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117 Cards in this Set

  • Front
  • Back
Purpose of preop assessment
Educate pt on
-preriop care (fluids, breathing)
-pain meds
-dec anxiety (d/t inc catachol)
-facillitate recovery
Purpose of preop assessment
Preop labs & tests
Plan of care
-guided by pt choice
-risk factors assoc w/
pt hx, surg considerations
Purpose of preop assessment
-Determine preop meds
-Informed consent
-motivate pt to follow prevent strategies (quit smoking)
Clinical & Org factors affecting preop assess
inc outpt procedures
3rd party payers (less preop time)
No consistnet system for risk assess
Sources of information
chart review
previous hosp records
lab/x-ray data
pt interview
discussion w/ surgeon (listen to their concerns about pt)
Chart Review
medical records
curent inpt records
old inpt records (prior OR, vitals)
Pt interview
ID yourself as SRNA
Ask pt if visitors or family memebers are ok to be in room
Vital stats
Current Meds
-OTC's (vitamins, herbs)
-Street Drugs (amphetamines,pot,coke,roids)
Social Hx
Tabacco (pack/day x yrs)
Alcohol (oz/wk)
Caffeine (coffee/pop /day)
Drug allg
Food (shellfish, eggs (dip)
Surg products (tape, betadine, latex (pappya)
Surg Hx
type of anesthesia
complications of anest/surg
Transfusion hx (complicate xmatch)
Family hx (maliganant hyper,slow wake up, lead pipe syn)
Phys exam
Focused assess (heart,lungs,airway,back,surg site
Review of sys
Possibly most important
5 main areas
Mallampati class
dental exam
thyromental distance
TMJ funct
Atlanto-occipital jt funct
Mallampati class
Class I
Soft palate
ant/post tonsillar pillars
visualize glottis
Mallampati Class
Class II
soft palate
fauces (slight diminished)
laryngoscopy (posterior commissure)
Mallampati Class
Class III
soft palate
uvula base
laryngoscopy (tip of epiglottis (chords not visualized well)
Mallampati Class
Class IV
hard palate only
Laryngoscopy (no glottic structures)
loose missing teeth
protruding teeth
Thyromental distance
neck fully ext
-dist from
-thyroid notch
-lower mandibular border
-3 finger breadths (short=anterior)
Atlanto-occipital jt funct
(limitation at C1 convexity, anterior airway)
how far can they ext their neck
-any dizziness
-necessary for sniffing pos.
-observe pt performing
TMJ funct
mouth opening
effort dependent
normal at least 2-3 fingerbreadths (vertical)
Respiratory system
Absent w/ mod exertion =no dz
Inc risk: post op pneumonia, reactive airway
Genearlly cancel elective 2-6 wks
Reason for cancelling d/t cough
Inc secretions, poss asp
Swelling of airway d/t cold is ___times more likely to happen with a cold after insturmentation of airway, 2-3 times likely with bag mask
11 times
Hx ER visit, hosp stay
-consider PFT
-assess wheezing in clinic/preop
Review meds/compliance
- inhalers
Preop orders
Inhalers preop
Continue bronchodilators
Inhalers to OR w/ pt
Hydration (previous night, OR)
note pack/yrs
#pack/days/yrs (regardless of quitting)
-Counsel pt
Can compromise intraop o2
Inc mucous/dec clillary act
Inc risk laryngospasm/bronchospasm
Suspected pulm path
major surg procedure
Cardiothoracic, maj abd
Assess FVC/FEV1 (note value/% of predicted)
Significant abnorm values need more detail tests
CV System
Mortality rate of preop MI 50%
CAD (MI-date,type SS)
Angina (stable vs un)
Exercise tolerance
CV testing
EKG (ST chang, Q wave indict ischemia/injury, reflects window in time, normal in 25-50% of pt w/ CAD
Indicated in pt greater than 45-50yrs
Exercise stress
Eval CAD
Assess myocardial reserve
Predictive value
<85% predict MHR -25% cardiac comp
>85% predict MHR 6% cardiac comp
ST dep >1mm + <85% MHR =33% cardiac comp
reflects mech charct of heart
wall motion
wall thickening (HTN)
valve fx
vent funct (estimate)
Dipyridamole Thallium Scintgraphy
Assess rev ischemia
Dipryridamole dilates cornary -> thallium is taken up by tissues
-Scan at begin, 4hrs
-Uptake eval
-Pt w/ redist inc intraop risk
Coronary angiography
gold standard
asses individual vessels
Valve defects
Previous MI
Inc risk for event
Risk approaches gen population >6 mos.
Chance of having intraop MI with MI in past 6,3 mos.
15% = 6mos
30% = 3mos
CHF (use mostly narcotic anesthesia intraop)
most predictive of intraop isch
Exam- rales,orthopnea,tachypnea,jvd,tachycardia
Postpone surg if poss.
Emergency: pharm to inc CO
Invasive monitor
SBP >160, DBP >90
-note control/compliance
-Possible ASPVD
Expect intraop HTN
-Consider cancelling to optimize control
-If pt takes meds may have to do other measures
GERD (Cont H2, rapid seq)
PUD (caution NG)
Bowel obst (don't give reglan)
Hepatobillary (inc risk of heapatitis
ETOH abuse (induct P450)
Inc anesthetic need
Live dz (LFT's)
Assess effect on coaguation
Aucte GB dz
Renal (monitor esp in AAA)
Crt clr best measure of renal reserve
HD (H&H, K+, fluid status
(perfer not to do surg after HD d/t dec fluid status)
DM- impaired synth, secretion, use of insulin
Hx of hypo/hyper glycemia
Microvascular dz assoc (renal, cardiac,pvd, autonomic dysfunct: delay GI empty (GERD, labile BP)
DM preop
IV D5LR 125/hr
1/2 dose of intermediate insulin
Blood gluc check on admit
avoid-hypo/hyper glycemia
Goal of 100mg/dl
Endocrine Thyroid
Euthyroid in OR
-note cause, tx
-assess SS, (cold intol, skin manifest, energy
-Thyroid function
Endocrine Hyperthyroid
Continue propylthiouracil & propranolol
airway dev d/t goiter
xray neck r/t dev of trachea
rev CT scan of thyroid
Cancel of hyperthyroid
Adrenocrotical Disorders
Hyperadrenocorticism (Cushings-alklosis,inc fluid)
Hypo- addision's (need steroid 100 solucort pre,post,intra
Adrenocrotical Disorders Steroids
tx for asthma , autoimmune
-may need to supp d/t surg stress
-assess fluid & elyte change (hypo/hypertension)
Neuromuscular system
Source of problem
stroke (outcome, weakness, meds)
Cervical or lumbar disc dz
-note parethesias, sciatia, limits
Arthritis Degen jt vs RA (diff intub w/ RA r/t neck get xray)
Females of childbearing eval for preg
Oral contras (inc risk of DVT)
OB Pt's (comp preg, delivery, epidurals, anesthetics)
Preop testings
Consider relevence for each test
Positive finding in H&P
Anticipation of significant changes d/t surg
High risk population
Preop testing
General Guidlines
older than 50 = EKG, CXR
Premenopause females no preop test
<50 HCG, H/H
ASA Classification Class I
Healthy pt
ASA Classification Class II
Mild systemic dz (mild htn)
ASA Classification Class III
Severe Systemic dz (not incapacitating) (renal failure)
ASA Classification Class IV (constant threat to life)
Incapacitating systemic dz (CHF, Mal htn,
ASA Classification Class V
Moribund pt (less than 24hrs w/w/o surg will die )
ASA Classification Class VI
Organ donor
ASA Classification Class E
Emergency qualifier
Informed consent
Choice of technique
Site of surg
coexist dz
position of operation
elective or emeregency
pt preference
Informed consent
Discussion tailored to pts need
N/V, Airway (sore throat
Dental inj
Preiph neurop, cardiac dys/MI
Atelectasis, Aspiration
Stroke, Allg drug rxn
Progress note
Standardized consent
Pt dx
gen nature of proced
prospects of succes
prog if procedure performed
Informed consent
An essential element of safe anesthesia practice
Clear, concise, communication, primary care strategy, legible doc, risks benefits, consequences if refused, signature of pt
Preop meds
Relief of anxiety
sedation, amnesia, analgesia
dec secretions, dec autonomic response
reduce gastric vol & inc pH
Pt Prep/preop meds
Antiemtic effects
reduction of anesthetic
facillitate induction (versed dec amt need of dip )
Allg prophalaxis
Psych prep
Good counseling = best preop
Explain procedures & sequence
Answer questions
Talk to both pt/family
Pharm Prep
Chosen considering pt individualized
knowledge of pharm agent
preop time available
desired endpt
Sedative hypnotics/tranquilizers
Versed PO .5mg/kg, IV .5-5mg
Diazepam PO 5-20mg
Lorazepam PO/IM 1-4mg (long post op sleep)
provide analgesia before induction
-regional anesth
-blunts response to endotrach intubation
- Morphine IM 5-15mg
- Fentanyl IV (needs to be monitored)
Originally used to decrease secretions assoc w/ inhal anesth
Side effects
CNS tox
-central anticholinergic synd
-tx antilerium
Properties of Anticholinergics
-for intubation, intraoral procedures, bronchoscopic procedures
Scopolamie > Glycopyrolatez > Atropine
Properties of Anticholinergics
Sedation & Amnesia
Scopolamie> >Atropine> glycopyrolate
Properties of Anticholinergics
Vagolytic action
Blockade of ACh on SA node
Atropine> Glycopyrolate > Scopolamine
Gastric fluic pH & vol
Pts at risk of aspiration
full stomach
Mendelson's syn (asp pneumonitis pH 2.5/ 25ml of contnets
Preop fasting
NPO after MN (controversial)
-studies suggest clrs 2-3 ok
-peds pts risk
hypovol, hypoglycemia
Aspiration prophylaxis
H2 recp antag
dec gast secretions w/ H+ ion conc
Few side effects
multiple dose regimens more effective than single
Aspiration prophylaxis
More potent, specific, longer acting
Dose IV 50-100mg
Duration: 9 hrs
Fewer SE than cimetadine
Aspiration prophylaxis Famotidine
H2 recpt antag
IV 20mg every 12 hrs
Metabolism: liver
Cleared: Renal
Aspiration prophylaxis
Neutralize gastric contents
100% effective inc pH >2.5
Give 15-30min prior to induct
Na Citrate .3M
No damage to lungs if asp
Quick act good for emergency
No inc gastric volume
Aspiration prophylaxis
Droperidol .625mg IV (arrhy)
Metoclopramide inc gastric empty (avoid in bowel obst)
Ondansetron 5 HT3 recpt antag
(4mg prior to surg, intra, or as rescue for NV
Implications for specific drugs
Anti HTN's
may cause dehydration
some will potentiate anesth
continue on day of surg
Specific drugs Diuretics SE's
may cause dehydration
give day of surg
Specific drugs Antianginal
Ca+ ch/ beta blks nitrates
give day of surg
Specific drugs Antidysrhythmic
generally continued
possible SE's
Do not D/C w/o consulting
Specific drugs Bronchodilators
use of aminophylline controversial
-volatic agents are bronchodilators
-aerosolized bronchodialtors and corticos as needed
Specific drugs Insulin
Tight control
Tight control, expensive, difficut (state of art)
Loose control favored for minor surg
Tight control
- improve hemodynamics
-improve wound healing
Specific drugs Insulin
Loose control
no insulin/start IV/check BG
Start dextrose, give 1/2 dose insulin/ check BG
Specific drugs Oral Hypoglycemics
Hold day of surg
DC metformin 1wk prior to surg (d/t lactic acidosis)
Specific drugs Corticosteroids
Note detailed hx of use
May need stress dose
Prednisone >10mg/day >6mos
(intra op)
Specific drugs
Thyroxine hold or give
Antithyroids should give
Specific drugs Anticonvulsants
Sould take
May induce liver enzy
Alter pharmacokinetics or other anesthetic drugs (inc need of drugs)
Specific drugs MAOI's
DC prior two weeks to surg
(d/t inc catechol stores)
-Caution w/ meperidine
Specific drugs Tricyclics
continue until day of surg
blk reuptake of NE
May prolong sleep or myocardial depress
- exag response to Ephedrine
-dec BP -> Neo
Specific drugs Lithium
Cont until day of surg
Muscle relaxant
Specific drugs Anti- inflams
interferes with plt function
surgeon will decide whether to continue
Specific drugs Anticoags
Surgeon will regulate/ may consult anesth
Switch to Heparin
Stop 3-4 hr pre-op
INR if regional anesth given
Specific drugs Antineoplastics
Take a good hx
look of agents
-Bleomycin (O2 tox keep FIO2 below 30%)
Adriamycin (heart value)
Specific drugs Antiglaucoma
Cholinesterase inhib
Beta Blkers (makes succholine last longer
Specific drugs Antibiotics
Beaware of cross sens
May potentiate NMB's (Gentamycin)
Specific drugs Opiods & Benzo's
-know last dose
-titrate according to need
-If on gtt may need more
Specific drugs Recreational drugs
remain non-judge
emphasize safety
look for withdrawl
Preanesthesia Doc
Review preop eval if done by another provider
-Review preop note
-pt exam
-agreement w/ assess/pain
-documentation of updated counseling
Anesthesia Document
What goes on it
Data from case
Basic checks of OR
Equipment, gas supply
Drugs, Vitals
Monitoring Pt
Eval of oxygen
-alarms set
-low flow alarm
Pulse ox
Continous valuation of adequacy of ventilation
Auscl breath sounds
Audible disconnect alarm on vent
ID CO2 in exhaled gas after intubation
Cont EKG
Document HR/BP Q 5min
Pts under General Anesth are monitored by
auscult of heart sounds
monitoring of intra art BP
Ultrasound perph pulse monitoring or pulse plethysmography
Drugs & agents used
Amounts given and times
Bolus drugs
Infusion drugs
Drugs & agents used Amount of controlled drugs
Type, amt, times given
Fluids given (time based & totaled)
Bld doc by reference #
Urine out (time base & total)
Bld loss (time base & total)
Techniques and monitors used
list all techniques not implied on record
List all monitors not clearly implied on record
- Unusual events
time base
narrative note
action taken
Post op status
doc mental status /LOC
Doc airway & vent status
Doc adequacy of pain cont
Sensory level & monitor funcntion if regional anesth
Vitals, SpO2
Post anesth Doc
Pt eval on admission to PACU
Pt eval on d/C from PACU
Time based record in PACU
Other Documentation
care given
pain control
unusual events or complications
Post anesth visit
Times dates of visits
Pt condition, VS, Pain, food inake if sigmificant
Complications of Care
Questions answered.