Intro to History, pre-op assesment, lab, and chart review Flashcards Preview

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Flashcards in Intro to History, pre-op assesment, lab, and chart review Deck (30)
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1

What are the components of a preoperative evaluation?

(11)

  1. Patient medical history (chart review and history)
  2. physical exam
  3. medications/allergies
  4. laboratory testing/diagnostic testing
  5. medical consultation (if indicated)
  6. assigning ASA physical status class
  7. NPO status (fasting status and risk of aspiration)
  8. formulation of plan (meds, equipment, position)
  9. discussion of plan (educate and decrease anxiety)
  10. informed consent
  11. documentation

2

what are the 6 purposes of preoperative evaluation?

  1. obtain pertinent medical history
  2. formulate plan of anesthetic care
  3. obtain informed consent
  4. patient education
  5. improve efficiency, reduce cost of perioperative care
  6. utilize operative experience to motivate patient to more optimal health status

3

What are the 3 main questions answered by the preoperative assessment?

  • Is the patient in optimal health?
  • Could health problems or medications unexpectedly influence perioperative events?
  • Can, or should, the patients physical or mental condition be improved before surgery?

4

What is the optimal situation regarding a preoperative assessment?

  • a pre-op clinic visit about 1 week before surgery
  • patient interview and examination
  • promotes patient teaching and anxiety reduction
  • allows time to schedule appointments with medical consultants and complete required pre-op diagnostic testing
  • obtain informed consent prior to operative day

5

Who requires early pre-op assessment?

  • Angina, CHF, MI, CAD, poorly controlled HTN
  • COPD/severe asthma, airway abnormalities, home O2 or ventilation
  • IDDM, adrenal disease, active thyroid disease
  • liver disease, ESRD
  • massive obesity, symptomatic GERD
  • severe kyphosis, spinal cord injury

6

What kind of information can you get off the OR schedule?

  • Demographics- name, age, gender
  • procedure and diagnosis
  • length of procedure and position
  • surgeon (s)
  • type of anesthesia 

7

What should you look at when doing chart review?

  • Demographics- name, age, sex
  • diagnosis/procedure
  • surgical consent
  • prior H&P (from surgeon or internist)
  • nursing notes
  • patient questionnaire
  • lab results
  • EKG, PFTS, X-ray, etc
  • vital signs
  • medication list
  • allergies

8

What are the 4 parts of the pre-op interview?

  1. Introduce yourself
  2. Confirm patient ID, diagnosis and procedure
  3. Past medical history
  4. Past surgical history

9

How do you calculate BMI?

what is the scale of BMI?

Weight (kg) / height2 (m2)

< 25 = Normal

25-30 = overweight

30-35 = obese

35-40 = morbidly obese

10

How do you calculate ideal body weight?

male = 105 lb + 6 lb for every inch > 5ft

female = 105 lb + 5 lb for every inch > 5 ft

11

What is included in the physical exam? 

(general systems)

  • General impression
  • airway
  • heart lungs
  • CNS/PNS
  • vital signs 
  • surgical site

12

Physical Exam:

What do you assess while getting a general impression?

  • height
  • weight
  • physical features
  • mental status
  • vital signs

13

Physical Exam:

How do you assess the airway?

  • Mallampati classification
  • thyromental distance
  • head and neck movement
  • neck circumference
  • interincisor distance
  • dentition
  • relevant craniofacial deformities
  • **looking for predictors of difficult airway management

14

Physical Exam:

How do you assess the heart?

  • Auscultation
    • rate
    • rhythm
    • murmors
    • bruits
    • extremity pulses

15

How do you assess the different valves?

  • Aortic valve: 2nd-3rd Right sided interspace
  • Pulmonic valve: 2nd-3rd Left sided interspace
  • tricuspid valve: left sternal border
  • mitral valve: apex

16

Physical Exam:

How do you assess the lungs?

  • Inspection
  • auscultation
  • percussion

17

Physical exam:

How do you assess the neurologic/ musculoskeletal system?

  • Extent of the neuro exam really depends on baseline deficits, disease or surgical procedure
    • motor: gait, grip strength, ROM, ability to hold arms forward, etc
    • Sensory: distinction of vibration, pain, light touch along dermatomes
    • muscle reflexes
    • cranial nerve abnormalities
    • mental status
    • speech

18

Physical Exam:

What are some other considerations?

  • Surgical location
  • IV access
  • positioning
  • monitoring needed

19

Why should you not go too crazy ordering labs?

  • Lab tests are NOT great disease screening tools
  • follow up of abnormal results is constly
  • non-indicated tests increase risks for patients
  • batteries of tests present medico-legal risk to providers
  • excessive testing decreases facility efficiency and reduces resources available to care for others

20

How should you decide what lab tests to order?

  • Is the test needed to confirm a suspicion?
  • is the suspected abnormality linked to morbidity?
  • Is there a higher than average likelihood of an abnormality?
  • Will a positive or negative result affect the case management in any way?

21

Sensitivity vs specificity

  • sensitivity- true positive; you have the disease and the test is positive
  • specifity- true negative; you don't have the disease and the test is negative

22

What is the difference between:

minimally invasive

moderately invasive

highly invasive

  • minimally invasive: little tissue trauma, minimal blood loss
  • moderately invasive: modest disruption of normal physiology; anticipate some blood loss
    • may need invasive monitors and/or ICU
  • highly invasive- significant disruption of normal physiology
    • commonly require transfusion and ICU care

23

What are the current ASA NPO status guidelines?

  • 2 hrs for clear liquids all patients
  • 4 hrs breast milk
  • 6 hours formula or solids; light meal
  • 8 hours heavy meal fried or fatty food, gum and candy
  • **follow policy of the institution

24

What patients are considered an aspiration risk?

  • extreme ages (<1 yr or >70 yr)
  • ascites (ESLD)
  • Collagen vascular disease, metabolic disorders (DM, obesity, ESRD, hypothyroid)
  • Hiatal hernia/GERD/Esophageal surgery
  • mechanical obstruction (pyloric stenosis)
  • prematurity
  • pregnancy
  • neurologic diseases
  • having eaten food or non-clear liquids

25

What are the ASA physical status classifications?

  • I - normal, healthy patient; no systemic disease
  • II - mild to moderate systemic disease, well controlled, no functional limitation; smoker
  • III - severe systemic disease, functional limitation
  • IV - severe systemic disease that is a constant threat to life
  • V - moribund patient, not expected to survive with or without the surgical procedure.
  • VI - patient declared brain dead whose organs are being harvested for donation
  • E - emergency operation required

26

Who do you discuss the anesthetic plan with?

  • supervising staff
  • patient
  • surgeon
  • OR team

27

What should you tell the patient to help prepare them?

  • Discuss choices of anesthetic technique 
    • consent- written and verbal
  • Explain IV
  • Describe use of local anesthetics, medications, fluids
  • discuss airway management plan
  • explain monitors- placement and purpose
  • discuss postoperative recovery
  • discuss pain management plan

28

What needs to be included with informed consent?

  • Explanation of the planned anesthetic
  • explanation of options available
  • risks and benefits
  • pt understanding and cooperation
  • ***without consent, can be charged with assault and battery
    • need consent from parents for minors
    • signature of pt and witness

29

Patient preparation final checklist:

  • IV/Fluid status
  • pre-medication
  • anesthetic plan
  • labwork- results, labwork needed
  • CKG, CXR, needed? 
    • use an old one for comparison
  • blood products?
    • check availability
  • need for inhaler, steroid coverage, antibiotics, aspiration prophylaxis

30

What do you need to document for your pre-op evaluation?

  • H&P
  • informed consent
  • NPO status
  • medications
  • allergies
  • ASA physical status class
  • pre-operative vital signs
  • labs, tests, and consults