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Chapter 95
Unit 14: Nursing Care of Preoperative Clients
| Question | Answer |
|---|---|
| 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 |
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