So at the moment I am on an orthopedic ward and recently I did a spoke visit to the pre-assessment unit. These are a few of the many things I learnt doing pre-assessments. There is a lot of information to gather and it is important not to miss anything!
– Always check for allergies/sensitivities. When reading through the notes of one patient who I was pre-assessing I found no allergies recorded. However, on asking the patient I found that he had recently taken penicillin and had a bad reaction causing his tongue to swell. Allergies can develop at any time and so it is vital to always check for allergies!
– Patients with diabetes should be 1st on the operating list- their BM should be between 6 and 10. A hypo is classed as anything 4 and under and a hyper is 14 +.
– Drugs classed as complementary therapies should be stopped a week before the operation. I was surprised to learn that:
Garlic and ginkgo supplements cause increased bleeding
Valerian and Kava cause hypersomnia (or somnolence) which is an excessive need for sleep
Large amounts of grapefruit alter hepatic drug metabolism and can cause QT interval prolongation
Ephedra (diet pills) can cause cardiovascular disturbance
St John’s Wort can cause sedation, confusion and withdrawal, especially when mixed with a general anesthetic
– Drugs which can still be taken on the day of surgery are: anti-anginals, anti-arrythimics, anti-epileptics, Parkinson’s meds (except for Selegiline), anti-psychotic, anti-retrovirals, COPD/Asthma medication, beta-blockers, calcium channel blockers, cardiac glycosides, H2 receptor antagonists (ranitidine), immunosupressants, lithium, long-term benzos, long-term opioids, nitrates (GTN), proton pump inhibitors, statins, steroids and thyroid medication.
– To discuss with the anesthetist/surgical team – anti-platelets (Aspirin 75mg is generally ok. Aspirin takes 3 weeks to get out of the system so if the patient really needs to stop their Aspirin, it will only be effective if stopped for 3 weeks before), anti-coagulants, HRT, combined oral contraceptive, cytotoxic chemo, cytokine modulators (for Rheumatoid Arthritis), monoamine oxidase inhibitors, tamoxifen.
– To omit the day before and the day of surgery – ace inhibitors (ramipril).
– To omit the day of surgery – angiotensin receptor blockers, alpha blockers (doxazosin), anti-depressents and diuretics.
– For diabetes medication, metformin can be taken on the day usually. However as patients are nil by mouth unless having a minor op, a lot of diabetes medication can be omitted. For example Gliclazide which increases the amount of insulin produced in the pancreas. If patients are not eating then they will not need extra insulin as they will not be taking in any glucose which needs breaking down.
– Joint replacements always need 2 blood samples which are then crossmatched. This is because there is an increased likelihood of the need for a blood transfusion (although it is now pretty uncommon for joint replacements to need blood transfusions due to cell salvage and surgical techniques which limit blood loss). 2 are taken on separate occasions to make sure the sample is from the correct patient.
– All patients need MRSA tests.
-Many patients suffer from “white coat syndrome” – wait until the patient is calm and more relaxed before doing the blood pressure in pre-assessment. Do them manually for more accurate results – also this can be less intimidating for patients than an electrical blood pressure for patients. Sometimes electronic blood pressures can bruise patients and go very tight, also the machines often make noises such as loud beeps which patients can find worrying. I prefer to do manual blood pressures full stop as I think they are more accurate!
– When gathering past medical history from patients, particular conditions to look out for are those which cause excess bleeding such as hemophilia (hemo=blood phillia=love) or if patients are on anti-platelets or anti-coagulants which could cause excess bleeding. Other conditions to look out for are those which affect the respiratory system (especially if patients are having a G.A.) such as Asthma, COPD. Also any cardiovascular conditions – this can effect how suitable patients are for surgery.
– Also very importantly, ask the patient if they or any close family member (such as mother, father, brother, sister) have had DVTs, strokes, CVAs, PEs. This can increase their risk of having a blood clot.
– Ask if any of their blood family has had bad reactions to general anesthetics if the patient has never had a G.A. before.
– Do not bombard patients with information. As many of the patients I pre-assessed had to come back for 2nd blood samples, me and the nurse I worked with agreed not to give too much information verbally as there was another opportunity nearer the time for the patient to ask questions and find out more. Patients can only take in so much info and it can be very overwhelming for them listening to everything. Somewhere I read that patients only remember about 20% of what they are told in assessments. Therefore, it is important to give the patient the hospital number to ring if they have any more queries, also to give them relevant reading with information tailored for them and their particular operation to take home.
-I met a patient with haemochromatosis which is an inherited iron overload disorder. The patient had to have regular phlebotomy to keep his iron levels under control. Too much iron is bad for the liver as the body runs out of places to store it and so stores it in the liver which can cause scarring (fibrosis) and liver enlargement (heptaomegaly). Fibrosis can become cirrohsis if left untreated. It is a potentially lethal condition.
– ECGs are done on patients who have caridac problems, also on older patients and patients undergoing bigger operations such as joint replacements.
– Urine tests are important as you do not want patients with infections having surgery. If urine samples are positive for anything then it is important to send them off for further testing (culture and sensitivity) and so any infections can be treated before surgery.
– Blood test results:
Full blood count (FBC) – the most widely used blood test
Haemoglobin (HB)– low HB can indicate blood loss, anemia, cancers and kidney disease amongst other things
White blood cell count (WBC) – a high amount can indicate infection
Platelets – diseases cause an increase in platelets due to inflammation. Platelets help the blood to clot. A high amount increases the risk of blood clots for patients. A low amount means the blood won’t clot well and so excessive bleeding could be a problem during and after surgery.
Ferritin – low ferritin can indicate anemia.
These are just some of the things I dotted down in my few days on pre-assessment. Hope it is interesting to read 🙂