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*Health Assessment > History & Physical > Flashcards

History & Physical Flashcards

1
Q

What are the 10 components of a preop anesthesia eval?

A
  1. pt history (chart review/history taking from pt/family)
  2. PE
  3. Labs (review and order PRN)
  4. medical consult
  5. ASA Physical Status Class
  6. NPO status
  7. Formulation Plan (anesthesia plan)
  8. Discussion of Plan (educate pt to dec anxiety)
  9. Informed consent
  10. documentation
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2
Q

When does a preop H&P need to be completed before surgery?

A

-H&P within 30 days of surgery

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3
Q

Why do we do a preop assessment/eval?

A
  • optimize care
  • minimize morbidity/mortality
  • minimize surgical delays/cancellations (identify issues prior to surgery)
  • determine post-op disposition (ICU/PACU)
  • eval health and further consult/testing PRN
  • develop most appropriate anesthetic plan
  • communication b/n surgery and anesthesia
  • should be efficient and cost-effective
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4
Q

What are the 3 main questions answered by preop assmt?

A
  1. is pt in optimal health?
  2. can health problems or meds affect periop events?
  3. can/should pts physica/mental health be improved before surgery?`
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5
Q

Where do we obtain pts data for preop eval?

A
  • medical history (medical record/pt interview)
  • PE
  • tests/labs
  • special consultation/reports
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6
Q

When is the optimal time to have preop clinic visit? Why?

A
  • 1 week preop
  • allows time for further consults or testing; patient education/plan and dec anxiety; obtain consent
  • preop clinics are effecienct, standardized but not always available
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7
Q

Who requires early pre-op assmt?

A

-multiple co-morbidities: angina, CHF, MI, CAD, COPD, IDDM, Thyroid dz, liver dz, renal dz, spinal cord injury,e tc

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8
Q

What info does the OR schedule provide? (5)

A
  • pt name, age, sex
  • procedure/diagnosis
  • length/position
  • surgeon
  • anesthesia type
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9
Q

What info can be obtained from chart review (outpatient/inpatient) ?

A
  • demographics
  • procedure/diagnosis
  • surgery consent (identifies side/procedure)
  • previous h&p
  • RN notes
  • labs/tests
  • questionnaires
  • VS
  • medications
  • allergies
  • progress notes
  • old anesthetic records - h/o complications? i.e. MH, n/v, a/w difficulties
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10
Q

What are the 6 purposes for preop interview?

A
  1. pt medical history
  2. form anesthesia care plan
  3. informed consent
  4. patient education
  5. improve efficiency, reduce cost
  6. use operative experience to motivate pt to more optimal health status
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11
Q

What do you do during a preop interview (3)?

A
  1. introduce anesthesia provider
  2. confirm pt ID, Dx, procedure
    * *use open-ended questions, general to specific, organized and systematic, layperson terms, individualized, control environment (family, lighting, interpreter, etc)
  3. look for co-existing dz (review of systems: head to toe)
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12
Q

What do you assess w/ preop interview?

A
  1. medications (allergies, reactions), current Rx (taken or held?), OTC (ASA, NSAIDs), herbals
  2. previous anesthesia/surgery (complciations, fam hx, OB deliveries?)
  3. exercise tolerance (detects how well pt will tolerate anesthetic)
  4. h/o sleep apnea
  5. h/o ETOH abuse
  6. drug abuse
  7. tobacco use
  8. females: LPM (pregnancy risk?)
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13
Q

What do you assess first with a physical exam?

A

-general impression: ht/wt, physical features, mental status, VS, examine surgical site PRN

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14
Q

How do you assess airway during a PE?

A
  • mallampatic classification
  • thyromental distance
  • head/neck movement
  • neck circumference
  • interincisor distance
  • dentition
  • relevant craniofacial deformities
  • look for predictors of difficult a/w mgmt
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15
Q

How do you assess heart/CV during a PE?

A
  • heart: auscultate HR, rhythm, murmurs, bruits (carotids), extremity pulses
  • CV: bruits, extremity pulses/edmea
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16
Q

How do you assess lungs during a PE?

A
  • inspect
  • auscultate
  • percussion (rare)
  • palpation
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17
Q

How do you assess neuro during a PE?

A
  • depends on baseline defecits/dz or surgical procedure
  • motor: gait, strength, grip, hold arms forward, etc
  • sensory: vibration, pain, touch along dermatomes
  • muscle reflexes: deep, superficial, pathologic
  • cranial nerve abnormalities
  • mental status
  • speech
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18
Q

How do you assess musculoskeletal during a PE?

A
  • gait, ROM, deficits
  • obesity
  • VS
19
Q

What is categorized as obesity?

How do you determine ideal body weight (IBW)?

A
  • obesity = 20% over IBW w/ BMI of 30-39.9 kg/m2
  • IBW (male) = 105 lb + 6 lb per inch > 5 ft
  • IBW (female) = 100 lb + 5 lb per inch > 5 ft
20
Q

What other external things do you assess during a PE?

A
  • surgical site (confirm!)
  • IV
  • pt position
  • monitoring
21
Q

Why is pre-op lab testing needed?

A
  • reduce anesthetic morbidity
  • inc quality of periop care
  • dec cost of periop care
  • return pt to desirable functioning
22
Q

Is it productive to add more lab tests? Why/why not?

A
  • no, lab tests not good dz screening tool
  • f.u abnormal result is costly
  • nonindicated tests inc risk for pts
  • excessive tests = dec efficiency and reduces resources
23
Q

How do you decide if additional lab tests are needed?

A
  • will result of this test change management of anesthetic?

- will results of test improve pts outcome?

24
Q

What is 1. sensitivity and 2. specificity?

A
    • result in patient WITH dz

2. - result in patient withOUT dz

25
Q

Describe minimally invasive surgery.

A

-little tissue trauma, minimal blood loss

26
Q

Describe moderately invasive surgery.

A

-modest disruption of normal physiology, anticipate some blood loss

27
Q

Describe highly invasive surgery.

A
  • significant disruption of normal physio, often require transfusion and ICU care
  • may require preop HCT, etc; more likely to require more preop labs
28
Q

What are some common preop lab tests?

A
  • H&H
  • chem
  • coags
  • LFTs
  • RFT
  • UA
  • Pregnancy test
  • EKG
  • CXR
  • PFT
29
Q

What role do consults play w/ preop evals?

A
  • controversial

- if consult needed purpose is NOT to clear for surgery but to ADVISE for health mgmt during surgery

30
Q

What is the purpose of ASA status?

What does it do?

A
  • to classify the physical condition of pt requiring anesthesia and surgery
  • reflects PREOP status
  • is independent of operative procedure and does not identify risk
  • communication tool b/n anesthesia providers
31
Q

Describe the ASA Physical status classification.

A

I - normal, healthy, no systemic dz
II - mild to mod systemic dz, well controlled, no functional limits
III - severe systemic dz, functional limits
IV - severe systemic dz that constantly threatens life
V - moribund patient, not expected to survive w/ or w/o surgery
VI - declared brain dead w/ organs being harvested for donation
E - emergency operation required; identified after status # (i.e. I.E, II.E)

32
Q

Describe NPO status ASA guidelines.

A
  • 2 hrs for clear liquids
  • 4 hrs for breast milk
  • 6 hrs for formula or solids; light meal
  • 8 hrs for heavy meal, fried/fatty food, gum/candy
  • follow institution guidelines
  • some MDs prefer to use NPO 6-8 hrs
33
Q

What criteria makes a pt an aspiration risk despite their NPO status?

A
  1. age extremes 70 y/o
  2. ascites (ESLD)
  3. collagen vascular disease, metabolic d/o (DM, obesity, ESRD, hypothyroid)
  4. hiatal ehrnia/GERD/esophageal surgery
  5. mech obstruction (pyloric stenosis)
    - prematurity
    - PREGANCY
    - neuro dz
34
Q

What is included to formulate an anesthetic plan?

A
  • anesthesia type
  • drugs
  • monitors
  • a/w
  • positioning
  • intraop monitoring
  • postop care
35
Q

Who do you discuss the anesthetic plan with?

A
  • supervising staff
  • patient
  • surgeon
  • OR team
36
Q

What info does the patient need to know from anesthesia?

A
  • choices of anesthetic technique
  • IV placement
  • LA, meds, fluids to be used
  • a/w mgmt
  • monitors - placement/purpose
  • postop recovery
  • pain mgmt plan
  • transport process to OR
  • postop care - PACU, pain relief, a/w
  • possible outcomes: sore throat, blood transfusion, facial swelling, nasal packing, etc
37
Q

What does informed consent consist of? How do minors give consent?

A
  • explanation of planned anesthetic
  • explanation of options
  • risk vs benefits
  • pt understanding & cooperation
  • anesthesia provider, pt and witness signature
  • minors - parent/guardian consent
38
Q

What if there is not signed informed consent?

A

-considered assault/battery

39
Q

What do you confirm w/ OR team?

A
  • time/length of procedure
  • anatomical location
  • position
  • xray?
  • additional meds?
  • procedures
  • OR table position
40
Q

Describe the final preop check list.

A
  • IV/fluid status
  • premeds
  • anesthetic plan
  • labs?
  • EKG, CXR?
  • blood products? availability and need
  • inhaler needed? steroids? Abx? aspiration prophylaxis?
41
Q

What needs to be documented for preop eval?

A
  • H&P
  • informed consent
  • NPO status
  • meds
  • allergies
  • ASA physical status class
  • preop VS
  • lab, tests, consults
42
Q

SEE “TIME” SLIDE

A

SEE “TIME” SLIDE

43
Q

SEE “CURRENT TREND” SLIDE

A

SEE “CURRENT TREND” SLIDE

*Health Assessment (3 decks)

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