Download Pre op Assessment - Iowa Society of PeriAnesthesia Nurses

Preop Assessment:
Pulling It Altogether,
What Am I Looking For?
Nancy Strzyzewski MSN, RN,
CPAN, CAPA
Objective

Identify common co morbidities that should
be identified during preop assessment
The Cardiovascular Golden
Rule

OXYGENATION!!

Maximize oxygen delivery to body tissues – optimize
perfusion

Minimize oxygen consumption of the myocardium
 Supply versus Demand

Increase MVO2 = angina? = ischemia

Gusick, G. (2010) Cardiovascular care. In PeriAnesthesia Nursing Core
Curriculum Preprocedure, Phase I and Phase II PACU Nursing, 2nd ed, L.
Schick & P. Windle, Saunders, St. Louis.
Key Ingredients of Oxygen
Delivery
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Cardiac Output (amount of blood ejected
from the ventricles per minute)
Hemoglobin
Arterial oxygen saturation
Cardiac Output Equals….

Stroke Volume (SV) x Heart Rate

Stroke Volume – amount of blood ejected
from ventricle with each heart beat
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Preload – volume of blood filling the ventricle at
end of diastole
Afterload – pressure ventricle must overcome to
to eject blood (systemic)
Contractility
Maximize Oxygen Delivery and
Minimize Demand
“Every assessment and intervention focused
toward optimizing tissue perfusion” Core, p.
699.

Adequate cardiac function

Assessing Cardiac Output 

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SV
Afterload
Contractility
Assessing Cardiac Output –
Stroke Volume
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Pre load – volume
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Assessing and treating factors that affect Pre load
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Volume – BP, HR, EBL, I and O, volume returning
back to heart
Bleeding, clotting times, blood products
Assessing Cardiac Output –
Stroke Volume

Afterload – resistance to ejection from
ventricle

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Increased by: peripheral vasoconstriction,
obstruction to flow – valvular stenosis, pulmonary
embolism, inc ventricular diameter, blood viscosity
Decreased by: peripheral vasodilation,
incompetent valves
Assessing Cardiac Output –
Stroke Volume

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Assessing and treating factors that affect
Afterload
Non-cardiac causes:
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Temperature – hypothermic, hyperthermic
Vasoconstriction – HTN
Vasodilation – spinal (sympathetic block), sepsis
Assessing Cardiac Output –
Stroke Volume

Contractility

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Increased by: sympathetic nervous stimulation
Decreased by: ischemia/hypoxia, hypothermia,
hypomagnesemia, hypokalemia, hypercalcemia,
acidosis/hypercapnia
Assessing – HR, Rhythm, SNS stimuli,
Resp/Metabolic imbalances
Common CV Diseases - HTN

Risk factor for: ischemic heart disease

Major cause of CHF, CVA, arterial aneurysm
and end-stage renal disease

Conditions associated with: OSA, left
ventricular hypertrophy
Pre op Assessment - HTN

Evidence of End organ damage:
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Angina
Left ventricular hypertrophy
CHF
Cerebrovascular disease/ CVA
Renal insufficiency
Meds – ACE inhibitors
Post Anesthesia Concerns HTN

Assessment – pain, fluid overload, causes of
(full bladder?, PONV?)

Treatment goal – minimize the risks of
myocardial ischemia, congestive heart failure,
stroke, bleeding
Stoelting, R. & Dierdorf, S. (2002) Handbook for Anesthesia and Co-existing
Disease, 2nd edition. Churchill Livingstone, p. 62 – 73.
Common CV Diseases - CAD

Accumulation of plaque narrows vessels,
obstructs flow

Increased risk for: MI, diabetes, HTN, renal
disease, CHF

Pre op assessment?
Perianesthesia Concerns - CAD

Inc risk for MI due to:

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Decreased oxygen supply: hypotension,
vasospasm, anemia, hypoxia
Increased oxygen demand: sympathetic
stimulation, surgical stress/pain
Post anesthesia care?
Common CV Diseases – Valvular
Disease

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Stenosis, insufficiency or mixed
Stenosis – narrowing of valvular orifice,
increases resistance to blood flowing out
Insufficiency – regurgitation of blood through
valve into the previous chamber
Valvular Disease – Pre op
Assessment
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H&P
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CHF – exercise tolerance
Heart murmur?
Dysrhythymias – espec atrial fibrillation
Ischemic heart disease
Angina
Prior to Admission meds
Perianesthesia Concerns Valvular

ECG monitoring – rhythm and rate issues
Systemic BP
Systemic vascular resistance
Pulmonary vascular resistance

Pressure or fluid overload?
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Pulmonary Issues
Most common:
 unexplained dyspnea,
 asthma,
 chronic obstructive pulmonary disease (COPD)
 obstructive sleep apnea
Pre op Assessment - Asthma
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Age of onset
Known triggering events
Hospitalization for
Known allergies
Cough
Sputum – change in color/characteristic
Previous anesthetic history
Current medications
Perianesthesia Concerns Asthma
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Brochospasm
Oxygenation
Obstructive Sleep Apnea
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Pattern of repeated collapse of the upper
airway during sleep with cessation of
breathing
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Threat to patent airway – anesthetic agents,
opioids
Pre op Assessment - OSA
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Obesity – BMI
Neck size
History of: snoring, daytime somnolence,
fatigue, pulmonary and systemic HTN, MI,
CHF, right and left ventricular hypertrophy
Sleep studies? CPAP?
Perianesthesia Concerns - OSA
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Monitoring respiratory function
Oxygen saturation v.s. end tidal carbon
dioxide monitoring
Opioid use
Extended stay in PACU
CPAP use in PACU
Safe transfer of care
Questions?