N928 - Basic Principles > Pre-Op Assessment & Documentation > Flashcards

Pre-Op Assessment & Documentation Flashcards

(106 cards)

Study These Flashcards
1
Q

Purpose of the pre-op assessment

A
  1. evaluate current physical status
  2. optimize the patient for surgery
  3. Minimize Perioperative Morbidity & Mortality
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Goals of pre-op evaluation (6)

A
  1. OBTAIN medical & surgical history
  2. EVALUATE pt & determine need for pre-op studies or consultations
  3. FORMULATE anesthetic plan
    (to)
  4. MINIMIZE perioperative morbidity & mortality
  5. OPTIMIZE pt safety and satisfaction
  6. PREVENT surgical cancellations & delays
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

AANA Standard #2

A

Preanesthesia patient assessment and evaluation

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

AANA Standard #3

A

Plan for Anesthesia care

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

AANA Standard #4

A

Informed consent for anesthesia care & relevant services

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

AANA Standard #5

A

Documentation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

AANA Standard #6

A

Equipment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

AANA Anesthesia Care Documentation includes (13)

A
  1. Name & MRN
  2. Name of all anesthesia providers involved
  3. Immediate pre-op anesthesia assessment & evaluation
  4. Anesthesia safety checks (AGM, drug supply, gas supply, monitors)
  5. Monitoring of the patient (oxygenation, ventilation, circulation, body temperature, skeletal muscle relaxation)
  6. Airway management techniques
  7. Name, dose, route & time of drugs & anesthetics
  8. Patient positioning (who positioned, type of devices used)
  9. Name and amount of IV fluid or blood products
  10. IV lines inserted (technique / location)
  11. Complications / Rxn / Problems
  12. Status of patient at end of anesthesia
  13. Document in a timely and legible manner
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Modification to AANA standard

A

MUST BE DOCUMENTED

the modification & why

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

ASA Preanesthesia Standard (6)

A
  1. Review medical record
  2. Interview & examine pt [discuss Hx, including anesthesia & medical experience and therapies]
  3. Order / Review pertinent labs, tests, or consultations
  4. Order appropriate pre-op medications
  5. Ensure consent is obtained
  6. Document in the chart the above has been performed
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Principles of pre-op evaluation

A
  1. Verify pt identity (name, DOB, surgeon, surgery, laterality)
  2. Verify and document proposed surgical procedure and preoperative diagnosis
  3. Consider anesthetic implications
    * *RESPECT PRIVACY
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Pre-op Interview Clinic

A

1-2wks before, clinic or phone
* if optimization / pre-arrangement is needed, anticipate

  • MUST still VERIFY INFORMATION DOS
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Essential Components

A
  1. BMI
  2. Allergies
  3. NPO status
  4. Medications
  5. Previous anesthesia complications
  6. Family history of MH
  7. possibility of pregnancy
  8. systems review
  9. Baseline cognition
  10. AIRWAY ASSESSMENT
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

5 As

A 
Ate (NPO status, GERD?, Aspiration risk?)
Allergies
Anesthesia history
Airway
Alert (neuro)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

BMI

A

[ lbs / (inches^2) ] x 703

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

lbs → kg

A

half of lbs

subtract first or first 2 digits

120lbs → 60 → (-6) = 54kg
300 lbs → 150 → (-15) = 135kg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Normal BMI

A

18.5 - 24.99 kg/m^2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Overweight BMI

A

25-29.99 kg/m^2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Obese BMI

A

> 30

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

Allergies

A

What allergen?
Type of reaction? = was it a side effect vs rxn?
Throat / tongue swelling, difficulty breathing = anaphylaxis

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

Specifically ask about allergies to:

A 
Drugs
Dyes
Contrast
Latex
Foods
Tape
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Surgical history

A 
What kind of surgery?
When?
Why?
Type of anesthesia?
Complications [PONV, MH, awareness, prolonged wakeup / unplanned admission]
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Recall is defined as

A

Awareness under general anesthesia

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

Anesthesia history

A 
difficult intubation?
letter or medical alert bracelet.
sore throat > 48hours after surgery
significant weight change since last surgery
MANY surgeries (visual s/s; chart)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Malignant Hyperthermia
``` Inherited myopathy Volatile anesthetics or depolarizing NMB → hypermetabolic state AVOID TRIGGERS = TIVA pt or family hx MH What was the outcome? Genetic testing completed? ```
26
Anesthetic implications of repeated surgery
- scars / adhesions - airway damage / patency - Allergies - Anxiety
27
Reason for NPO guidelines | nil per os
reduce the risk for aspiration (Morb&Mort) | Asp → chemical burn of tracheobronchial tree and pum parenchyema → INTENSE parenchymal inflammatory reaction
28
NPO Recommendations & who they are for
For HEALTHY, "NORMAL" individuals 2H clear liquid (water, black coffee, tea, pulp-free juice, carbonated beverages) 4H Breastmilk 6H "light meal" low or non-fat - formula, cows milk, tea/coffee with creamer, full liquids, gum, hard candy 8H Full meal, fried, fatty food
29
Factors that increase risk of aspiration
"Full stomach" or non-compliance with NPO Increased intra-abdominal pressure Diabetes (especially uncontrolled) Pregnancy Obesity, SBO, Ascites, GERD (especially uncontrolled) TRAUMA (SNS stimulation = ↓ gastric motility) Bulimia
30
baseline physical exam for comparison later (8)
``` vital signs heart/lung sounds breathing pattern peripheral pulses peripheral edema bruising/scaring BASELINE SENSORY/MOTOR DEFICITS MENTAL STATE ```
31
mental state assessment
awake, alert, oriented, demented, confused, combative, mental retardation (MR)
32
GOAL OF ANESTHESIA
RETURN PATIENT TO BASELINE STATUS (same or better than before)
33
Airway visual assessment
Identification of structures (hard & soft p, tonsils, faucial pillars, uvula, dentition, upper lip bite test, thyromental distance, sternomental? distance, neck circumference, mobility/ROM, interincisor distance)
34
Airway "tests"
Mallampati Class (I, II, III, IV & the oh so rare 0) - 3 & 4 greater chance of difficult airway; dependent upon patient cooperation Inter-incisor (3 finger breadths) Thyromental distance; BAD <6cm, GOOD 3 fingers >7cm Sternomental Distance; BAD <13cm, GOOD >14cm Neck circumference; GOOD <45cm & BMI <40 Upper lip bite; Class 1, 2, 3 (whole lip, half lip, no lip bite) Prayer Sign/Table top test; ↓ joint/cartilage mobility (atlanto-occipital joint involvement = ↓ ROM Dentition; malnourished, drug abuse Cervical mobility/ROM
35
TMJ
ball and socket joint; mandible & maxilla muscles, tendons, bones Disorders: teeth grinding, nail biting, gum chewing, malocclusion, stress-clenched teeth, jaw trauma
36
Patil's Test
Thyromental distance, head fully extended. upper edge of thyroid to mentum; short distance implies visualization during intubation may be difficult - more anterior larynx - more acute angle - less space to displace/ compress tongue
37
cervical spine mobility / sniffing position
oral - pharyngeal - laryngeal axis alignment. | allows view of glottic opening
38
dentition
loose, chipped, cracked, broken, removable DOCUMENT any crowns, implants, devices, removable objects?
39
Neck circumference indicative of difficult intubation
>45cm | BMI >40
40
difficult mask ventilation prediction
``` Mask seal Obesity Age >55yr No teeth Stiff lungs ``` ``` Beard Obesity No teeth Elderly (>55 yr) Snores ``` ``` Facial hair ROM Over 55 yr Zzz (OSA / snore) Edentulous Neck surgery / trauma / radiation ```
41
difficult intubation pneumonic
``` Look for pathology Evaluate 3-3-2 rule Mallampati classification Obstruction Neck mobility (pain or tight?) ``` Look @ face/neck (mass, injury, bleed) Evaluate (ROM, thickness, circumf, surgical Hx) Thyromental distance Incisors; opening; 3 fingers Teeth (chips, cracks, loose, missing, dentures, braces) Grade, Mallampati Overbite (oral space, TMJ, tonsillar hypertrophy, abscess, mandibular compliance)
42
facial hair can do 2 things
1. difficult to get mask seal | 2. disguise potential difficult airway
43
female patients
possibility of pregnancy; | last menstural period
44
Medication Hx / current medications | Question which ones? (8)
``` OTC / Rx, vitamins, minerals, herbals, home remedies why? how long? how often? last dose? Pursue questioning on the following: Anticoagulants Anti-dysrhythmias Anti-hypertensives Beta-blockers Bronchodilators Diuretics Opioids Vasodilators ```
45
medications to TAKE DOS
``` beta blockers GERD meds Ca+ channel blockers bronchodilators antiarrhythmias steroids diuretics (if for HF) antipsychotics thyroid medications ```
46
medications to HOLD DOS
``` oral hypoglycemics ACE inhibitors (PROFOUND hypotension) A2RB Diuretics (as long as its not for HF) Herbal supplements ``` -per surgeon's order anticoagulants
47
Cardiovascular pre-op assessment
HTN, angina, CAD, MI, valvular dz, syncope, CHF, edema, dyspnea, arrhythmias *LISTEN to heart*
48
Hx HTN
duration of dz EXERCISE TOLERANCE (METS) recent EKG Medication? how long, compliance, controlled? DOCUMENT current meds
49
single best indicator of cardiopulmonary function
Exercise Tolerance
50
Angina / CAD / MI
Exercise Tolerance s/s, precipitating factors, last chest pain, date of MI METHODS OF RELIEF INTERVENTIONS, if any? EKG, ECHO, cardiac cath, most recent cardiologist visit, cardiac clearance
51
cardiac clearance
Recent (w/n 6 mo) MI = 6 months Newly diagnosed CHF or CHF w/ hospitalization w/n 6 mo = 6 months Aortic Stenosis = 12 mo or more recent if change in symptoms
52
Risk of 2nd MI is highest w/n
6mo of MI
53
Valvular Dz
Do they take ATB for dental work? stenosis or regurgitation - need recent or comparative EKG, ECHO, cardiology notes/consults/clearance
54
syncope & cardiac arrthymias
causes, if known last episode, any treatment? CONSIDER CIRCULATION BLOCK -review notes / past & current EKG do they have a pacemaker or AICD (magnet)
55
arrythmias
type intermittent or continuous interventions or current medical management? anticoagulants or antiarrhythmic?
56
congestive heart failure
current status, controlled? recent weight gain / pedal edema? dyspnea or difficulty lying flat - do you sleep sitting up? last hospitalization recent changes in management current EKG & ECHO with documented EJECTION FRACTION *take diuretics DOS*
57
respiratory
``` Asthma / COPD / chronic bronchitis / emphysema Recent URI / cough or cold Pneumonia Tuberculosis OSA / snore Tobacco use / Vape ```
58
Asthma
Frequency / Last attack Triggers / hospitalizations? Ever been intubated or ICU? Treatment regimen; controlled or uncontrolled? Meds, dose, route, last dose rescue, frequency of use current or past oral steroid use Antibiotic treatment Pediatrics - changes in activity, lethargy, appetite, fluid intake
59
Emphysema
Home oxygen use? Inhaler / Nebulizer / Corticosteroid use Pulmonology reports / PFTs / ABGs / CXR
60
Tuberculosis
``` INH therapy **CHECK LFTs** symptomatic vs latent [productive cough, chest pain, fatigue, loss of appetite/weight, fever, chills, night sweats] New onset / worsening of symptoms Isoniazid (INH) therapy CXR if symptomatic ```
61
OSA
*bring CPAP or BIPAP with you | Document settings
62
Tobacco use
per day, type, years, Pack year = # years x packs per day or (#cig per day x years smoked) / 20 FORMER SMOKERS; same information, quit date
63
Nervous
Stroke / TIA Seizures Headache Neuropathy
64
Stroke / TIA
``` Date of occurrence Cerebral blood flow studies Carotid doppler Angiogram *RESIDUAL DEFICITS*? - hemiparesis, dysphagia, visual disturbances DOCUMENT ```
65
Headaches
``` frequency type triggers / relief debilitating? have you seen a neurologist? medications? ```
66
Seizures
Hx , type, last, frequency, cause, MEDICATIONS, *CHECK BLOOD LEVELS OF MEDS* *TAKE MEDS DOS*
67
Neuropathy
Unique positioning needs Choice of anesthetic *do not block a limb with neuropathy* PROVIDES BASELINE site of neuropathy, type - numbness, tingling, pain, loss of sensation, "pins & needles", "goes to sleep" in fingers/ toes? one side or both? DOCUMENT
68
GI : GERD
recognize patients at risk for aspiration *High incidence of GERD associated with? Ask about: Meds, OTC/RX, controlled/uncontrolled, factors and frequency of reflux, DYSPHAGIA?, *TAKE GERD MEDS DOS* RSI = 30-40 Newtons cricoid pressure = 6.6-8.8 lbs = 3-4 kg
69
Hiatal Hernia
heartburn, regurgitation, nausea severity? treatment?
70
Bowel obstruction
date of obstruction surgical intervention? past or present ostomy? Crohn's? IBS?
71
Endocrine
Diabetes | Thyroid Dz
72
Diabetes
RSI Meds? controlled vs uncontrolled? HgbA1c
73
Thyroid : Hyperthyroidism
weight loss, ↑ HR (need B blocker?), heat sensitivity, nervousness, irritability, tremors, anxiety, muscle weakness U-thyroid? check pulse
74
Thyroid: Hypothyroidism
weight gain, cold intolerance, fatigue, depression, dry skin, muscle cramps *ASSESS GOITERS & encroachment upon airway
75
Autoimmune: Rheumatoid Arthritis (RA)
inflammation, pain, stridor, hoarseness, dysphagia, painful speech, steroid use **POSSIBLE CERVICAL SPINE INSTABILITY** atlantoaxial instability = GET FLEXION / EXTENSION FILM; looking for atlantoaxial SUBLUXATION *potentially difficult airway d/t TMJ dz, ↓ C-spine mobility, ↓ arytenoid joint mobility
76
Musculoskeletal
*SUX is bad news bears* Muscular Dystrophies = progressive weakening & atrophy MS, MG, myopathy, fibromyalgia, myotonias, obestity, Sjogrens syndrome
77
Hepatic
What dz? Bruise or bleed? Protein level? Coag [Pt/Ptt] LFT [AST/ALT] ``` Hepatitis: type, date, treatment Jaundice: origin [ETOH vs unknown] Cirrhosis: scaring → impaired fxn Alcohol: frequency, types, amount *consider coagulation studies & EKG ```
78
Renal
Last dialysis? How much did they take off? Weight gain? Acute vs Chronic failure ESRD - dialysis? *lytes / renal panel / EKG / Pt/Ptt / LFTs
79
Alcohol / Drugs
What, amount, frequency, last dose, route, duration of use * Acute intoxication = ↓ dosages * Chronic use = ↑ dosages
80
Hematological / Coagulation
Hx anemia, coagulopathies, ITP/TTP/HUS, DVT, PE, sickle cell, anticoagulant use, transfusion history, bleeding tendency
81
MISC in pre-op
Hx malignancy Hx psychiatric illness / dementia / alzheimers Hx infectious dz / HIV / AIDS / Herpes
82
Anesthetic Plan includes (5)
``` Type of anesthesia Airway device Type of induction Medications Monitoring modalities / special equipment ```
83
ASA Physical Status
1 - normal healthy 2 - mild systemic dz 3 - severe systemic dz 4 - severe systemic dz that is a *constant threat to life* 5 - moribund patient not expected to survive without surgery 6 - declared brain-dead; anticipating organ procurement (donor) E - EMERGNCY (add to any of the above)
84
EMERGENCY CASE
``` consent, if possible consider "FULL STOMACH" anticipate possible equipment needs medication considerations blood products available? is additional help available? ```
85
Informed consent
Discuss anesthetic plan, alternatives, risks, potential complications. Answer questions Obtain written consent STANDARD #4
86
What to document?
- Verified identity - invasive procedures - techniques used - special eq used (doppler / ultrasound) - ventilation modes - incision - inducation - intubation - extubation - verified surgical procedure - AGM check - Times (in/out of room, atbx) - transport time & location - patient status - collaborative efforts & communication (Dr. X notified of 500mL blood loss) - name of individuals who perform a given procedure
87
If the patient has neuropathy, do NOT
place neuraxial block to that extremity
88
Cultural considerations
- acceptance of blood products - confirm AND/DNR status: usually suspended while in the OR - religious tokens
89
Assess pain ideology
"you're the headliner, I'm just the backup" How do you perceive pain? What are your pain goals → Some discomfort is likely - b/c surgery. How can you communicate discomfort to us?
90
Blood Transfusion
Acceptance | History
91
Major CV Risks
Unstable coronary syndromes, acute/recent MI w/ ischemic risk, unstable/severe angina, decomp HF, significant / symptomatic / uncontrolled arrhythmias, high grade AV block, severe valvular dz
92
Intermediate CV Risks
Mild angina, Hx MI, pathological Q waves, compensated HF, DM (insulin dependent), renal insufficiency
93
Minor CV Risks
Age, abnormal EKG (LVH, LBBB, ST-T abormalities), non sinus rhythm, low functional capacity, Hx stroke, uncontrolled HTN
94
METs
1 MET - cannot care for self fully 4 MET - 1 flight of stairs >10 MET - strenuous sports (football, skiing, basketball, swimming)
95
Surgery: High Risk >5% Cardiac risk
emergent operations (especially in elderly), aortic/major vasculature, peripheral vascular, prolonged surgery with major fluid loss/shifts
96
Surgery: Intermediate Risk <5% cardiac risk
carotid endarterectomy, head/necck, intraperitoneal, intrathoracic, orthopedic, prostate
97
Surgery: Low Risk <1% cardiac risk
endoscopic, superficial, cataract, breast surgery
98
ASA 1
Healthy, non-smoker, minimal ETOH use, normal BMI
99
ASA 2
Mild systemic dz PREGNANCY smoker, social alcohol drinker, obesity, well controlled DM/HTN, mild lung dz
100
ASA 3
Severe systemic dz *substantive functional limitations* 1 or more moderate dz: Uncon DM/HTN, COPD, BMI>40, active hepatitis, alcohol dependence, pacemaker, moderate ↓ EF%, ESRD, dialysis, Within the last 3 months [MI, CVA, TIA, CAD/stents]
101
ASA 4
Severe systemic dz that is a *CONSTANT* threat to life: RECENT <3mo [MI, TIA, CVA, CAD/stents], ongoing cardiac ischemia, valve dysfunction, severe ↓ EF%, shock, sepsis, DIC, ARD or ESRD w/o regular dialysis
102
ASA 5
Moribund patient who will not survive without surgery. Ruptured abd/throac aneurysm, massive trauma, intracranial bleed w/ mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction.
103
ASA 6
Declared brain-dead patient whose organs are being removed for donor purposes.
104
Time sensitive surgery
stable, but required intervention; w/n days to weeks | [tendon/nerve injuries, cancer procedures]
105
Urgent surgery
condition threatens life, limb, organ; w/n 6-24 hours | [perf bowel, compound fx, eye injury]
106
Emergent surgery
life, limb, organ-saving; w/n 6 hours | [ruptured aortic aneurysm, major trauma to thorax/abdomen, acute increase in ICP]
N928 - Basic Principles
flashcards
Decks in class (22)
# Cards
Brainscape helps you reach your goals faster, through stronger study habits.
© 2026 Bold Learning Solutions. Terms and Conditions