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Chapter 95

Unit 14: Nursing Care of Preoperative Clients

QuestionAnswer
Anesthesia & moderate sedation. What is anesthesia? (Pg. 1082) Chemical agent administered prior to a surgery to induce loss of consciousness, amnesia and/or analgesia.
What is moderate sedation? A type of anesthesia; client does not lose consciousness, but induction of amnesia and analgesia is still achieved.
Anesthesia is a state of depressed ____ activity, marked by depression of _____, and loss of responsiveness to ____ &/or muscle _____. -depressed CNS activity -depression of consciousness -loss of responsiveness to stimulation -&/or muscle relaxation
Anesthesia; 2 classifications are? General or local
General anesthesia; loss of ___ Sensation, consciousness & reflexes. -method for major surgery or one requiring complete muscle relaxation
Local anesthesia; loss of ____, w/o loss of ____ Sensation, w/o loss of consciousness -they block transmission along nerves= loss of autonomic function & muscle paralysis in a certain area of the body
Risk factors for anesthesia (general); Pg. 1083 Fam hx MH Resp. disease (hypoventilation) Cardiac disease (dysrhythmias, altered CO) Gastric contents (aspiration) Alcohol or drug use disorder
Risk factors for anesthesia (local) Allergy to ester-type anesthetics Alterations in peripheral circulation
Phases of general anesthesia; Induction, maintenance, emergence
Induction phase of general? (what occurs) IV lines initiated, prep medications given, airway secured
Maintenance phase of general? Surgery performed, airway maitenance
Emergence phase of general? Surgery completed, removal of assistive airway devices
What are anesthetics uses during general anesthesia classified as? Injectable or inhaled
What are inhaled anesthetics? Volatile gases or liquids that are dissolved in oxygen
How are injectable anesthetics given? IV
Halothane (Fluothane), isoflurane (Forane), and nitrous oxide are? Inhaled anesthetics; in combination w/ oxygen
Benzodiazepines, etomidate (Amidate), propofol (Diprivan), ketamine (ketalar) & short-acting barbiturates such as methohexital (brevital) and thiopental (pentothal) IV anesthetics *propofol is the most commonly used; can be used while clients are on mechanical ventilation, during radiation therapy & having a dx procedure.
Do not administered propofol is client has an allergy to _____? Eggs or soybean oil
Inhalation anesthetics are eliminated how? Through exhalation; rate depends on pulmonary ventilation and blood flow to the lungs *Post op o2 & deep breathes are important
Adjunct meds w/ anesthetics: Opioids; Fentanyl (sublimaze) Sufentanil (sufenta) Alfentanil (alfenta) Uses: sedation & analgesic for pain pre/post op s/e: depresses CNS (respiratory) -delays awakening from surgery, constipation/urinary retention, nausea/vomit
Adjuncts: Benzodiazepines; Diazepam (Valium) Midazolam (Versed) Uses: low anxiety prep, promote amnesia, mild sedation (unconsciousness) w/ moderate to very little respiratory depression S/e: administer slowly or can results in resp/cardiac arrest
Adjuncts; Antiemetics; Odansetron (Zofran) Metoclopramide (Reglan) Promethazine (Phenergan) Uses: decrease post anesthetic nausea/vomit, reglan ^ gastric emptying, promethazine induces sedation, decrease risk for aspiration S/e: dry mouth, dizzy -reglan: caution w parkinsons or asthma -Promethazine; resp depression & asthma
Adjuncts; Anticholinergics; Atropine (Atropair) Glycopyrrolate (robulin) Uses; decrease risk of bradycardia -Block muscarinic response to acetylcholine by decreasing salvation, bowel movement, gastrointestinal secretions -slow mobility of GI -decrease risk for aspiration s/e: urinary retention, tachy, dry mouth
Adjuncts; Sedatives; Pentobarbital (nembutal) Secobarbital (seconal) Uses: sedative effect for pre anesthesia sedation or amnesia effect -induction of general anesthesia s/e: avoid giving w/in 14 days of starting/stopping MAO inhibitor resp. depression
Adjuncts; Neuromuscular blocking agents; Succinulcholine (anectine) Vecuronium (norcuron) Uses; skeletal muscle relaxation for surgery -airway placement, in conjunction w/ IV anesthetic agents s/e: total flaccid paralysis, requires mechanical ventilation
Nursing actions w/ adjuncts and anesthesia: -consent, void, bed position, monitor Consent received before meds Void before meds (can't get out of bed) Bed lowest position, side rails up Monitor airway & o2 sat, VS, labs, drains/tubes/IVsites, level of sedation (LOC)
If hypotension occurs from a s/e of meds or dehydration? Lower head of bed, give IV fluid bolus
Complications of general anesthesia.. 1. MH -what is it? & what agents can trigger it Malignant hyperthermia -acute life threatening emergency -inherited muscle disorder, chemically induced by anesthetic agents -triggering agents; inhalation anesthetic, muscle relaxant succinylcholine
MH is a hypermetabolic condition causing…? Alteration in calcium activity in muscle cells -muscle rigidity, hyperthermia, damage to CNS
S/S MH Tachycardia first -dysrhythmias, muscle rigidity, hypotension, tachypnea, skin mottling, cyanosis, myoglobinuria -high temp late sign; 1-2 degree rise every 5 minutes
Tx for MH: -Stop surgery -Dantrolene (Dantrium) - muscle relaxant -100% o2, ABGs -infused iced 0.9% NS -cooling blanket, ice to axillae/groin/neck/head
2. Overdose of anesthetic could happen w poor liver/kidney function, older adults, etc. *do preop screening, know preexisting conditions & inform provider/surgeon
3. Unrecognized hypoventilation s/s: cardiac arrest, hypoxia, damage to the brain, death (lack of oxygen and gas exchange) TX: monitor the end-tidal co2 levels of expirations, malfunction of equipment? ventilate pt
4. Intubation problems injury to teeth, lips, vocal cord during intubation, neck injury, sore throat -TX. nurse assist, have available tracy set-up
Local anesthesia: 3 main methods Topical, local infiltration, regional nerve block
Topical local anesthesia; Applied directly to the skin or mucous membranes
Local infiltration; Injected directly into the tissues through which the surgical incision is to be made
Regional nerve block; Injected into or around specific nerves; four types
The different types of regional nerve blocks; Spinal, epidural, nerve block, field block, peripheral
Spinal regional nerve block; Anesthetic is injected into the CSF in the subarachnoid space to provide autonomic, sensory, and motor blockade to the body below the level of innervation
Epidural regional nerve block; Injected into the epidural space in the thoracic or lumbar areas of the spine, where sensory pathways are blocked and motor function remains
Nerve block; Injection of anesthetic around or into an area of nerves to block sensation. Often used for surgery to an extremity or chronic pain
Field block; Injection of anesthetic around the operative field commonly used for procedures of the chest, plastic surgery, dental, and hernia repairs
Peripheral; Injection of anesthetic into a specific nerve for analgesic and anesthetic use
Procaine (Nocovain) and lidocaine (xylocaine) i.e. of local anesthetics
Concurrent administration of a _____ such as ____ is often used w/ local anesthetics to prolong the effects and decrease the risk of systemic toxicity Vasoconstrictor, epi
Complications of local anesthetics; 1. Toxic reaction (pg. 1087) s/s; headache, blurred vision, metallic taste, etc. -establish airway, o2, sat, inform surgeron, etc. -fast-acting barbiturate; thiopental (pentothal) or methohexital (brevital) -labs, etc.
Comp of local anesthetics; 2. CSF leakage (spinal & epidural) Severe headache when HOB is up -lower hob, quiet env't, well hydrated to promote CSF loss
Moderate sedation (Pg. 1088) Sedatives and/or hypnotics to the point where the client is relaxed enough that minor procedures can be performed w/o discomfort, yet the client can respond to verbal stimuli, retains protective reflexes, is easily a rousable, and can maintain an airway
Who can administer moderate sedation? Qualified provider; anesthesiologists, CRNAs, attending providers, RNs certified in ACLS
Procedures that may require moderate sedation include: Minor procedures; dental, podiatric, plastic, opthalamic Dx procedures, cardioversion, wound care, reduction & immobilization of fxs, placement & removal of implanted devices, catheters & tubes
Opioids, anesthetics, benzodiazepines are for Moderate sedation
Morphine, fentanyl (sublimaze), alfentanil (alfenta) opioids
Propofol (diprivan) anesthetics
Midazolam (versed), diazepam (valium), lorazepam (ativan) benzodiazepines
What is used to reverse the adverse reactions to opioids? Naloxone hydrochloride (Narcan)
Benzodiazepines, to reverse the effects use ____ Flumazenil (Romazicon)
NPO guidelines; no eating or drinking up to 6 hours before -clear liquids okay up to 2 hours before
Following equipment must be present during the procedure: Fully equipped ER cart; emergency meds, airway, ventilatory equipment, defibrillator, IV supplies -100 percent o2 source, administration supplies, airways, manual resuscitation bag, and suction equipment -ECG monitor/display equipment, VS equipment
When can the nurse remove the monitor and emergency equipment from the bedside? When the client is fully awake and assessment criteria returns to good levels
Typical discharge criteria; LOC, BS, CDB, fluids, void, absence of.. loc on admission VS stable for 30-90 mins ability to CDB ability to tolerate oral fluids ability to void absence of nausea, vomiting, SOB, dizziness
Created by: mary.scott260!