CHAPTER 16. History and Physical Examinations
Rose Ferrara-Love
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. State goals of preoperative history and physical exams.
2. Plan a subjective and objective patient exam.
3. Discuss the importance of completing a system review.
I. THE NURSING HISTORY AND PHYSICAL EXAMINATION
A. General health
1. Questions and observations regarding overall health include:
a. General appearance
b. Height
c. Weight
(1) Often converted to kilograms to facilitate rapid calculation of medication doses in milligram per kilogram (mg/kg) format
(a) Weight in pounds (divided by 2.2 equals weight in kilograms)
(b) Weight in kilograms (multiplied by 2.2 equals weight in pounds)
(2) Obesity
(a) Many freestanding surgical centers enforce weight restrictions because of increased risk of anesthesia complications.
(i) Usually 300 lb (136.4 kg)
(3) Recent unplanned weight loss
d. Recent or current infection
(1) Upper respiratory infections
(2) Lower respiratory infections
e Allergies
(1) Food
(2) Drugs
(3) Environment
f. Nutritional habits
g. Physical handicaps
(1) Use of adjuncts for walking
2. Family history
a. Problems with anesthesia
(1) Malignant hyperthermia (MH)
(a) Anesthetic-related deaths
(b) MH testing
(i) Caffeine-halothane contracture test
3. Physical examination includes observation.
a. Skin
(1) Color
(2) Turgor
(3) Elasticity
(4) Presence of bruises
(a) May necessitate report to authorities if abuse is suspected
(5) Other injuries
(6) Dryness
(7) Lesions
(a) Mucous membrane
(8) Cleanliness
(9) Dental hygiene
b Abnormalities
(1) Posture
(2) Gait
(3) Mobility
(a) Use of wheelchair, walker, or cane should be noted.
(4) Pain at rest
c. Physical characteristics
(1) Potential complications for intubation
(a) Short, stocky neck
(b) Cervical fusion or arthritis
(c) Thick tongue
(d) Temporal mandibular joint disease
(e) Dental or orthopedic abnormalities
d. Vital signs should be obtained to identify aberrancies and for baseline measurements.
(1) Blood pressure
(a) Dynamic measurements that change minute to minute
(i) Response to:
[a] Environment
[b] Physiologic demands
(b) Average ranges
(i) 100 to 135 mm Hg systolic
(ii) 60 to 80 mm Hg diastolic
(c) Orthostatic measurements with underlying cardiac or hypertensive history
(2) Pulse rate
(a) Average range 60 to 100 beats per minute
(3) Respirations
(a) Average rate
(i) 12 to 20 breaths per minute
(ii) 16 to 25 breaths per minute in elderly
(b) Use of accessory muscles of respiration
(c) Shape and symmetry
(d) Sternal abnormalities
(i) Pectus carinatum
[a] Chicken breast or pigeon breast
(ii) Pectus excavatum
[a] Breastbone caves in resulting in sunken chest appearance
(iii) Anterior-posterior diameter increased
[a] May be normal with:
[1] Age
[2] Hyperinflation
(e) Abnormal breathing patterns
(i) Küssmaul
(ii) Cheyne-Stokes
(iii) Biot’s
(4) Temperature (see Chapter 24)
(a) Oral temperatures are considered normal at 96.4° F (35° C).
(b) Rectal temperatures average slightly less than 1° F higher.
(c) Axillary temperatures are approximately 0.5° F to 1° F lower.
(d) Tympanic thermometer readings are approximately 0.5° F to 1° F higher than oral readings.
(e) Temporal thermometer readings are more accurate than tympanic thermometer readings.
(f) Variances in normal ranges
(i) Normal physiologic status
(g) Extrinsic forces
(i) Medication
(ii) Recent exercise
(iii) Effort
(iv) Anxiety
(v) Fear
B. Medication history
1. Medication protocol affects types of medications and anesthetic agents used.
a. Helps avoid untoward drug interactions or withdrawal episodes
2. Include in history form
a. Names
b. Dosages
c. Frequency
(1) Date and time of last dose
(a) Medication reconciliation upon admission and before discharge
d. Length of time prescribed
e. Effects
f. Nonprescription drugs
(1) Aspirin
(a) Prolongs bleeding time
g. Herbal preparations
h. Habit-forming drugs used
(1) Tobacco
(a) Number of pack years
(i) Number of packs per day × number of years
(ii) Attempts to stop
(b) Smokeless tobacco
(i) Amount per day
(2) Alcohol
(a) Type
(b) Amount
(c) Frequency
(d) Changes in reaction to alcohol intake
(3) Recreational
(4) Prescription
i. Side effects
j Allergic reactions
(1) Specific drug
(a) May know only category of drug (i.e., antibiotic)
(b) Identify if related categories will be used in the ambulatory surgery center (ASC).
(2) Specific reaction
(a) True allergy or expected side effect
(3) Usually documented in red
(a) Highly visible
(i) On medical record
(b) On patient identification band
(4) Environmental and food allergies
(a) Allergy to eggs may have possible cross-sensitivity with propofol.
(b) Allergy to bananas, kiwis, peaches, water chestnuts may have link with latex allergies.
(i) Cutaneous exposure (i.e., latex)
[a] Anesthesia masks, head straps, rebreathing masks, tourniquets, ECG patches, adhesive tape, surgical gloves
[b] Other sources: elastic bandages, rubber positioning rings, rubber shoes, elastic clothing, balloons, Koosh balls, sporting equipment
(ii) Mucous membrane
[a] Nasogastric tubes, balloons, nipples, pacifiers, products used in dentistry, urinary catheters, glove contact with vaginal mucosa, enema kits, rectal pressure catheters (especially in patients with spina bifida and impaired bowel control)
[b] Other sources: condoms
(iii) Inhalation
[a] Often associated with glove powder
(iv) Internal tissue
[a] Intraoperative resulting from surgical gloves contacting the peritoneum or internal organs
(v) Intravascular
[a] Disposable syringes, medication aspirated from vials with latex stoppers, injection of medication via ports of intravenous tubing (latex can leech into solutions injected)
C. Nutrition status
1. Weight history
a. Typical day’s diet
(1) Salt
(2) Saturated fats
(3) Food habits
(a) Ethnicity
(4) Dentition
2. Physiologic processes dependent upon proper nutrition
a. Wound healing
b. Oxygen transport
c. Enzyme synthesis
d. Clotting factors
e. Resistance to infection
3. Diseases associated with poor nutrition
a. Crohn’s disease
b. Malignancies
c. Chronic obstructive pulmonary disease
d. Ulcerative colitis
4. Indications of malnutrition
a. Anorexia
b. Recent weight loss
c. Dull hair
d. Brittle nails
e. Diagnostic tests
(1) Decreased lymphocytes
(2) Decreased serum albumin and transferrin levels
5. Obesity complicates:
a. Administration of anesthesia
(1) Requires higher-than-normal levels of anesthetic agents
(a) Fat-soluble agents tend to prolong effects.
(2) Increased stress on cardiovascular system
(a) Increased oxygen needs
(b) Increased carbon dioxide production
(i) Associated with increased body mass
b. Technical aspects of performing procedure
(1) Often difficult to intubate
(a) Difficult to maintain airway
(i) Increased risk of aspiration
(ii) Increased intra-abdominal pressures
(b) Gastric contents higher in volume and more acidic
(2) Problems with positioning
(a) Weight of abdominal and chest contents can cause respiratory embarrassment when in Trendelenburg position.
(3) Difficult to perform venipuncture
c. Patient’s recovery
(1) Electrolyte and fluid balance essential for homeostasis (see Table 16-1)
(a) Regulates cardiac rhythm
(b) Muscle strength
(c) Distribution and metabolism of drugs
(i) Mental alertness
| Electrolyte Normal Value | Physiologic Functions | Excess | Deficiency |
|---|---|---|---|
| Potassium (K) 3.5-5.5 mEq/L | —Nerve conduction —Muscle contraction —Enzyme action for cellular energy production —Regulates intercellular osmolality | —Generalized muscle weakness, flaccidity; can affect respiratory muscles, paresthesia —Cardiac: bradycardia, ventricular ectopy and fibrillation, third degree heart block, asystole (>7.0 mEq/L) —ECG changes: flat or absent P wave, wide ORS, peaked T wave, prolonged PR interval | —Muscle weakness, flaccidity, fatigue, leg cramps, ↓ deep tendon reflexes, shallow respirations, weak, thready pulse, hypotension —Cardiac: atrial dysrhythmias, premature ventricular contractions (PVCs), atrioventricular (AV) blocks, cardiac arrest (<2.5 mEq/L) —ECG changes: flat or inverted T wave, depressed ST segment, U wave present, potentiates digitals toxicity, premature atrial contractions (PACs) or PVCs —Abdominal cramping, anorexia, malaise, nausea and vomiting, muscle weakness, headache, confusion, lethargy, convulsions, coma |
| Sodium (Na) 135-145 mEq/L | —Transmission and conduction of nerve impulses —Regulates vascular osmolality —Regulates neuromuscular activity via sodium pump | —Excitement; thirst; dry, sticky tongue and mucous membranes; oliguria; flushed skin; confusion; lethargy; coma; convulsions; hypo- or hypertension; elevated temperature | —Abdominal cramping, anorexia, malaise, nausea and vomiting, muscle weakness, headache, confusion, lethergy, convulsions, coma |
| Calcium (Ca) 8.5-10.5 mg/dl | —Nerve and muscle activity —Myocardial contractility —Maintains cell permeability —Converts prothrombin to thrombin —Formation of teeth and bones | —Lethargy, depression, apathy, anorexia, nausea and vomiting, muscle weakness, headache, confusion, decreased attention span, slurred speech, hypertension —Cardiac: heart block, PVCs, idioventricular rhythms, cardiac arrest —ECG changes: shortened QT interval | —Anxiety, excitement, hyperreflexia, grimacing, numbness and tingling of lips or fingers, muscle cramps and spasms, laryngospasm, convulsions, tetany, dysrhythmias including ventricular tachycardia (VT) —Positive Trousseau’s sign: carpal spasm after inflation of blood pressure cuff on upper arm to 20 mm Hg over systolic for 3 minutes, shows tetany —Positive Chvostek’s sign: abnormal facial spasm when facial nerve is tapped at the angle of the jaw —ECG changes: prolonged QT interval |
(2) Signs of dehydration
(a) Loss of skin turgor
(b) Listlessness
(c) Orthostatic hypotension
(d) Rapid and thready pulse
(e) Dryness of mucous membranes
(f) Thirst
(3) Cardiovascular
(a) Symptoms of cardiac disease
(i) Chest pain or tightness
(b) Palpitations
(c) Chronic fatigue
(d) Loss of appetite
(e) Angina
(f) Swelling of the ankles
(g) Paroxysmal nocturnal dyspnea
(h) Exhaustion
(4) Particular importance
(a) Recent cardiac surgery
(b) Myocardial infarction (MI)
(i) Considered most important indicator of anesthesia morbidity
(c) Generally elective, non-urgent surgery postponed for at least 6 months after an MI
(d) Angina
(e) Aortic stenosis
(f) Poorly controlled dysrhythmias
(g) Congestive heart failure (CHF)
(h) Extremes in blood pressure (high or low)
(i) Presence of pacemaker
(5) Physical examination parameters
(a) Apical pulse
(i) Rate
(b) Rhythm
(c) Quality
(d) At least one blood pressure reading
(e) Palpation of peripheral pulses
(f) Observation for edema
(g) Clubbing of fingers
(h) Cyanosis
(i) Distention of neck veins
(j) General energy level
(k) Respiratory ease
(l) Auscultation of heart for murmurs
(i) Systolic murmur over right sternal border, second intercostal space may indicate presence of aortic stenosis.
(ii) Associated with unexpected dysrhythmias
(m) Diminished stroke volume
6. Cardiac drugs
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a. Maintain normal routine preoperatively.
(1) Do not skip doses.
(a) Beta-blockers
(b) Calcium channel blockers
(c) Antihypertensives
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