question

what type of procedures should have a preoperative evaluation?

answer

Must be done for every procedure regardless of type of anesthesia being provided

question

how does the practice advisory define the preop evaluation?

answer

"the process of clinical assessment that precedes the delivery of anesthesia care for surgery and for non-surgical procedures"

question

where should information regarding the preop exam be complied from?

answer

from multiple sources that should include medical records, patient interview, physical examination and medical test results

question

Goals and objective of preoperative evaluation: why is it so important?

answer

-identifies co-morbities, patient risk factors, and surgical risks for morbidity and mortality so that an optimal anesthetic plan is established to reduce the risk of preoperative complications -allows the opportunity to evaluate the patient for further needs including consultations, testing, etc... -prevents morbidity/mortality -minimizes surgical delays/cancellations, thus reducing costs - promotes preoperative efficiency -promotes patient satisfaction -allows opportunity for education on intraoperative and postoperative care, i.e. fluid shifts, monitors, pain control, drains/tubes, prolonged intubation, etc -determine postoperative disposition of the patient -provides an effective communication tool among care providers

question

what can an inadequate preoperative assessment increase?

answer

patients risk for mortality six-fold. several large-scale epidemiological studies have indicated that inadequate preoperative preparation of the patient may be a major contributory factor to the primary causes of preoperative mortality

question

When is the optimal time for preoperative assessment? why?

answer

-earlier the better -allows time to order/review labs, diagnostic tests, consultations, optimize patient health status -allows ample time for discussion of anesthesia options, risks, and to obtain informed consent

question

Describe the practice advisory statement on timing of preoperative evaluation:

answer

timing of evaluation is based on the severity of the disease and invasiveness of surgery

question

when should patients undergoing high/medium surgical invasive surges be evaluated?

answer

at least the day before surgery

question

when should a patient undergoing a low invasive surgical procedure be evaluated?

answer

on the morning of surgery or the day before

question

when should patients with severe medical conditions be evaluated?

answer

before the day of surgery

question

describe preoperative screening clinics

answer

used to conduct preoperative anesthesia evaluations prior to surgery, especially to those patients with multiple risks/co-morbidities

question

advantage/disadvantage of preoperative screening clinics:

answer

Advantage: -reduces cancellations by 89% -reduces costs -reduces labs/consultations -increases pt satisfaction -increase compliance with national regulations (i.e. advance directives, living wills, durable power of attorney, etc) -allows time for patient optimization prior to surgery Disadvantage: -more costs to the patients (extra time off work)

question

do preoperative assessments change anesthesia plans?

answer

yes, studies have shown up to 20% of anesthetic plans for ASA I and II are changed due to preoperative assessment

question

What type of patients should be evaluated early?

answer

o Their medical condition inhibits them to engage in normal daily activities o Medical conditions that requires continuous assistance or monitoring within the past 6 months (i.e. Coumadin) o Recent hospital admission (2mg/dL) o Morbid obesity

question

when should preoperative assessment be repeated? and by whom?

answer

should ALWAYS be repeated and reviewed by the actual anesthesia provider IMMEDIATELY before the start of the anesthetic

question

Components of a preoperative evaluation:

answer

-current diagnosis/planned surgery -medications -determination of patient's medical condition -vital signs -physical examination of heart and lungs

question

where should you start when preforming a preoperative assessment?

answer

Review the chart before you talk to the patient!! if chart is not available, search for alternative means for medical history such as pre-op forms filled out by the patient, telephone interviews, etc.

question

When conducting a chart review for preoperative assessment, what should be reviewed?

answer

-search for previous anesthesia records -surgical consent forms -surgical site marked (if evaluating on day of surgery -history and physical (timed, dated, and signed by MD) -consult reports and clearances -test results -recent vital signs, Height, Weight -medications -DNR status

question

What should be looked at when reviewing previous anesthesia records?

answer

-determine patients previous airway history and documented findings -cormach and lehane grading system -type of laryngoscopy blade used -assistive devices (eschmann, glidescope, oral airway, etc) -ease of BMV (one person vs two) -PACU complications (prolonged stay due to N/V/Pain, CPAP, etc

question

Most important part of the interview process:

answer

to develop a trusting relationship with the patient -will increase patient compliance with preoperative instructions and reduce patient anxiety, and increase patient satisfaction

question

How should you communicate with patients during the interview process?

answer

• Find a balance between being too "stiff" and being "too casual" • Example: • Active listening.... Be cautious of your reactions, i.e startled? Surprised? Grimace? • Good eye contact (if culturally acceptable)... don't look at computer the entire time • Avoid overuse of professional jargon • Gentle re-direction... "I understand what you are saying but now we need to focus on you"... • Find a balance between being too "stiff" and being "too casual" • Example: • Active listening.... Be cautious of your reactions, i.e startled? Surprised? Grimace? • Good eye contact (if culturally acceptable)... don't look at computer the entire time • Avoid overuse of professional jargon • Gentle re-direction... "I understand what you are saying but now we need to focus on you"...

question

how should crying patients be dealt with during interview?

answer

• a hug or slight touch on the hand is permissable; • offer tissues, • let them know it "ok to cry" • It's ok to say "I'm sorry for your pain' • Allow the patient some time to cry and resume interview when patient is ready

question

how should angry patients be dealt with during the interview?

answer

• Acknowledge the problem.... "I understand you are angry with the long wait time. I am going to do my best to get you through this process quickly, but allowing enough time to ensure I have all the necessary information that's needed to provide a safe anesthetic to you for your surgery" • Do NOT become defensive • If patient is still angry, ask he/she "What can make this situation better"?

question

how should anxious patients be dealt with during the interview?

answer

• Keep questions short • Pace the conversation • Keep calm demeanor

question

how should hard of hearing patients be dealt with during interview?

answer

speak slowly, ensure lips are visible to patient to allow for lip reading... it's not always effective to speak loudly -be cognizant of how loudly you speak due to HIPAA

question

Replicate a good introduction for patient interview:

answer

Good morning Mr._______. My name is __________, CRNA (shake hands). I will be your anesthesia provider today. I see you have a wonderful support system. (introduce self to family members) Is it Ok for me to ask you questions regarding your health with your family members present? Mr/Mrs, what are you having done today? What is the reason for the proposed procedure? Have you discussed the procedure with your surgeon? I have reviewed your chart, I need to verify some of the information you have given to the nurses in preop.

question

What should be communicated to the patient when you introduce yourself?

answer

• Knock before you enter • Introduce yourself, your title (CRNA, SRNA, MDA, AA), and your role... Introduce yourself to the family members as well • Verify the right patient for the right procedure for the right doctor... ask patient if its ok to review medical history in front of family members before you proceed

question

when obtaining a medical history, what should be noted about comorbidities?

answer

a simple notation of comorbidities is an inadequate preoperative evaluation -components should include: severity, current or recent exacerbations, stability, past and current treatment modalities, degree of control, limitations on activity

question

Goal of the review of systems:

answer

to identify any possible undiagnosed medical conditions and co-morbidities not stated by the patients

question

components of the review of systems:

answer

-airway anomalies -cardiovascular -pulmonary -hepatic -renal -endocrine -neuro

question

what should be assessed for obstructive sleep apnea?

answer

snoring, daytime sleepiness, HTN, obesity

question

what should be assessed with GERD?

answer

heartburn (frequency, severity, treatment)

question

who should receive a pregnancy test?

answer

UPT on ALL childbearing women (ages 12-50), including those with history of tubal ligation, uterine ablation

question

If a patient has a history of chest pain, what should be assessed?

answer

PQRST (provokes, Quality, Radiates, Severity, Time) pressure, tightness, heartburn, anxiety, etc

question

Cardiac red flags:

answer

-Unstable angina, recent MI (6 months), decompensated CHF, significant arrhythmias, severe valvular disease -Recent coronary artery angioplasty with stent -Uncharacterized or undocumented cardiac findings such as chest pain that has not been evaluated, murmur of unknown etiology, new EKG abnormalities, LBBB

question

What are METS?

answer

Metallic Equivalents of Exercise Tolerance -assigns a number to patients functional capacity

question

How is 1 MET defined?

answer

The rate of oxygen utilization at rest and is equivalent to 3.5ml 02/kg body weight/minute

question

At what MET should you investigate history further?

answer

if MET is < 4 need to determine whether its due to pathologic reason (CHF) or physical (bad knee)

question

Estimated energy of 1 MET

answer

-Self care -Eating, dressing, or using the toilet -Walking indoors and around the house -Walking one to two blocks on level ground at 2 to 3 mph

question

estimated energy of 4 METs

answer

-Light housework (e.g., dusting, washing dishes) -Climbing a flight of stairs or walking up a hill -Walking on level ground at 4 mph -Running a short distance -Heavy housework (e.g., scrubbing floors, moving heavy furniture) -Moderate recreational activities (e.g., golf, dancing, doubles tennis, throwing a baseball or football)

question

what are patients that are unable to perform 4 or greater METS at risk for?

answer

at increased risk for preoperative complications

question

What should be evaluated for surgical history?

answer

all past surgical procedures and interventions

question

why is the surgical history important?

answer

o Can provide further information about a patient's history • Example: Rarely a patient understands that he has CAD or CHF but a previous PTCA or CABG tells you otherwise. Some patients believe CAD no longer exists after surgery/interventions. o Can aid in deferring certain preoperative tests. • Is UPT necessary in a patient with history of hysterectomy?

question

describe what is assessed during the anesthetic history:

answer

-types of anesthetics the patient has received -complications/problems from previous anesthetics

question

What types of complications/problems should be assessed for during the anesthetic history?

answer

o Untreated pre-op anxiety o Intubation difficulties... how else can you assess this? Ask if they had a sore throat (more common with difficult airway), old surgical history o Respiratory problems postoperatively... " trouble waking up" could be due to overmedication, esp with versed o Unstable vital signs postoperatively... how can you assess this? Ask if they had to stay long in PACU or go to ICU o PONV thin, young women, non-smokers, GU procedures, ear procedures, laproscopic, pain o Severe post-op pain o Prolonged PACU stay/unanticipated hospital admission o Postoperative delirium might need to decrease dosages of meds. Maybe don't give versed, atropine, phenergan, etc

question

What should be assessed for family history of anesthesia complications?

answer

specifically ask if any IMMEDIATE family member ever experienced an adverse reaction to anesthesia

question

types of familia anesthetic complications:

answer

-malignant hyperthermia -pseudocholinesterase deficiency -porphyoria -G6PDG deficiency

question

Describe what is assessed when reviewing medications:

answer

•Prescriptions (dose and schedule, how long has patient been on the medications?) •PRN medications... last dose? •Over the counter meds (OTC) •Herbs/supplements - ^ risk for bleeding: garlic, ginkgo, ginseng, G- supplements - ^ sedative effect: Kava, valerian - ^cytochrome p450 enzyme: St. John's wort,

question

reason for holding hypertension meds prior to surgery?

answer

easier to treat hypertension than hypotension worse outcomes with hypotension

question

Concern and management with ACE inhibitors:

answer

Concerns: -refractory hypotension -intolerant of hypovolemia -withdrawal can increase AF and/or rebound hypotension Management: -withhold am of surgery -hydrate -do not respond to typical pressor when hypotensive

question

concern and management with Beta blockers

answer

Concern: -hypotenson -bradycardia Management: -give am of surgery -hydrate -discontinuing can lead to increased preoperative morbidity

question

concern and management of calcium channel blockers:

answer

Concern: -Hypotension -negative inotropic effects with decrease in automaticity Management: -give am of surgery -hydrate and treat hypotension with pressers

question

concern and management with anticoagulants:

answer

Concern: -bleeding if drug continued -blood clots/embolism if meds discontinued management: -withhold meds unless instructed otherwise by cardiologists (stents) -draw coagulation studies am of surgery

question

concern and management with NSAIDS: ASA, Toreador, Etodolac, Celebrex, Ibuprofen

answer

Concern: -bleeding Management: -usually withhold 3-7 days prior to surgery -exception: COX 1 inhibitors: celebrex

question

concern and management with diuretics:

answer

concern: -hypovolemia -hypokalemia management: -hold am dose -check am K level -consider foley

question

concern and management with antiarrhytmics: amniodarone, cardizem

answer

concern: -cardiac depression -prolonged NMB, especially with amiodarone -resistance to atropine and may need pacing management: -continue medications -prepare to give pressers and to pace

question

concern and management with MAOI

answer

concern: -hypertension due to increase NE -seritonin syndrome management: -avoid demerol, dextromethorphan, anticholinergics, ephedrine -differentiate older vs new MAOI to determine if it should be continued for surgery

question

concern and management with tricyclics

answer

concern: -HTN crisis -arrhythmias management: -watch for cholinergic symptoms if discontinued

question

concern and management of SSRIs

answer

concern: -serotonin syndrome management: -continue am of surgery

question

concern and management with insulin:

answer

concern: -hypoglycemia -hyperglycemia management: -check am glucose -hold short acting insulin -continue basal rate/long acting (even for insulin pump)

question

antiparkinson med management:

answer

continue am of surgery

question

narcotics management:

answer

continue am of surgery

question

Describe allergy assessment:

answer

-ask about medications, food, dyes, substances (latex) -differentiate between side effect vs allergic reaction -type of reaction

question

concern with tropical fruit and egg and soy allergies:

answer

tropical fruit is linked to latex allergy (banana, avocado, papaya concern with egg and soy allergy to propofol. if reaction to egg is anaphylaxis, avoid propofol

question

high risk patients for latex allergies:

answer

-chronic exposure to latex (health care professionals) -spina bifida -9+surgical procedures -intolerance to balloons -allergy to banana, avocado, papaya (tropical fruits)

question

describe concern with rubber and latex in medication vials:

answer

concern for reaction to rubber stop; however, AANA has done research that shows if you use it just once (one stick, one syringe) evidence shows there should not be a reaction

question

components of social history

answer

-occupation -overseas travel -tobacco -ETOH -illicit drug use

question

what is important to assess with tobacco history?

answer

Pack years: increased preoperative pulmonary complications if 20 pack year smoker

question

how to assess pack years for smoking:

answer

#pack smoked per day x number of years smoked

question

systemic effects of nicotine:

answer

increase HR, BP, 02 consumptions, and peripheral vascular resistance

question

1/2 life of nicotine

answer

40-60minutes

question

how does smoking affecting the carboxyhemoglobin curve?

answer

shifts it to the left. >12% indicates smoking

question

describe effects of cigarettes have on carbon monoxide and oxygen:

answer

Carbon monoxide: 300x's more affinity for Hgb than oxygen, thus O2 transport is drastically reduced esp if CO levels >15%; half- life of carbon monoxide 130-190 minutes

question

half life of carbon monoxide

answer

130-190 minutes

question

how long should pt stop smoking cigarettes prior to surgery? why?

answer

at least 12-24 hours reduces cardiopulmonary effects from nicotine and carbon monoxide, thus decreased HR, BP and carboxyhemoglobin values normalize

question

Describe effects if patient stops smoking for >8wks prior to surgery:

answer

decrease preoperative complications -improve ciliary function -decrease secretions -overall improvement in pulmonary mechanics

question

why is smoking a concern for anesthesia?

answer

because smoking causes airways to become irritable and when irritants are added during surgery (i.e. anesthetic gases), airways become more reactive and lead to greater chances of bronchospasms

question

how many pack years is concerning for anesthesia?

answer

>20 years

question

concern with ETOH use/abuse

answer

-increased risk for arrhythmias -increased infections -withdrawal -synergistic affects with acute intoxication -prolonged bleeding

question

CAGE questionnaire for alcohol

answer

C: Cutting down A: Annoyance by criticism G: Guilty feeling E: eye-opener drink

question

how many drink should be a red flag for tolerance?

answer

two a day

question

How long does the patient need to sustain from alcohol before post-op complications are reduced?

answer

>4wks

question

When should cases be cancelled for alcohol levels?

answer

above the legal limit

question

what is important to document with alcohol use?

answer

-how much -what type -when was your last drink

question

what can be assessed for possible drug use/abuse?

answer

-track marks -scarring -thrombotic veins -sq abscesses -pupil constriction (opioids) -pupil dilation (amphetamines -nystagmus (PCP) -malnourshiment (amphetamines) -poor dentition (amphetamines)

question

what is a main concern with cocaine use?

answer

-cardiac complications (i.e. MI) -difficult to manage hypotensive states -should always get EKG and BP prior to case, if anything is abnormal, cancel or postpone the case

question

signs of marijuana use:

answer

-tachycardia -labile blood pressure -euphoria -poor memory

question

anesthetic concerns with marijuana:

answer

-literature shows more irritable than cigarettes (more prone to bronchospasm) -site specific on whether to cancel case -always get EKG

question

anesthetic concerns with anabolic steroid use:

answer

-increased hepatic dysfunction -hypercoagulation -MI -prone to blood clots

question

if a patient is a chronic anabolic steroid user and becomes hypotensive, what should be done?

answer

may need stress dose of steroid intra-op to improve BP

question

Review nagelhout box 19-4

answer

Review nagelhout box 19-4

question

NPO status

answer

clear liquid- 2hr breast milk - 4hr infant formula- 6hr non-human milk- 6hr light meal- 6hr fatty meal- 8hr

question

what should be done with NPO status and chewing gum?

answer

-known to increase gastric acid secretion and motility, but canceling cases is not typically necessary if gum chewing occurs morning of surgery

question

review nagelhout box 19-21 and 19-22

answer

review nagelhout box 19-21 and 19-22

question

concern with hiatal hernia or severe pain

answer

at increased risk for aspiration -both need RSI with ETT despite NPO status

question

minimum preoperative physical examination according to practice advisory:

answer

-airway -pulmonary -cardiovascular

question

most important physical assessment parameter:

answer

airway assessment -should be done on al patients regardless of anesthetic technique

question

5 elements of airway exam:

answer

-Mallampati -Dentition -Oral Aperture -Thyromental distance or hyomental -Neck range of motion

question

Describe Mallampati: how is it performed?

answer

used to asses tongue size relative to oral cavity -pt should open mouth as wide as they can and stick out tongue with head upright and in a neutral position. phonation should not occur -have patient protrude upper/lower incisors at this time also

question

most common reason for anesthesia related claims:

answer

dental damage during airway manipulation

question

what should be included in dentition exam?

answer

-document loose/missing teeth and overall dentition status. if patient at risk, tell them -school age children at increased risk -document dentures/partials/plates/bridges and whether they are permanent or nonpermanent

question

should partials or dentures be removed?

answer

always for EGD and ETT -provider specific for colonoscopy because they may assist in ventilation

question

which teeth are most important to document?

answer

central and lateral incisors and cuspids #6,7,8,9,10,11

question

what is assessed with examining oral aperture?

answer

-tongue size -ability to protrude -heavy facial hair -neck size -TMD -dentition -TMJ

question

length of upper incisors

answer

relatively long nonreassuring

question

inter incisor distance

answer

<3cm non reassuring

question

visibility of uvula

answer

Mallampati >2 non reassuring

question

shape of palate

answer

highly arched or very narrow. non reassuring

question

compliance of mandibular space

answer

stiff, indurated, occupied by mass, or nonresident are non reassuring

question

thyromental distance

answer

less than three ordinary finger breadths = non reassuring

question

length of neck

answer

short = non reassuring

question

thickness of neck

answer

thick = non reassuring

question

neck ROM

answer

pt cannot touch tip of chin to chest or cannot extend neck = non reassuring

question

what does thyromental distance predict?

answer

predicts ability to anteriorly displace tissue to expose the larynx during direct laryngoscopy

question

non reassuring thyromental distance

answer

<6cm or 3 finger breadths indicates possible difficult intubation;

question

non reassuring hyomental distance

answer

<2 finger breadths can indicate possible difficult airway

question

describe the 3-3-2 rule

answer

• The 3-3-2 rule holds that in patients with normal relative anatomy the following apply: normal mouth opening is three (of the patient's) fingerbreadths; a normal mandible dimension will likewise allow three fingerbreadths between the mentum and the hyoid bone; and the notch of the thyroid cartilage should be two fingerbreadths below the hyoid bone.

question

what does neck circumference/neck ROM predict?

answer

-predicts ability for neck extension/manipulation to aid in laryngoscopy -provides reassurance to anesthesia provider the ability to manipulate neck without causing cervical spine injury or vertebral artery copmression

question

non reassuring neck circumference:

answer

>60 cm may be associated with increased risk for difficult airway (30%) -if combined with one other risk factor (MP 3 or 4, decreased TMD, etc), difficult airway incidence increases to 60-70%

question

goal of the review of systems:

answer

to identify possible undiagnosed medical conditions and comorbidities

question

what should BP be maintained within?

answer

20% of normal

question

How do you calculate BMI

answer

[weight(pound)/Height (inches)] x height (inches) x 703

question

how is ideal body weight calculated?

answer

Male: 105lb +6lbs (q inch >5ft) Female: 100lb + 5lb (q inch > 5 ft)

question

extreme obesity BMI

answer

>40

question

obesity BMI

answer

>30

question

morbid obsiety

answer

2x IBW

question

what history should be reviewed when conducting cardiovascular assessment?

answer

-HTN -Left ventricular function (CHF, echo) -MI -valve disease -Arrhythmias -CIED (cardiac implanted electronic device

question

which co-exisiting diseases/conditions increase the likelihood of undiagnosed CV disease?

answer

-Dm -obesity (CAD, METS) -HLD -Aneurysms -PVD -Tobacco -previous cardiac/vascular surgery

question

which previous cardiac test should be reviewed for cardiovascular assessment?

answer

echo, cath lab, ekg, etc

question

what should be inspected on CV assessment?

answer

-edema -JVD -SOB -Fatigue -METS -CIEDs -EKG

question

what should be palpated during CV assessment?

answer

-pulses -bilateral BP -CIEDs (may be in abdominal cavity) -pitting edema -temperature of extremities

question

difference between bell and diaphragm on stethescope

answer

bell: light skin contact; low frequency sounds diaphragm: firm skin contact, high frequency sounds

question

What does an S3 indicate?

answer

heart failure/fluid

question

mitral regerg and aortic stenosis pneumonic

answer

MRSA: mitral regurg systolic ASSS: aortic stenosis systolic sternum

question

what histories should be assessed when conducting respiratory assessment?

answer

-ashtma -copd -emphysema -bronchitis -OSA -pneumonia -URI (children) pleural effusion (CA pts) -tobacco -pulmonary surgeries -steroids -CA

question

what should a patient be asked with a hx of asthma?

answer

use of inhaler, hospital admissions, previous intubations

question

what should be assessed during inspection of respiratory assessment?

answer

-ease of breathing. can pt talk without stopping? -accessory muscle use -chest expansion equal -barrel chest -chest xray -use of 02, cpap, bipap -cough (productive vs nonproductive) -tracheal deviation -shape and color of nails -vital signs (RR, o2 sats) -smoking/smell of smoking

question

what should be assessed during palpation of respiratory assessment?

answer

-crepitus -subcutaneous emphysema -chest stability

Assessment: Anesthesia Preoperative Evaluation and Assessment – Flashcards

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards