Exam 1 - Principles of Nurse Anesthesia - Pre-op Assessment
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| The extent of the pre-op work-up depends on what 3 things? | 1) Medical condition of the Pt
2) Type of surgery being performed
3) Type of anesthesia required for the surgery
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| Name the 3 assessment areas in the pre-op: | 1) Review of medical records
2) Pt interview
3) Physical exam
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| The preanesthesia assessment clinic benefits patients by allowing them to complete what 5 things prior to surgery? | 1) Registration
2) H & P
3) Teaching
4) Consults
5) Dx testing
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| How soon before surgery should a patient with a complex medical history be evaluated for surgery? | 1 week
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| What are the 8 categories of health conditions whereby a patient would benefit from an early preop assessment? | 1) General
2) CV
3) Respiratory
4) Endocrinologic
5) Hepatic
6) Musculoskeletal
7) Oncologic
8) GI
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| What 4 General Health conditions benefit from an early preop? | 1) Inability to engage in normal ADLs
2) Conditions necessitating continual assistance or at-home monitoring w/in the past 6mos.
3) Acute episodes or exacerbations of chronic conditions w/in the past 2mos.
4) Meds that will require schedule modificatio
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| A patient with a history of what 6 CV conditions would benefit from an early pre-op anesthesia assessment? | 1) Angina
2) CAD
3) MI
4) Symptomatic arrhythmias
5) Poorly controlled HTN (dia >110, sys >160)
6) CHF
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| What 3 respiratory conditions necessitate an early pre-op? | 1) Asthma or COPD req'ing chronic meds; acute exac. or progression of these dx's w/in past 6mos.
2) H/o major airway sx, unusual airway anatomy, upper/lower airway tumor or obstruction
3) Chronic resp. distress req'ing home vent assistance or monitoring
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| What 3 endocrinologic factors would benefit from an early pre-op assessment? | 1) Diabetes treated with insulin or oral antidiabetics
2) Adrenal d/o
3) Active thyroid dx
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| What hepatic condition would benefit from an early preop assessment? | Active hepatobiliary disease
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| What musculoskeletal factors benefit from an early preop assessment? | 1) Kyphosis/scoliosis w/functional compromise
2) TMJ w/restricted mobility
3) Cervical or thoracic injury
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| What 2 oncologic conditions benefit from an early preop assessment? | 1) Pt receiving chemotherapy
2) Oncologic process w/significant physiologic residua or compromise
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| Patients with what GI symptoms would benefit from an early pre-op anesthesia assessment? | 1) Massive obesity (>140% IBW)
2) Hiatal hernia
3) GERD
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| What can provide a basic direction of the patient interview and assessment? | Patient chart
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| The "current medical information" in a patient chart contains key pieces of information for surgery. What are the 7 key pieces of information noted in the current medical history? | 1) Surgical consent
2) Surgeon's name/date/proposed surgery
3) Baseline data (Ht/Wt, VS)
4) Progress notes and consults
5) Medical treatments w/drug doses and schedules
6) Diagnostics (XR, labs)
7) Social factors (cultural factors, coping mech
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| The pt interview is designed to reduce ______ and increase _______. | anxiety, patient satisfaction
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| What does plasma cholinesterase break down and what can a deficiency of this enzyme lead to? | Acetylcholine; prolonged paralysis w/paralytics
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| Patients that are reported as latex ______ should be treated as latex ______. | Sensitive; allergic
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| Where should latex allergic patients be placed in the OR schedule? | 1st case
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| What exam diagnoses a genetic predisposition for latex allergy? | Caffeine muscle biopsy
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| Who is at risk for latex allergies? | 1) Spina bifida pts
2) Healthcare workers
3) Individuals w/frequent exposure to latex
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| Nicotine is a toxic _____ that produces a _____ effect in the cardiovascular system. | alkaloid, ganglionic
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| What are the ganglionic effects of nicotine? (6) | Increased:
1 - HR
2 - BP
3 - Myocardial contractility
4 - Myocardial O2 consumption
5 - Myocardial excitement
6 - PVR
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| CO has an affinity for HGB that is _______X greater than O2. | 250-300
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| Preop smoking cessation for at least ______ weeks may greatly improve pulm. mechanics. | 8
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| What are 3 anesthetic complications noted in children exposed to second-hand smoke? | 1) laryngospasm
2) coughing on induction or emergence
3) post-op desats
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| Chronic alcoholism creates resistance/tolerance to CNS depressants such as _________, ________, and __________. | hypnotics, opioids, inhaled gases
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| Increased morbidity and mortality is associated with ETOH abuse due to what 4 effects? | 1) poor wound healing
2) infx
3) bleeding
4) hepatic injury
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| What are the 2 most popular illicit drugs? | cocaine, MJ
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| What are s/s of illicit drug use? (6) | 1) evidence of injections
2) pupil constriction
3) lymphadenopathy
4) malnutrition
5) poor dentition
6) nasal perforation
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| What are the s/s of MJ use? | 1) tachycardia
2) labile BP
3) euphoria
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| What are the s/s of cocaine/amphetamine use? | 1) HTN
2) excitement
3) hallucinations
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| What are the s/s of hallucinogenic use? | 1) dissociative reactions
2) hallucinations
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| What two organ systems are negatively affected by anabolic steroid use? | hepatic and endocrine
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| What are 4 supplements that contribute to anticoagulation? | Garlic, gensing, ginko ginger
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| How is the minimum alveolar concentration (MAC) of anesthesia affected with chronic alcoholism? | MAC is increased
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| Ginger can alter serum levels of __________. | glucose
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| Ephedra is a CNS [stimulant/depressant]. | stimulant
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| What two herbal supplements have CNS depressant qualities? | Ginger and kava kava
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| St. John's wort has been used to treat what psychologic malady? | Depression
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| The physical airway exam includes assessments of what features? | 1)Teeth 2)Inside of the mouth 3)Mandible 4)Neck
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| What is the patient asked to do during the Mallampati classification? | Open their mouth as wide as possible and extrude their tongue without phonation.
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| The Mallampati exam is used to assess which features in the airway? | Tonsils, tonsillar fossa, pharynx
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| What is visible in each classification of the Mallampati scoring system? | Class: 1)Entire tonsil clearly visible 2)Upper half of tonsil fossa is visible 3) Soft and hard palates clearly visible 4)Only the hard palate is visible
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| The lower the Mallampati score the __________ the intubation, the higher the Mallampati score the ___________ the intubation. | Easier, harder
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| The thyromental distance is the space between what two features? | Prominence of the thyroid cartilage and bony point of the lower mandibular border
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| What is associated with a difficult endotracheal intubation in regards to the thyromental distance? | <7cm or three finger breadths
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| The [thyromental/sternomental] distance is said to be more predictive of a difficult airway. | sternomental
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| The sternomental distance measures the space between what two features? | The upper border of the manubrium sterni and bony point of the lower mandibular border
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| A sternomental distance of less than _______cm is suggestive of a difficult airway. | 13.5
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| 4 finger breadths is approximately _______in. | 3
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| What does the interincisor distance measure? | The degree of mouth opening
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| The degree of mouth opening is controlled by what joint? | temporomandibular joint
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| How far between the upper and lower incisors should an adult be able to open their mouth? | At least 4cm (2 large finger breadths)
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| The antlantooccipital function measures the degree of movement between what two body parts? | Head and neck
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| Moderate flexion of the neck on the chest and full extension of the atlantooccipital joint aligns the axes of what three important airway features? | Oral cavity, pharynx, larynx
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| The McGill position is also known as the ________ position. | "sniff"
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| What types of oral equipment should be removed prior to surgery? | Dentures and partial plates
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| The removal of what object can prevent aspiration during anesthesia? | Loose teeth
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| Obesity is defined as a bodyweight more than _________% above ideal bodyweight (IBW). | 20
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| Morbid obesity is defined as a bodyweight more than __________% above IBW. | 40
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| What is the equation used to calculate IBW for men? Women? | Men: 105lbs + 6lbs for each inch > 5ft // Women: 100lbs + 5lbs for each inch > 5ft
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| What is a more specific approach to measure weight in relation to height? | BMI
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| What is the equation to calculate BMI? | Weight in kg divided by height in meters sq.
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| What is the BMI range to be considered overweight? Obese? Morbidly obese? | 1)25-29.9 2)30-35 3)>35
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| What are illnesses associated with obesity? (8) | 1)HTN 2)Dysplipidemia 3)CHF 4)Gallstones 5)Hernias 6)OSA 7)OA 8)Respiratory disorders
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| What possibility needs to be considered with the obese patient? | Difficult intubation
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| What type of intubation needs to be considered with the difficult airway? | Fiberoptic
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| What two types of medications should be considered in preparation for a fiberoptic intubation? | Anticholinergics and antisialagogues
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| What inflammatory arthropathy causes severely compromised upper airway management of the cervical spine? | Ankylosing spondylitis
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| What pharmacologic considerations should be made for patients with ankylosing spondylitis? | NSAIDs, corticosteroids
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| Patients who have been on steroids must be considered for a ______________ dose of steroids. | Pre-op
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| Rheumatoid arthritis affects the mobility of __________. | Joints
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| In what three ways does rheumatoid arthritis affect the airway? | 1)Limited ROM of the TMJ 2)Restrictions in vocal cord movement 3)Tracheal stenosis
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| Hoarseness, stridor, painful speech, and dysphagia are all signs and symptoms that can occur with exacerbations of what inflammatory disease? | Rheumatoid arthritis
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| What cardiopulmonary complications may occur with ankylosing spondylitis and rheumatoid arthritis? (5) | 1)Restrictive lung disease 2)Pleural effusions 3)Pericardial effusions 4)Polychodritis 5)Cardiac conduction abnormalities
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| The initial neuro exam consists of assessment of what 4 areas? | 1)Musculoskeletal 2)Sensory system 3)Cranial nerves 4)Mental status
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| What are clinical manifestations of neurological disease? | 1)Increased ICP 2)Sympathetic overactivity 3)Fever and leukocytosis 4)Coma and obtundation
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| A glasgow coma scale of less than _______ is considered comatose. | 8
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| A Glasgow coma scale of less than _______ requires mechanical ventilation support. | 7
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| If indicated, a neuro preop assessment should be followed by what 5 things? | 1)review of diagnostic results 2)neurology consult 3)interpretation of CT scans 4)review of the degree of cerebral vascular occlusion 5)12-lead ECG and cardiology consult
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| Anesthetic management of a patient with a neurological disorder should include monitoring levels of what two things? | Anticonvulsants (if presently taking) and glucose
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| In relation to anesthesia, what medications should be avoided in patients with neurological disorders? | Sedatives
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| In relation to anesthesia, what medications should be given to patients with neurological disorders? | Corticosteroids
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| Evaluation of the CV system should include what key points? (3) | 1) Pre-existing cardiac disease 2)Disease severity, stability, and prior treatment modalities 3)Type of indicated surgery
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| What are the MAJOR CV risk factors for anesthesia? (8) | 1)Unstable coronary syndrome 2)Recent MI 3)Unstable/severe angina 4)CHF 5)High grade AV block (3rd degree) 6)Symptomatic ventricular arrhythmias 7)Supraventricular arrhythmias 8)Severe valvular disease
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| What are 4 INTERMEDIATE CV risk factors for anesthesia? | 1)Mild angina 2)Prior MI 3)Compensated or prior CHF 4)Renal insufficiency
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| What are the 6 MINOR CV risk factors for anesthesia? | 1)Advanced age 2)Abnormal ECG 3)Rhythm other than sinus 4)Low functional capacity 5)History of stroke 6)Uncontrolled systemic HTN
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| The New York Heart Association (NYHA) divides patients into categories that assess what factor? | Degree of heart failure with CV disease
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| What is stable angina characterized by? | Substernal discomfort w/exertion but relieved with rest or SL NTG
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| What is unstable angina characterized by? | Angina is progressive with increases in frequency, intensity, and duration that is less responsive to medications or rest.
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| Which patients are at prominent and great risks for a peri-operative MI? | Patient with left ventricular failure and especially ischemic cardiomyopathy
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| What are pertinent signs and symptoms of LVH or ischemic cardiomyopathy? | Rales, resting tachycardia, S3 heart sounds, JVD
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| In the presence of CHF, surgery should _____________. | Postponed
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| Cardiac valve incompetence is also known as cardiac valve _______________. | regurgitation
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| What are the two most common valves of stenosis and/or regurgitation? | Aortic, mitral
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| What is the most common cause of valvular disease? | Rheumatic fever
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| It is imperative to obtain a pre-op _________ for patients with a history of cardiac valve disease or arrhythmias. | EKG
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| What significant pre-op labs should be collected in a patient with a history of cardiac disease or valvular disease? | Potassium, magnesium, serum levels of antiarrhythmics
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| What are the three categories of ventricular arrhythmias? | Benign ventricular, potentially malignant, malignant
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| Describe each category of ventricular arrhythmias. | Benign: unifocal PVCs w/low periop risk. Potentially malignant: known heart disease on antiarrhythmic Rx. Malignant: Heart disease w/hemodynamic compromise and family h/o sudden death.
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| When is the DOO/VOO mode necessary for a patient with an intrinsic pacemaker? | When electrocautery of cardiac muscle is involved
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| True/False: Pacemakers can mask toxic effects. | True
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| Succinylcholine is associated with an increased release of what electrolyte? | Potassium
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| What are two indications for pacemaker placement? | Persistent bradycardia, bi-fascicular block
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| When should pre-op cardiac testing not be performed? | When results will not influence the patient management
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| What are the two types of chemical stress tests? | Adenosine and dobutamine
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| Which stress test involves coronary steal syndrom? | adenosine
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| What occurs in the adenosine stress test in relation to coronary blood flow? | Blood flow is redestributed without negative inotropic effects
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| What three values indicate poor ventricular function? | CI <2.2, LVEDP > 18mmHg, EF <40%
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