Case Study Patient Undergoing Anaesthesia Essay

Case Study Patient Undergoing Anaesthesia - Essay Example Patient was referred to the pre-anaesthetic check up (PAC) clinic where she was evaluated and given a PAC form with clearance for general anaesthesia. Preoperative assessment Pre anaesthetic assessment followed the standard protocol of history taking, physical examination and investigations. Apart from off and on abdominal pain with nausea for the past 3 months, no other complaints were elicited. There was no history of jaundice. Questions pertaining to other systems (cardiac, respiratory, neurological, endocrine) revealed no abnormality. There were no positive histories of drug allergies, previous surgery, drug addiction, smoking or alcohol abuse. Patient had no active respiratory tract infection. Her vital parameters (weight, heart rate, blood pressure, temperature, and respiratory rate), general physical examination (no pallor, icterus, cyanosis, lymphadenopathy, pedal oedema) and systemic examination were within normal limits. Airway assessment predicted no difficulty in airway m anagement. As the surgeons had already gotten her liver function tests done, which were normal, no additional investigations in a young healthy female without associated co-morbidities were required and the patient was classified as ASA grade I. Patient was briefly explained about the anaesthetic procedure and all her queries were satisfactorily answered. She wasn’t overtly anxious, but she did express her apprehensions regarding the degree to which the procedure was likely to be painful. She was explained that the necessary pain medications will be given to her and best possible efforts in this regard would be done. A written and informed consent for anaesthesia was obtained. Thus, patient’s physiological as well as psychological needs were well addressed (Miller et al 2009). Pre operative instructions were explained to the patient verbally and were mentioned on her PAC form as well. She was instructed to bring the PAC form along with all other clinical documents and report to the preoperative holding area in the morning at a specified time on the day of surgery accompanied with a responsible adult as an attendant. Her pre-op orders included fasting orders (nil per oral) for 8 hours prior to surgery, a mild anxiolytic tablet and aspiration prophylaxis tablet (antacid) to be taken the night before surgery and in the morning with a sip of water. (Miller et al 2009). Anaesthetic procedure As the patient had been administered only a mild anxiolytic and no sedatives, she arrived walking in the preoperative area on the morning of the scheduled date. Her PAC form was reviewed and she was enquired about any fresh complaints. Her vital parameters were recorded along with temperature at the tympanic membrane. She was found to be afebrile (36.5?C). She was asked to change into OT clothes and was then shifted inside for induction of anaesthesia. Theatre preparation had been done prior to arrival of the patient inside. This involved maintaining the ambient t emperature (22?C in this case) and humidity levels and anaesthesia machine, medication and resuscitation equipment check. Anaesthetic equipment was checked in accordance with the guidelines currently in use issued by the Association of Anaesthetists of Great Britain and Ireland. Alarm limits on the monitor were set according to the patient. Drugs for anaesthesia were prepared, labelled and kept on the workstation. Emergency cart was checked for