalopathy
    • Asterixis
    • Myoclonus
    • Lethargy
    • Confusion
    • Seizures
    • Coma
  • Autonomic Neuropathy
  • Peripheral Neuropathy

S/P Dialysis

  • Disequilibrium syndrome (dialysis related) transient CNS disturbance after rapid ↓ in ECF osmolality compared w/ ICF osmolality
  • Dementia
83
Q

Hematological Assessment: Renal Failure

A
  1. Anemia typical Hgb = 6-8 g/dL
    • ↓ erythropoietin and RBC production and ↓ cell life span
    • GI blood loss, hemodilution, bone marrow suppression
    • Excess PTH replaces bone marrow w/ fibrous tissue
    • Most pts tolerate anemia well (exception CAD)
      • ↑ 2,3- DPG (diphosphoglycerate) + metabolic acidosis = favors Right shift
  2. Impaired platelets (qualitative) = prolonged bleeding time
    1. ↓ plt factor III activity
    2. ↓ adhesiveness & aggregation
  3. Impaired WBC function = infections
  4. Release of defective von Willebrand factor**
  5. Dialysis = Residual anticoagulation vs promotion of hypercoagulable state
  6. Hypocomplementemia w/ dialysis
84
Q

Renal Function Tests to assess Renal Tubular Function

A

Renal Tubular Function = reflects concentrating ability of kidney vs nephron function (GFR)

  • Urine Specific Gravity (1.003-1.030)
  • Urine Osmolarity (38-140 mOsm/L)
85
Q

Labs and Tests: Blood Urea Nitrogen

A
  • Normal BUN = 10-20 mg/dL
  • Varies inversely w/GFR & directly w/protein catabolism
    • > 50 mg/dL is indicative of ↓GFR (in pts w/ nml diets)
  • The most common cause of ↑BUN is CHF 2◦ to reabsorption of BUN (RAAS is on high)
  • BUN is not a sensitive index bc urea clearance also depends on urea production
  • BUN can be abnormal despite a normal GFR due to:
    • High protein diet
    • GI bleed
    • Febrile illness
86
Q

Labs and Tests: Plasma Creatinine (Cr)

A
  • Plasma Cr is a specific indicator of GFR (plasma Cr is freely filtered but not reabsorbed)
  • 8-17 hr lag time after change in GFR before ↑ Cr levels are seen
  • Suggestive [but not indicative] of Acute Renal Failure
  • Usually 50% ↑ in plasma Cr reflects a corresponding ↓ in GFR
  • Skeletal muscle = source of Cr (more muscle mass = higher baseline Cr)
  • Elderly pt: Cr levels stay normal/constant d/t:
    • ↓ muscle mass and GFR
    • If CR ↑ in elderly, may be indicative of renal failure
87
Q

Labs and Tests: Creatinine Clearance

A

Creatinine Clearance approximates GFR

24 hr collection most accurate although 2 hr tests also helpful

100-120 mL/min = Normal

60-100 mL/min = ↓ Renal Reserve

40-60 mL/min = Mild Renal Impairment

25-40 mL/min = Moderate Insufficiency

< 25 mL/min = Renal Failure

< 10 mL/min = ESRD

88
Q

Hyperkalemia treatment if symptomatic or > 6/5 meq/L

A
89
Q

Normal RBC

A

male: 4.6-6.2 million/mm3
female: 4.2-5.4 million/mm3

90
Q

Normal Hgb

A

Male = 13.5-18 g/dL

Female = 12-16 g/dL

91
Q

Normal Hct

A

male = 40-54%

female = 38-47%

92
Q

Normal WBC

A

5,000-10,000/mm3

93
Q

Normal bleeding time

A

3-10 min

94
Q

Normal platelet count

A

150,000-400,000 cell/mm3

95
Q

Prothrombin time (PT)

A

10-12 sec

96
Q

Internationalized Normalized Ration (INR)

A

0.8-1.2

97
Q

Normal plasma thromboplastin time (PTT)

A

25-35 sec

98
Q

Normal activated clotting time

A

90-120 sec

99
Q

Normal thrombin time

A

9-11 sec

100
Q

Normal fibrinogen

A

160-350 mg/dL

101
Q

Coagulation Abnormalities in Renal Failure Pt

A
  • If regional anesthesia is planned need coag panel!!!!
  • ↑ bleeding despite normal PT, PTT
  • Bleeding Time best screening test
  • Important cause of coagulation issues- release of defective von Willebrand factor
    • Rx:
      • Desmopressin (0.3-0.4 mg/kg over 30 min)
      • Cryoprecipitate 10 units IV over 30 min
  • Blood warmer set up and ready to go
102
Q

Cardiac Labs and Tests in Renal Failure Pt

A

EKG

  • Hyper or hypokalemia
    • HyperK (Concern above 5.0) → Tall T waves, ST depression, wide QRS
    • HypoK → peaked or flattened T waves, prolonged PR & QT
  • Hypocalcemia → Prolonged QT
  • Ischemia
  • Conduction blocks
  • LVH

Echocardiography

  • Hypertrophy
  • Ventricular EF
  • Wall motion abnormalities
  • Pericardial fluid
103
Q

Pulmonary Labs and Tests in Renal Failure Pt

A
  • CXR (look for butterfly wings, enlarged heart)
    1. Fluid status
    2. Determine presence of HTN related CV disease
    3. Pericardial effusion
    4. Uremic pneumonitis
  • ABG – hypoxia and acid/base status especially if dyspnea noted on exam
104
Q

Musculoskeletal Assessment:
The Temporomandibular Joint

A
  • Place tips of index finger just in front of the tragus of ear - ask patient to open mouth.
  • Fingertips should drop into joint spaces as mouth opens.
  • Check for smooth range of motion, swelling/tenderness.
  • Snapping & clicking normal
  • Ask pt to open & close mouth, protrude & retract (jutting the jaw forward), & perform side to side motion.
105
Q

Musculoskeletal Assessment: Cervical Spine

A
  • Flexion = Touch chin to chest
  • Extension= Look up at ceiling
  • Rotation= Turn head to each side looking directly over shoulder
  • Lateral Bending = Tilt head touching ear to shoulder

*Might have to do awake fiberoptic intubation if they can’t tolerate.

106
Q

Musculoskeletal Assessment: Shoulder Girdle

A

(adduction, abduction, flexion, extension, internal & external rotation)

  1. Abduct the arms to shoulder level.
  2. Raise arms vertical position above head palms facing each other.
  3. Place both hands behind the neck with elbows out to the side.
  4. Place both hands behind the small of the back.
107
Q

Musculoskeletal Assessment: The Shoulder

A
  • Thoracic Outlet Syndrome- compression of brachial plexus and subclavian vessels near the 1st rib
  • Be certain pt can work or sleep w/ arms elevated over head before putting arms beside head (prone positioning)
108
Q

Musculoskeletal Assessment: The Elbow

A

Ask pt. to bend and straighten elbow (flexion and extension)

With arms at sides and elbows flexed instruct pt. to turn palms up (supination) and palms down (pronation)

109
Q

Musculoskeletal Assessment: The Hip

A
  • Concentrate on ROM that can impact positioning
  • Flexion – supine pt. bends each knee to chest/abdomen
  • Abduction – supine pt. stabilize anterior superior iliac spine and abduct the extended leg until the iliac spine moves = limit!

*Perform this test if placing in lithotomy position or if pt at r/f hip issues (OA, etc.)

110
Q

Nervous System Assessment

A
  • Mental status (awake, alert, oriented X3)
  • Speech (clear speech, slurred)
  • Cranial nerves (don’t do on every pt)
  • Gait (Parkinson’s gait)
  • Motor function (note where we are starting from and document so we can note any changes or exacerbations post-op)
  • Sensory function
111
Q

Nervous System Assessment: Cranial Nerve 1

A

1 = Olfactory (smell)

112
Q

Nervous System Assessment: Cranial Nerve 2

A

2 = Optic (sight – confrontation test; pupillary rxn to light)

113
Q

Nervous System Assessment: Cranial Nerve 3

A

3 = Oculomotor (pupillary rxn to light; extraocular movements)

114
Q

Nervous System Assessment: Cranial Nerves 4 and 6

A

4 = Trochlear (extraocular movements)

6 = Abducens (extraocular movements)

115
Q

Nervous System Assessment: Cranial Nerve 5

A

5 – Trigeminal

Ask pt to clench their teeth as you palpate temporal and masseter muscles

Check sensation in areas circled

Corneal reflex (cotton ball)

116
Q

Nervous System Assessment: Cranial Nerve 7

A

7 – Facial

Ask pt to:

  • Raise both eyebrows
  • Close eyes tightly so you can’t open them
  • Frown, Smile
  • Show teeth
  • Puff out both cheeks
117
Q

Nervous System Assessment: Cranial Nerve 11

A

11 – Spinal Accessory

  • Ask pt. to turn head to each side against your hand
  • Ask pt to shrug both shoulders upward against your hand – trapezii strength
118
Q

Nervous System Assessment: Cranial Nerve 8, 9, 10, 12

A

8 – Acoustic (hearing)

9 – Glossopharyngeal and 10 – Vagus (voice hoarseness?, gag reflex, AHH- palate should rise symmetrically)

12 – Hypoglossal (tongue movement, ask them to move tongue side to side)

119
Q

Assessment of Muscle Strength Grading Scale

A
  • Test flexion and extension and compare symmetry
  • Grade on 0-5 scale
  1. No muscular contraction detected
  2. Barely detectable
  3. Active movement with gravity eliminated
  4. Active movement against gravity
  5. Active movement against gravity with some resistance
  6. Active movement against gravity with full resistance
120
Q

Head Injury: Assessment

A
  • Glasgow Coma Scale – defines neurologic function impairment
    • Eyes open - Never(1)- Spontaneous (4)
    • Best Verbal Response None (1) – Oriented (5)
    • Best Motor Response None (1) - Obeys commands (6)
  • Mortality closely related to initial score
  • Scores 8 or less considered severe (coma)- will require intubation and controlled ventilation for ICP & airway control
121
Q

Steroids

A
  • Suppression or dz of pituitary-adrenal axis will prevent pt from responding to stress of surgery appropriately
  • Any pt who has received corticosteroid therapy (suppression of pituitary-adrenal axis) for at least 1 month in the past 6-12 months needs supplementation periop
  • 2 possible regimens
    • 100 mg Hydrocortisone pre-op, intra-op and post-op
    • 25 mg Hydrocortisone pre-op + 100mg IV gtt over 12-24 hrs
122
Q

Methotrexate

A
  • Immunosuppressant used in MS, Ankylosing Spondylitis (AS) and RA
  • Immuno-suppression, anemia, thrombocytopenia, pulmonary, renal, hepatic toxicity
  • CBC
  • Chemistry Panel
  • Consider PFTs and LFTs if history warrants
123
Q

Multiple Sclerosis

A
  • These pts are generally on immunosuppressive meds
    • Any recent history of illness or infection?
      • Take extra care with infection prevention
  • Which meds are they taking and how often?
  • Steroids in the past year????
    • Be ready to give stress dose
  • Remission vs exacerbation intervals
    • If in middle of exacerbation, perhaps delay elective surgery
  • Severity and nature of symptoms
    • Respiratory status
    • Previous triggers​

DOCUMENT PRE-EXISTING DEFICITS

  • Paralysis (assess for motor strength)
  • Sensory disturbances (assess along dermatomes)
  • Autonomic disturbances (resting HR, orthostatic hypotension)
  • Visual impairment (cranial nerve check)
  • Seizures (meds)
  • Emotional Disturbances

Counsel pt regarding increased r/f relapse w/ surgery

124
Q

Guillain Barre

A
  • Document time course of dz
    • Precipitating factors
    • Onset of symptoms
    • Dz Progression (worsening, stable, improving)
  • Document severity and current state of symptoms
    • Facial paralysis – bulbar involvement (what other concerns might you have here????) protecting airway
    • Difficulty swallowing – pharyngeal muscle weakness
    • Impaired ventilation – current ventilatory support required (vent settings)
    • Decreased deep tendon reflexes– lower motor nerves
    • Extremity paresthesias
    • Pain – headache, backache, muscle tenderness + note meds helpful for pain control
  • ANS DYSFUNCTION!!!!!!
    • Review ICU flow sheets for VS trends
    • Vasoactive medication history for HTN and hypotension (ex. vasopressors, B-Blockers)
    • ECG, any recent arrhythmias?
    • Inquire w/nurse/patient regarding tolerance of position changes
125
Q

Parkinson’s Disease

A
  • Age of diagnosis, recent exacerbations and hospitalizations
  • Current and past symptoms (ex. oculogyric crisis (eyes stuck in one position), when? How long did it last? What helped?)
  • ANS symptoms (orthostatic BPs)
  • History of Pergolide therapy? CV function—cv testing might be needed
  • Temp regulation issues?
  • Pulmonary status optimized? (CXR, maybe won’t tolerate exercise bc of motor disability—hard to use as gauge for cv and pulm function, so may need pft if concerned)
    • Dysphagia and/or dyspnea
    • Pulmonary infection
  • Continue current med regimen and note side effects
    • Levodopa -what happens if the patient misses a dose?
    • Anticholinergics and MAO’s?
  • Note the natural ROM for positioning
  • Deactivate deep brain stimulators before electrocautery
126
Q

Intervertebral Disc Herniation/
Lower Back Pain

A
  • Natural ROM for positioning and laryngoscopy
  • Baseline motor strength & sensation in applicable areas
  • Medication regimen (ex. pt on high dose opioids), what drugs improve pain, what has been ineffective?
  • Consider potential for operative blood loss
    • CBC
    • Type and Cross
127
Q

Ankylosing Spondylitis

A
  • Evaluate for co-existing vasculitis, aortitis, aortic insufficiency, pulm fibrosis
  • Evaluate for severity of kyphosis (difficult airway)
  • SpO2, ECG, ECHO, CXR, PFTs
  • CBC, BUN/Creatinine
  • D/c NSAIDs at least 2 day pre-op
  • May have positioning challenges (Eval normal ROM)
  • ROM joints (esp. sacroiliac)
  • Pain mgt. hx.
  • ECG (cardiac conduction)
  • PFT (fibrosis)
  • Meds (NSAIDS, methotrexate, etc.)
128
Q

Spinal Cord Injury

A
  • Determine level of lesion
  • Acute or Chronic?
  • Acute
    1. Fluid and Blood Status
    2. CBC, Type and Cross, Chem 7
    3. ECG/ Chest X-ray
    4. Vasopressor requirement?
    5. Ventilatory support (current vent settings)?
    6. Associated injuries?
  • Chronic
    1. History of autonomic dysreflexia? What initiated it?
    2. Old OR/ICU records helpful – response to vasopressors, tracheal suctioning
    3. Ventilatory reserve – level of lesion
    4. Assessment of skin integrity
    5. Positioning – note normal ROM
129
Q

Cerebrovascular Disease Guidelines

A
  • History of recent TIA or CVA ↑ r/f peri-operative stroke
  • Optimal time for subsequent elective surgery after stroke is controversial
  • Ensure optimization has occurred
    • Emboli – PFO (patent foramen ovale) corrected?
    • A-fib 1-3 months anticoagulation therapy
    • Carotid bruit noted on exam?
      • Ask pt about TIA symptoms (be aggressive w/ questioning!)
      • Consider carotid doppler ultrasound study - refer vascular surgeon
130
Q

CVA, Head Injury, Intracranial Tumor

A
  • Mechanism of injury or illness
  • Location, size, and time course of lesion
  • CT/MRI report (secondary edema, hydrocephalus?)
  • Level of consciousness (LOC)
  • ICP status (current symptoms of headache, N/V, bradycardia, HTN, etc.)
  • Evaluate CV status
  • Consider cranial nerve assessment
  • Consider muscle strength and sensation assessment
  • Review current meds and treatments
    • Endocrine status (pituitary tumors)
    • Fluid status
    • CBC
    • T&C
    • Electrolyte panel
    • ECG
    • +/- Echo
  • Review current ventilatory status (vent settings and ABG results; CXR)?
  • Note baseline VS and set BP parameters
  • Continue current meds
    • Steroids or anticonvulsants, for example
131
Q

Seizure Disorder

A
  • Type of seizure activity; typical length, frequency, severity, & recovery period
  • Hx of status epilepticus (how long did it last, how was it treated, were treatments effective)
  • Precipitating/causative factors (ETOH withdrawal, brain tumor)
  • Pharmacologic Therapy
    • Testing directed based on meds - CBC, plt, electrolyte panel common
    • Routine levels of anticonvulsants unnecessary in pts w/ good seizure control
    • Cancel elective surgery until seizure disorder optimized by neurologist
132
Q

Systemic Lupus Erythematosus:
Physical Exam/Labs/Tests

A
  • Note natural ROM (arthritis)
  • Note neuromuscular strength, cranial and peripheral neuropathies
  • Note mentation (CNS involvement)
  • Fluid and electrolyte status – Chemistry Panel
  • Hematologic – CBC, PT/PTT and INR
  • Skin – note existing rashes (not to be confused with allergic reactions peri-op)
  • Distal extremities- Raynaud’s common - pulse ox readings difficult
  • Renal Function – glomerulonephritis, proteinuria, albumin level, chemistry panel
  • CV status – Echo, CV consult, pericarditis? Conduction abnormalities?, CHF, valvular dysfunction?
  • Pulm status – PFT’s (restrictive pattern)
  • GI – prone to N/V?
133
Q

SLE: Meds

A
  • Note dose amount, frequency, timing of last dose, side effects, etc.
  • Drugs that affect coagulation status
    • Ibuprofen
    • Indomethacin
    • ASA
    • Cox-2 Inhibitors
    • DVT preventative therapy
  • Immunosuppressive therapy
  • Steroids
  • Optimized by PCP or rheumatologist?
134
Q

Rheumatoid Arthritis

A
  • Focus areas: airway, neuro, pulm, CV
  • Note Natural ROM
    • TMJ – limited mouth opening (awake fiberoptic intubation)
    • Atlanto-axial joint – lateral neck radiograph or MRI
    • Cricoarytenoid arthritis – hoarseness, pain on swallowing, dyspnea, stridor, laryngeal tenderness
    • Individualized airway plan based on findings
  • Dyspnea is often a sign of cardiac ischemia in this population
    • PFTS and ABG if suspect lung involvement (restrictive pattern)
    • ECHO, ECG (cardiac conduction) especially if cardiac involvement suspected
  • Consider effect of meds: ASA, NSAIDS, methotrexate, immunosuppressive drugs and steroids
    • Balance preference to continue meds with anti-coagulation and immunosuppressive characteristics
135
Q

Osteoarthritis

A
  • Note Natural ROM– focus on key problem areas
    • If you note hip involvement and you’re doing lithotomy position, might do hip assessment from earlier
  • Meds for pain relief, what works/doesn’t work, last dose, etc.
136
Q

Myasthenia Gravis: History Taking

A
  • Note degree of skeletal muscle weakness, progression of dz
    • Note med history
    • Cholinesterase inhibitors
    • Steroids
    • Immunosuppressive therapy
137
Q

Muscular Dystrophy

A
  • Note progression of dz, natural ROM, muscle strength
  • Delayed gastric motility
  • Ventilatory status (PFT, cough strength)
  • Cardiac – ECG, perhaps ECHO
138
Q

Marfan Syndrome

A
  • Cardiopulmonary assessment – ECHO (valve assessment)
  • TMJ at risk
  • High PTX risk (avoid nitrous)
139
Q

Cancer Patient: Airway Assessment

A
  • Tracheal deviation or compression
  • Difficulty breathing (sign of airway obstruction)
  • Dysphagia
  • SOB
    • Preop airway assessment, cervical ROM, cervical X-ray, ENT consult
  • Radiation to head and neck→ permanent tissue fibrosis
    • Carotid artery dissection
    • Hypothyroidism
    • Difficult ventilation/intubation

May not be recognized on physical exam

140
Q

Cancer Pt: Mediastinal Masses

A
  • Anterior mediastinal masses can obstruct the great vessels (aorta, PA, PV, SVC), heart, trachea, and bronchi.
  • C/o dysphagia, dyspnea, wheezing, coughing (especially when recumbent)→SVC compression/syndrome, which leads to…
    • JVD
    • Facial, neck, chest edema, ↑ ICP, airway compromise
    • Fiberoptic intubation
141
Q

Head and Neck Cancers: Preop Considerations

A

Special anesthetic considerations:

  • Review imaging to determine if alternate airway management plan should be used
    • Plan for difficult a/w
  • Question pt regarding dysphagia & difficulty breathing (signs of airway obstruction) swallowing, voice changes
  • Surgical blood loss can be significant: T&C, CBC
  • Lack of access to airway during case: special equipment (securing ETT)
  • Hypercalcemia related to METS: check calcium level
  • Alcohol-induced liver dz: check LFTs
  • Chronic smoking hx: PFTs, pulm toilet, inhalers
  • May need nutritional therapy preop
  • May need invasive monitoring- esp A-line
142
Q

Oncologic Emergencies

A
  1. Spinal cord compression—
    • urinary/bowel incontinence
    • peripheral neuropathies
    • gait disturbances
  2. Cardiac tamponade—
    • muffled heart tones
    • elevated JVD, distended neck veins
    • progressive dyspnea
  3. Neutropenia sepsis—may present with low-grade fever or none, cough, arthralgia
  4. CNS metastasis—headaches, visual disturbances, balance/gait disturbances, confusion, n/v
  5. Tumor lysis syndrome—
    • ↑ uric acid, K+, & phos levels
    • Most often seen 12-72 hrs post chemo tx for hematologic malignancy
  6. SVC syndrome—obstruction of SVC
    • Swelling of hands, neck face, dyspnea, cough
143
Q

Breast Cancer surgery preop considerations

A
  • Poor IV access
  • At risk for lymphedema- avoid IVs and BP cuff on surgical arm
  • Check type of chemotherapy for complications
144
Q

Colon/GI CA surgery preop considerations

A
  • May be aspiration risk- give preop aspiration risk prophylaxis (no Reglan)
  • May be dehydrated from colon prep and/or obstruction- preop IV fluid
  • May need T&S or T&C
145
Q

Prostate CA surgery considerations

A
  • Robotic surgeries
    • Special positioning (steep Trendelenburg)
146
Q

Lung CA surgery preop considerations

A
  • Associated CAD
  • Pulmonary insufficiency after lung tissue resection
  • Potential for massive blood loss during surgical resection
  • Special equipment needed
  • Preoperative PFTs, DLCO, VO2 max, CXR, ABGs, O2sat
  • ? Cardiac stress testing
  • HCT/Hbg, T&C
147
Q

RBBB

A
  • Broad QRS: >120 ms
  • RSR’ pattern in V1-V3
    • Rabbit ears for RBBB
  • Wide, slurred S wave in lateral leads (I, aVL, V5-V6)
148
Q

If QRS is longer in duration, consider…

A

WPW, LVH, BBB

149
Q

Normal QRS complex

A

< 0.12 sec with progressive increased amplitude in V1-V6

150
Q

LBBB

A
  • ST segments and T waves
    • Directed opposite to the main vector of the QRS complex
    • ST elevation and upright T waves with negative QRS complex
    • ST depression and inverted T wave with positive QRS complex
151
Q

Determine Axis (EKG)

A
  • Normal vector of depolarization is from base to apex and endocardium to epicardium.
  • When this vector is not directed in this usual direction it is referred to as axis deviation.
  • To evaluate for axis deviation, examine the direction of the R wave deflection in lead I & aVF.
  • Axis deviation can occur w/ ventricular hypertrophy, conduction block, or physical change in position of heart.
  • Vectors tend to point towards areas of hypertrophy and away from areas of injury (MI)
152
Q

Normal axis deviation

A

•Normal axis has + R wave deflections in both lead I & aVF

153
Q

What does L axis deviation look like

A
  • Left axis deviation has a + R wave deflection in lead I but – R wave deflection in aVF
  • Leaving each other = Left axis deviation
154
Q

What does R axis deviation look like?

A
  • Right axis deviation has a – R wave deflection in lead I but + R wave deflection in aVF
  • Reaching each other = Right axis deviation
155
Q
A

Health Assessment (1 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions