Giving A Good Post-Op Report

After every surgery, you will take the patient from the OR and transport them to either the Post Anesthesia Care Unit (PACU) or the Intensive Care Unit (ICU). Generally, patients only go to the ICU if they were originally transported directly to the OR from either the ICU or Emergency Department. Once you arrive, you will be transferring the care of the patient over to the staff of each unit. In order to do so safely, you will need to learn how to give a proper post-op report. In most instances this will be to a member of the nursing staff, a resident in charge of patient care, or both. Everyone has a different way they like to give their reports, but for the most part, it will always include the same components. Below I have listed the things I consider to be important. They are listed in the way that I present them to the staff members, however you do not need to follow this same order. I do, however, think it is helpful to give the report in the same way each time. It makes things easier if you can find a rhythm.  

In the PACU

• Patient name, age, and gender. (These may not always be obvious) 
• Any known allergies along with a description of the associated reaction.
• What surgery the patient just underwent, including the surgical site. Pay attention to everything the surgeon did. If you are unsure, don’t be afraid to ask the nurse or a member of the surgical team before heading to the PACU.
• At this point you can also explain why the patient was having this procedure done in the first place, even if it seems obvious.
• Other significant medical conditions & history.
• This part can be tricky at times because you want to be thorough but are also on a bit of a time crunch. Use your best judgment to include things that may impact post-operative patient care. ie. HTN, cardiac issues, respiratory issues, neurological problems/deficits, renal/liver issues, sites of chronic pain, etc.
• It can be helpful to look at your pre-op interview sheet while talking to the nurse. Use it as a cheat sheet.
• This would be a good time to let them know about any preoperative lab values that may relate to their conditions (H/H, Blood glucose, Creatinine, etc.)
• Access sites – Be sure to include any peripheral IV’s, central lines, arterial lines, etc. Note if any of the lines have been giving you issues during the intraoperative period (Do they flush well? Are they positional? How is the CVP or arterial waveform?)   
• Medications and totals given- They don’t need to know about every single medication. For example, they don’t necessarily need to know that you gave propofol and lidocaine at induction since this likely will not impact how they care for this patient. I have listed below the medications that I like to include.
• Premedication – Versed, Pepcid, Reglan, Albuterol, etc.These are particularly import for shorter procedures where the medication may still be active by the time the patient wakes up.
• Pain medications – Narcotics (fentanyl, morphine, dilaudid), NSAID (Torodol), Ofirmev, etc. Include general times of when you gave these. It can give the nurse a better idea of when they may need more.
• Anti-emetics – Decadron, Zofran, did you run the case as a TIVA?
• Antibiotics – Ancef, Vancomycin, Zosyn, Clindamycin, etc.Include the times given. The patient may need a redose soon.
• Beta blockers, anti-hypertensives, cardiac drugs- Metoprolol, Labetalol, Hydralazine, etc. Many of these medications have long half-lives that can last well in to the post-operative period and can have profound effects on hemodynamic stability.
• Paralytic and reversal – I don’t usually give totals of these medications, just let them know that they were given.
• Ins and Outs –
• Total fluid given – Distinguish amongst crystalloids, colloids, and blood products.
• Urine output  
• Estimated blood loss
• Intraoperative course – How did the patient do during the procedure on our end of things.
• If the patient was stable the entire time, let them know that.
• BP issues- Hyper/hypotensive?
• EKG changes/changes in HR
• Respiratory troubles – problems oxygenating/ventilating?
• Difficulty managing the airway?
• Difficulty waking patient up?
• Any important lab value changes from ABG’s or VBG’s.

In the ICU

A report given in the ICU will be similar to one given in PACU with a few minor differences:

•  These staff are already familiar with these patients because they generally have been taking care of them for a period of time. For this reason, you do not need to include the patient’s medical history in your report.
• These patients are usually in pretty bad shape, that’s why they are in the ICU. They may already have a number of lines in. Just let the staff know if you added any new lines or took any out.
• Often times, you may take these patients to the ICU on drips in an effort to control hemodynamic stability or keep the patient sedated. Be sure to tell the staff of any infusions they are still on, at what rate they are going, and if you anticipate that they will need to stay on them.
• It is important to be very thorough in describing any intraoperative events. These can carry over into the ICU and may impact how the patient is managed.  
• Patients will likely still be intubated. Specify if you would like any of the vent settings a specific way.
• All of the other components are the same as in your PACU report.

This may seem like a ton of information, but with some practice, you can really make a report quick and concise while still including all of the necessary information. Pay attention to how your instructors deliver their reports and try to mimic their style while creating your own. 

Roles in Patient Care

If you have spent any time in the operating room at all, then you know that optimal patient care relies on a number of different people working together as team. It wasn’t until I had spent a few weeks working in the hospital that I began to see how each person fits in and what that meant to me as an anesthesia provider.  

Early on in your education, especially in the first few weeks, it can be difficult to tell what role each person assumes and what their responsibilities are. Reading this sheet will help to prepare you for (most) all the interactions you will have on a regular basis. Understanding what everyone’s role is, in relation to you and the patient, can make things run more smoothly and ultimately keep the patient safe. Understand that you will meet many other people working in the hospital that are not covered in this document, this is just a beginner’s guide. 

Pre-op Holding Nurse:

Keep in mind how important your interactions are in the preoperative holding area. This is often where patients and their family members have first contact with the perioperative staff members, and first impressions can be lasting. The preop holding nurse is usually the first person to greet the patient. It is this nurse’s duty to get the patient changed into a gown, provide information about the surgery, deliver emotional support, and maintain a baseline hemodynamic status. In addition to this, these nurses must ensure that all preoperative data has been accumulated. This includes taking vitals, drawing labs, retrieving medication lists, gathering consents, and sometimes starting IV’s.

You will often meet these nurses when you first come to meet and preop the patient prior to surgery. Keep in mind that they are very busy in the mornings and they may not have completely all of their duties by the time you arrive. That being said, their duties do not automatically disappear because you have arrived and also need to speak with the patient. It is important to be respectful and work together. Ask if they are finished before heading in, and if not, ask if you can listen in and ask the patient questions while they do what they need to.

     

Circulating Nurse:

This is the nurse that you will be in contact with the most during your days in the OR. Essentially, they are another advocate for patient care and safety during the entire perioperative period. Usually, you will meet this nurse when you go to speak with the patient just before heading to the OR. They also have preoperative questions to ask and will confirm that all consents and needed paperwork are in order. Once ready, this nurse will take the patient to the OR with you. Once there, they will help get the patient on to the OR table and offer you assistance with induction. They are also the ones who prep the patient, help position, insert the foley, and provide the surgeon with any needed equipment that the scrub tech might not have direct access to. Keeping everything in order, the circulating nurse is responsible for making sure that everything runs smoothly, paperwork is completed, and the patient is safe. After surgery, you will transport the patient to PACU as a team and each give a separate report to the PACU nurses. In general, these nurses will be very familiar with where everything is in the OR. Don’t be afraid to ask for their help.

     

Attending Surgeon:

Sometimes referred to as the “captain of the ship.” He or she is the one that has brought the patient to be operated on and will manage the patient postoperatively and after discharge. Being the ones that are performing the surgery, they usually have the most influential voice in the OR and call most of the shots. The staff surgeon will many times be in and out of the room, only directing residents. Other times, they will be more hands on for the duration of the case. It is important to pay attention to the moves that and emotions that the surgeon expresses during the surgery. Even if they aren’t great at communicating, you can be clued in to what is going on just by observing.  

In all of your interactions with the surgeon, just keep in mind that the ultimate goal is patient safety. There may be times in which something the surgeon is doing or requests does not correlate with this. In these instances it is important to respectfully communicate your concerns with them. If you feel your voice is not being heard, don’t hesitate to contact your instructor or attending.

 

Surgical Resident or PA:

Just as in any medical specialty, part of the educational path for MD’s and DO’s includes a residency training program. Surgery is no exception. Following medical school, they must go through years of training in which they work directly under the supervision of an attending surgeon. This means that they will often start cases, finish cases, and work alongside the surgeon during the bulk of the procedure. In private institutions where residents do not work, you may see a PA in their place to help speed up the daily routine and allow the attending to run multiple rooms at once.

 

Early on in your education it may be difficult to distinguish which members of the surgical team are staff and which are residents or PA’s. Generally, the resident of PA will start the case and the attending will arrive once things have gotten started. Additionally, it will usually be the resident or PA closing the surgical site at the end of the case.

Scrub Tech:

Also referred to as surgical technicians, these healthcare professionals are an important part of the surgical care team. Their educational training is focused in the knowledge and skills associated with sterile and aseptic techniques. It is their job to have knowledge of hundreds of surgical procedures. This ensures that they can anticipate the surgeon’s next move and provide them with the tools and equipment that they need.

You will usually first see this person in the OR. They will generally be wearing sterile gown and gloves and working with the table of surgical instruments. It is important, especially early on, to be conscious of anything in the OR that is considered sterile, including people, the instrument table, and the surgical field. You do not want to get to close to or touch these areas and cause contamination. The scrub tech can be helpful in reminding you what areas are considered sterile and can often provide insight in to how much irrigation has been used during surgery to help you calculate patient blood loss.  

Attending Anesthesiologist:

These are the physicians that make our job possible. As it is stated in our title, we are to assist them. On most days, the anesthesiologist will be supervising two to three rooms. This means that they are in charge of the anesthetic care of multiple patients/surgeries at once while AA’s and residents handle the direct management. To make their job easier, it is important that we, as AA’s and students, do our best to gather and relay as much information about the patient prior to surgery beginning. Once in the room, they will lead induction and designate any perioperative management plans. Once the surgery is underway, you will see that it is crucial to inform your attending on how things have progressed. In many institutions, they would also like to be there for extubation. Part of our job is being adaptable to different anesthesiologist’s styles. It may take time to pick them up but can pay off on the long run.

   

Anesthesia Tech:

Learn to love the anesthesia techs because they will become one of your greatest resources as an anesthesia provider. It is their job to ensure that the anesthesia carts and machines are properly functioning and have all the necessary supplies at the beginning of the day and in between cases. They handle everything from syringes to arterial line and hot fluid line setups. When cases are over, they help to turn over the rooms and restock equipment that was used. Anesthesia techs also handle any special equipment you may need. For example, they are the ones you can call if you need to perform a fiber optic intubation. Many will even stay in the room while you are operating this equipment in an effort to help troubleshoot any issues. In addition, they set up the necessary equipment to deliver anesthesia in outside of OR locations such as MRI and CT.

It is possible that you will see one of the techs in the morning when you are setting up the room. They usually make rounds in the morning to ensure that the rooms are ready to go for the morning cases. You will also see them in between cases. Be sure to keep the phone number and location to the tech room handy because you will often need to get in touch with them to request certain things. Keep in mind that the techs are covering many OR’s at once. Try to anticipate any equipment you may need and call as early on as possible. This will give them enough time to get it to the room by the time you actually need it.

PACU Nurse:

As you may already be well aware, PACU stands for Post Anesthesia Care Unit. This is the area you will usually take patients directly after surgery (unless they need to go to ICU). The patient will stay in this area for a period of time to recover before heading back to their room or before going to stage II (the next step before heading home). PACU nurses are the nurses that take care of patients in this area. They are responsible for ensuring that the patient has adequate pain control, is not nauseous, is comfortable, receives any needed medications, and remains hemodynamically stable. Their job is made much easier by a job well done by the anesthesia team in the OR.

   

You will first meet this nurse as you are rolling your patient in to the PACU. Once the patient is hooked up to monitors, connected to oxygen, and charting is completed, you will need to give a report to this nurse. The circulating nurse will also give the PACU nurse a report. Do not be afraid to repeat certain information that you feel is important. I cannot stress the importance of giving an adequate report to these nurses. They need to quickly be made familiar with the patient’s medical history, allergies, medications, IV access, Ins and outs of fluids, medications, and any intraoperative events of significance. The direct patient care is now in their hands. 

Just remember that you are just one member of a very large team. Learning to work and communicate everyone you work with will make your life easier and will lead to better outcomes for patients. 

Table Top and Drug Cart Setup

Hello ladies and gents. I am going to give you a walk through for some of the general setups you will be doing on a regular basis. These setups and photos were done at Memorial Hermann - TMC, a teaching institution.  A similar setup will be done at the outside hospitals but get the specifics for those setups from a 2nd year, for your own well-being, before you leave to said hospitals. Particularly at private institutions you will not prepare as many supplies since they don't want to be wasteful. My hope is for this to help simplify the setup process and allow you to see what it actually looks like. Below are the ways I typically set things up. I think all would be acceptable for any of you to do, in the right circumstances. I hope this can help you through your setups early on in the program until you discover your own preferences.

GENERAL ENDOTRACHEAL ANESTHESIA SETUP

Table top setup for a GETA case

The above image shows the table top setup for an adult general, endotracheal anesthesia case. The following should be included:

1. Oral area sizes 8, 9, 10 (80mm, 90mm, 100mm).
2. Miller 2 and Mac 3 blade. If you patient is tall/large consider using a Mac 4 instead of 3 and keep the Miller 2 out. If possible leave the blade in the packaging while connected to the handle.
3. Straight connector + accordion connector. This gives some flexibility to the circuit and is useful in cases with position changes or bed rotation.
4. Tongue depressor. Just to have in a situation where that pesky tongue is giving you trouble.
5. Temperature probe.
6. Humidivent. Keeps the patient's airway warm and humid.
7. Lubricant. Used to place and OG/NG tube, LMA, and a few other applications.
8. OETT 7 and 8 styletted to your favorite curvaceous shape with a 10 cc syringe attached. (You will see many ways to shape the tube, do what your preceptor wants until you find what you like best and shape it that way.)
9. Notice the suction to the left. This may not be considered part of the table top setup but it is near the setup in this instance and is very important. Always have suction setup, working, and on.

Drug cart setup for a GETA case

Here you can see the drugs for a GETA and how I organize them. This is assuming you are not doing a rapid sequence intubation. In this case you could use rocuronium as you paralytic but most will use succinylcholine. Here are the components of an adult GETA drug setup:

1. Versed - 2 cc syringe.
2. Fentanyl - 3 or 5 cc syringe (I'd go with a 5 if you are unsure).
3. Rocuronium - 5 cc syringe
4. Lidocaine - 10 cc syringe
5. Propofol - 20 cc syringe
6. Ephedrine - 10 cc syringe (This is currently back ordered don't make a syringe until you hear otherwise. It must be diluted in a 10 cc syringe to 5 mg/mL. But y'all know that!)
7. Phenylephrine - 10 cc syringe (This is pre-made and ready to go. All you have to do is take is from the cassette).

This is just how I choose to organize my drugs. I have my pressors in one area, induction meds in another, and narcotics in another. I may suggest separating your paralytic from the propofol and lidocaine so you have that separated as well. Your call. 

LMA SETUP

Table top setup for an LMA case

You will notice this looks very familiar. If you are doing an LMA case this is how I would go about setting it up. It's the same as a GETA case with the addition of two LMAs. The idea is to have a back up LMA in case one does not seat/fit well or malfunctions. In this setup I have a 4 and 5. For women or smaller men you may choose to get out a 3 and 4 instead. Notice the OETT tubes and blades are still out. This is done so that in a critical situation your stuff is ready to go and you can quickly secure the airway. When using an LMA you will use the lubricant. Here you would use it on the point and superior surface to ease placement. Don't worry about doing this until your preceptor has decided which LMA to use and you know how to lube. The above setup is a little cluttered in order to get everything in the picture. I would place the blades and OETTs on a lower surface or on top of the machine so that they are readily available but not in the the way. Again, your call.

Drug cart setup for LMA case

Same as the GETA setup minus the paralytic. Keep in mind you will use other drugs regularly in cases. This is just the setup to get you through a normal induction. Anti-emetics, more pain meds, sympatholytics, etc. will be made and drawn up after induction unless your preceptor tells you otherwise.

IV KIT SETUP

IV kit components

Shown above are the components that go in the basin labeled "8" to make up your IV kit. Making these correctly and well will show your preceptor your ready to try and place an IV. It should make the process a little easier for you. The components are listed below:

1. Tourniquet
2. Tegaderms - make sure you get the right size.
3. Tape - some use plastic tape(shown above), some use silk. Its a good idea to have both in order to appeal to your preceptor.
4. Needles and catheters. Shown left to right in pairs 16 ga, 18 ga, 20 ga. To start you could just put two 18 ga and two 20 ga because those are what will be placed, most likely.
5. Alcohol swabs - we don't want anymore infections spreading.
6. 4 x 4's - for that bloody mess that is just inevitable sometimes.
7. Flush syringes - these are made by placing a lure lock on the end of a 10 cc flush syringe.
8. Basin - all of these items should go neatly and organized in this container.

When you're starting off its a good idea to make sure there is two of everything in these kits so that if you are struggling, your preceptor can go try the other arm/hand without needing to take the equipment from you. The easiest way I remember all the items is to go through the process of placing an IV and ensure I have each piece I would need in the kit.

Everyone has their own way of doing these setups. This is a good place to start but if your preceptor tells you to do something else, do it. Until you find your own way do what your preceptor likes/asks. As you see more things pick out what you like and start to develop your own methods. Always have a reason behind your choices, however, and be ready to explain why you chose to do something a certain way.

Common Medications & Their Associated Conditions

Below we have made a list that will help you early on in your clinical rotations. When you see a pre-op medications list early on it can be very overwhelming and, at times, unhelpful because they can be long, illegible, and many of the drug you will not learn about until the spring. With this table you should be able to look at a patient's medication list and get a good idea of what conditions your patient has (this is assuming, of course, you have a good patient who is taking their meds). I have organized these meds based on the frequency in which they are seen and how much they can impact anesthesia. If you have an in-patient many of the meds will be different. Meds on the same line are similar (either by mechanism, targets, etc.) Patterns in the suffices helps a lot, such as all drugs ending in -pril are ACE inhibitors for hypertension and those ending in -statin are for high cholesterol. Brand names are in parentheses and if a drug is better known by its generic or brand name I only included the one it is best known as.

This list by no means covers everything that you will see in clinicals, but it is a good place to start. 

The epocrates app is your best friend when trying to learn these drugs. Many instructors use this app regularly. Even if you can't make out the full name, type out what you can read and many times it will narrow the search enough for you to figure out which drug you're looking for. After finding the drug in question, look at the pharmacology tab. Here you will find the mechanism of action which should give you insight into that the drug is used for. If that doesn't help, try Google.

Best of luck!

Hypertension

Metoprolol, Atenolol, Propranolol, Carvedilol(Coreg)       

Hydrochlorothiazide(HCTZ)

Clonidine                            

Lisinopril, Enalapril, 

Losartan(Cozaar)                        

Verapamil, Diltiazem

Nifedipine, Nicardipine, Amlodipine(Norvasc)

Diabetes

Insulin
Glyburide
Metformin

GERD

Ranitidine(Zantac), Famotidine(Pepcid)

Omeprazole(Prilosec), Pantoprazole(Protonix), Nexium

Alka-seltzer, Mylanta, Rolaids, Maalox, Tums

Pain

Codeine, Hydrocodone(Lortab), Oxycodone, OxyContin, Tramadol
Nalbuphine(Nubain), Buprenorphine

Aspirin(ASA), Ibuprofen(Motrin, Advil)

Acetominophen(Tylenol)

Hypothyroidism

Levothyroxine(Synthroid)

Asthma

Albuterol

Advair, Azmacort, Flovent, Pulmicort

Coagulopathies

Enoxaparin(Lovenox)

Warfarin(Coumadin)

Clopidogrel(Plavix)

Pradaxa

Psychiatric Drugs

Anti-depressants: Prozac, Zoloft, Lexapro

Anti-sseizure: Phenytoin(Dilantin), Keppra, Gabapentin

Parkinson's: Levodopa, Cogentin

Allergies

Diphenhydramine(Benadryl), Dimetapp, Claritin, Allegra

Hyperlipidemia

Simvastatin, Pravastatin

Lipitor, Crestor, Zocor

Medical Abbreviations, Part I

By now, you will have received the medical abbreviations pre-work assignment. The purpose of this assignment is to make you more conversant in medical-speak.  Abbreviations are important, not only because they are so common around the hospital, but, as you will come to learn, they are an indispensable means of efficient communication in a hectic and critical environment.

A master list of abbreviations can be found at the bottom of this page.

Everyone in healthcare uses abbreviations; from the anesthesiologist to the PACU nurses, the surgeons--even the janitors.  Abbreviations are particularly important when it comes to pre-operative evaluations (pre-ops) and anesthesia records (charts). Zoom in on the blank pre-op that I pulled from the web, below.  See how so many of the terms are abbreviated?

In the broader sense, learning abbreviations is an important step to becoming more confident and feeling like you belong in the OR.  It's easier to learn to walk-the-walk, when you already know how to talk-the-talk.

Now the truth is, just like the information on the drug card, you naturally pick-up abbreviations over time through daily exposure. Regardless, it is important to have a good working knowledge of them by the time you start your first clinical rotation.


When I got this assignment last year, and perused those three epic lists of abbreviations, my initial reaction (in abbreviation form) was '...wtf?'   Each list contains hundreds, if not thousands of abbreviations;  many of the same abbreviations appear on all three lists; and I think one of the lists is missing the asterisks '*' to signify abbreviations that might show up on a test.

According to our instructors, our class performed 'abysmally' on the abbreviations quizzes, and I think that was partly due to the confusing/chaotic nature of those three lists.  No one in my class really knew what to do, where to begin, etc etc; so we didn't study them very well (or much at all, in my case).

A shortcut to scoring in the C-B range on your first abbreviations quiz

I have made things a little easier by paring down all three long lists to one short list that contains only the most important terms. The terms I have selected are used by AA's on a daily basis, and for that reason, it is safe to assume they will constitute between 70-80% of the items on any given quiz the program throws at you.

Below, the same blank pre-op is broken down into individual categories--or, as they say in the industry, 'systems'--such as neurological, renal, cardiovascular, etc etc.  Abbreviations from each system have their own unique color, hopefully making them easier to memorize.  Finally, I have placed an asterisk next to 10-20 terms that are so ridiculously common, it's stupid.  You simply cannot function in the OR without knowing them.

Let's start from the top:

*****Abbreviations RE: Initial/Generic PRE-OP QUESTIONS*****

This is generally the first part of pre-op, when we ask the patient: "When was the last time you had something to eat or drink?" and "What medications are you currently taking" (terms in black)

*NPO--'nothing by mouth,' i.e. "the patient has not had anything to eat" since....
H/O--history of
MH--Malignant Hyperthermia
*PONV--Post-Operative Nausea and Vomiting
Hx--History

Not shown, but other abbreviations pertinent to this system are:

*NKDA--No Known Drug Allergy
N/V--Nausea/Vomiting
PO--'by mouth'
ASA--Aspirin (ASA is also the abbreviation for American Society of Anesthesiologists, which appears later on the pre-op)
bid--twice daily
tid--three times daily
qid--four times daily
Dx--Diagnosis
Dz--disease
*PMH--Past Medical History
*PSH--Past Surgical History

*****Abbreviations RE: LABS/PREGNANCY and the PHYSICAL EXAM*****

This section of the pre-op includes lab tests for blood (in red), pregnancy tests and questions related to pregnancy (light blue), and physical exam tests--such as listening to the patient's lungs (CTA), or making a visual assessment of their chin and throat (TMD) (green)

WBC--White Blood Cell

*H/H--Hematocrit and Hemoglobin

PLT--Platelet

Na--Sodium

K--Potassium

BUN--Blood Urea Nitrogen

Cr--Creatinine

PT--Prothrombin Time

PTT--Partial Thromboplastin Time

INR--International Normalized Ratio (a ratio of patient's PT versus the normal PT)

BTL--Bilateral Tubal Ligation
*LMP--Last Menstrual Period
TAH--Total Abdominal Hysterectomy

HCG--Human Chorionic Gonadotropin (for urine pregnancy test)

NEG--Negative

U/L--Upper/Lower 

*ROM--Range of Motion
TMD--Thyromental Distance
*CTA--Clear to Auscultation


Others:

HgB--Hemoglobin
CBC--Complete Blood Count
*RBC--Red Blood Cell
*ABG--Arterial Blood Gas

A/P:  Auscultation and Percussion
BBS--Bilateral Breath Sounds
PERRLA--Pupils Equal, Round, Reactive to Light and Accomodation
*A&O x4--Alert and Oriented to person, place, time and event

******Abbreviations RE: The CARDIOVASCULAR SYSTEM (CVS)******

A list of some of the most common cardiovascular diseases (purple)

*WNL--Within Normal Limits

*HTN--Hypertension

*CAD--Coronary Artery Disease

MVP/MR/AI/AS--Mitral Valve Prolapse, Mitral Regurgitation, Aortic Insufficiency, Aortic Stenosis (all diseases of the various heart valves)

PVD--Peripheral Vascular Disease

MI Hx--Myocardial Infarction history (heart attack history)

*CHF--Congestive Heart Failure

A. Fib--Atrial Fibrillation

A. Flutter--Atrial Flutter

PTCA--Percutaneous Transluminal Coronary Angioplasty

STENT--Stent (not an abbreviation)

*Hx CABG--Coronary Artery Bypass Graft history

AICD--Automatic Implantable Cardioverter Defibrillator

RBBB--Right Bundle Branch Block

LBBB--Left Bundle Branch Block

Others:

AAA--Abdominal Aortic Aneurysm 

EJ--External Jugular

IJ--Internal Jugular

SA Node--Sino-Atrial Node

That's it for this installment.  In Part II, we will finish out the second half of the pre-op. Have a good one!

Medical Abbreviations, Part II

Continuing on with the blank pre-op:

Systems are:  Pulmonary (light purple), Gastrointestinal (brown),  Renal (yellow), Endocrine (gray)

Pulmonary

*COPD--Chronic Obstructive Pulmonary Disease

*URI--Upper Respiratory Infection

*CPAP--Continuous Positive Airway Pressure

CXR--Chest X-Ray

Also:

BBS--Bilateral Breath Sounds

*OSA--Obstructive Sleep Apnea

LUL/LLL--Left Upper Lobe/Left Lower Lobe

RUL/RML/RLL--same as above, except right lung has a middle lobe

TV--Tidal Volume

MV--Mechanical Ventilation -or- Minute Ventilation

PFT--Pulmonary Function Test

Gastrointestinal 

*GERD--Gastroesophageal Reflux Disease

PUD--Peptic Ulcer Disease

Also:

*EGD--Esophago-gastro-duodenoscopy 

ERCP--Endoscopic Retrograde Cholangio-pancreatography

GB--Gallbladder

CBD--Common Bile Duct

IBD--Inflammatory Bowel Disease

TPN--Total Parenteral Nutrition

NG--Nasogastric Tube

Renal

*UTI--Urinary Tract Infection

BPH--Benign Prostate Hypertrophy

CKD--Chronic Kidney Disease

Also:

*ESRD--End Stage Renal Disease

ESWL--Extracorporeal Shockwave Lithotripsy

PKD--Polycystic Kidney Disease

PKU--Phenylketonuria

GFR--Glomerular Filtration Rate

TURP--Transurethral Resection of the Prostate

Endocrine

NIDDM--Non-insulin Dependent Diabetes Mellitus

*IDDM--Insulin Dependent Diabetes Mellitus

Also:

*DM--Diabetes Mellitus

DI--Diabetes Insipidus

JOD--Juvenile Onset Diabetes

JODM--Juvenile Onset Diabetes Mellitus

AODM--Adult-Onset Diabetes Mellitus

*ADH--Anti-Diuretic Hormone

ACTH--Adrenocorticotropic Hormone

*ACh--Acetylcholine

Assorted Anesthesia Terminology (black)


Assorted Anesthesia/Medical Terms

*GA--General Anesthesia

SAB--Subarachnoid Block

*MAC--Monitored Anesthesia Care

*CVC--Central Venous Catheter

PAC--Pulmonary Artery Catheter

TEE--Transesophageal Echocardiogram

ISB--Interscalene Block

FNB--Femoral Nerve Block

*ASA--American Society of Anesthesiologists

Also:

*TIVA--Total Intravenous Anesthetic

GETT--General (anesthetic) by Endotracheal Tube

*ETT--Endotracheal Tube

*LMA--Laryngeal Mask Airway

OPA--Oropharyngeal Airway

NPA--Nasopharyngeal Airway

*NSAID--Non-steroidal Anti-Inflammatory

...and that's it.  Still a daunting list, I know, but now at least it's a little more manageable.  As I said before, this is merely a list of abbreviations germane to an AA's practice.  I cannot make any guarantees, but I figure these abbreviations will comprise the majority of what you will see in the beginning of your practice as well as on any quizes. 

Medical Abbreviations - Master List

Pre-op:

*NPO--'nothing by mouth,' i.e. "the patient has not had anything to eat" since....
H/O--history of
MH--Malignant Hyperthermia
*PONV--Post-Operative Nausea and Vomiting
Hx--History
*NKDA--No Known Drug Allergy
N/V--Nausea/Vomiting
PO--'by mouth'
ASA--Aspirin (ASA is also the abbreviation for American Society of Anesthesiologists, which appears later on the pre-op)
bid--twice daily
tid--three times daily
qid--four times daily
Dx--Diagnosis
Dz--disease
*PMH--Past Medical History
*PSH--Past Surgical History

*WNL--Within Normal Limits

Blood/Labs/Testing:

WBC--White Blood Cell

*H/H--Hematocrit and Hemoglobin

PLT--Platelet

Na--Sodium

K--Potassium

BUN--Blood Urea Nitrogen

Cr--Creatinine

PT--Prothrombin Time

PTT--Partial Thromboplastin Time

INR--International Normalized Ratio (a ratio of patient's PT versus the normal PT)

*HgB--Hemoglobin
CBC--Complete Blood Count
*RBC--Red Blood Cell
*ABG--Arterial Blood Gas

Pregnancy/Obstetrics:

BTL--Bilateral Tubal Ligation
*LMP--Last Menstrual Period
TAH--Total Abdominal Hysterectomy

HCG--Human Chorionic Gonadotropin (for urine pregnancy test)

Physical Exam:

U/L--Upper/Lower 

*ROM--Range of Motion
TMD--Thyromental Distance
*CTA--Clear to Auscultation
A/P:  Auscultation and Percussion
BBS--Bilateral Breath Sounds
PERRLA--Pupils Equal, Round, Reactive to Light and Accomodation
*A&O x4--Alert and Oriented to person, place, time and event

Neurological:

*TIA--Transient Ischemic Attack (aka mini stroke)

*CVA--Cerebral Vascular Accident (aka stroke)

SNS--Sympathetic Nervous System

PNS--Parasympathetic Nervous System

Cardiovascular:

*HTN--Hypertension

*CAD--Coronary Artery Disease

MVP/MR/AI/AS--Mitral Valve Prolapse, Mitral Regurgitation, Aortic Insufficiency, Aortic Stenosis (all diseases of the various heart valves)

PVD--Peripheral Vascular Disease

MI Hx--Myocardial Infarction history (heart attack history)

*CHF--Congestive Heart Failure

A. Fib--Atrial Fibrillation

A. Flutter--Atrial Flutter

PTCA--Percutaneous Transluminal Coronary Angioplasty

STENT--Stent (not an abbreviation)

*Hx CABG--Coronary Artery Bypass Graft history

AICD--Automatic Implantable Cardioverter Defibrillator

RBBB--Right Bundle Branch Block

LBBB--Left Bundle Branch Block

AAA--Abdominal Aortic Aneurysm 

EJ--External Jugular

IJ--Internal Jugular

SA Node--Sino-Atrial Node

Pulmonary:

*COPD--Chronic Obstructive Pulmonary Disease

*URI--Upper Respiratory Infection

*CPAP--Continuous Positive Airway Pressure

CXR--Chest X-Ray

*OSA--Obstructive Sleep Apnea

LUL/LLL--Left Upper Lobe/Left Lower Lobe

RUL/RML/RLL--same as above, except right lung has a middle lobe

TV--Tidal Volume

MV--Mechanical Ventilation -or- Minute Ventilation

PFT--Pulmonary Function Test

Gastrointestinal:

*GERD--Gastroesophageal Reflux Disease

PUD--Peptic Ulcer Disease

*EGD--Esophago-gastro-duodenoscopy 

ERCP--Endoscopic Retrograde Cholangio-pancreatography

GB--Gallbladder

CBD--Common Bile Duct

IBD--Inflammatory Bowel Disease

TPN--Total Parenteral Nutrition

NG--Nasogastric Tube

Renal:

*UTI--Urinary Tract Infection

BPH--Benign Prostate Hypertrophy

CKD--Chronic Kidney Disease

*ESRD--End Stage Renal Disease

ESWL--Extracorporeal Shockwave Lithotripsy

PKD--Polycystic Kidney Disease

PKU--Phenylketonuria

GFR--Glomerular Filtration Rate

TURP--Transurethral Resection of the Prostate

Endocrine:

NIDDM--Non-insulin Dependent Diabetes Mellitus

*IDDM--Insulin Dependent Diabetes Mellitus

*DM--Diabetes Mellitus

DI--Diabetes Insipidus

JOD--Juvenile Onset Diabetes

JODM--Juvenile Onset Diabetes Mellitus

AODM--Adult-Onset Diabetes Mellitus

*ADH--Anti-Diuretic Hormone

ACTH--Adrenocorticotropic Hormone

*ACh--Acetylcholine

Assorted Terms:

*GA--General Anesthesia

SAB--Subarachnoid Block

*MAC--Monitored Anesthesia Care

*CVC--Central Venous Catheter

PAC--Pulmonary Artery Catheter

TEE--Transesophageal Echocardiogram

ISB--Interscalene Block

FNB--Femoral Nerve Block

*ASA--American Society of Anesthesiologists

*TIVA--Total Intravenous Anesthetic

GETT--General (anesthetic) by Endotracheal Tube

*ETT--Endotracheal Tube

*LMA--Laryngeal Mask Airway

OPA--Oropharyngeal Airway

NPA--Nasopharyngeal Airway

*NSAID--Non-steroidal Anti-Inflammatory

*PEEP--Positive-End Expiratory Pressure