Unit 14: Nursing Care of Preoperative Clients
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| Anesthesia & moderate sedation. What is anesthesia? (Pg. 1082) | Chemical agent administered prior to a surgery to induce loss of consciousness, amnesia and/or analgesia.
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| What is moderate sedation? | A type of anesthesia; client does not lose consciousness, but induction of amnesia and analgesia is still achieved.
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| 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
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| Anesthesia; 2 classifications are? | General or local
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| General anesthesia; loss of ___ | Sensation, consciousness & reflexes.
-method for major surgery or one requiring complete muscle relaxation
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| 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
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| 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
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| Risk factors for anesthesia (local) | Allergy to ester-type anesthetics
Alterations in peripheral circulation
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| Phases of general anesthesia; | Induction, maintenance, emergence
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| Induction phase of general? (what occurs) | IV lines initiated, prep medications given, airway secured
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| Maintenance phase of general? | Surgery performed, airway maitenance
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| Emergence phase of general? | Surgery completed, removal of assistive airway devices
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| What are anesthetics uses during general anesthesia classified as? | Injectable or inhaled
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| What are inhaled anesthetics? | Volatile gases or liquids that are dissolved in oxygen
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| How are injectable anesthetics given? | IV
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| Halothane (Fluothane), isoflurane (Forane), and nitrous oxide are? | Inhaled anesthetics; in combination w/ oxygen
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| 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.
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| Do not administered propofol is client has an allergy to _____? | Eggs or soybean oil
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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)
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| If hypotension occurs from a s/e of meds or dehydration? | Lower head of bed, give IV fluid bolus
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| 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
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| MH is a hypermetabolic condition causing…? | Alteration in calcium activity in muscle cells
-muscle rigidity, hyperthermia, damage to CNS
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| 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
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| 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
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| 2. Overdose of anesthetic | could happen w poor liver/kidney function, older adults, etc.
*do preop screening, know preexisting conditions & inform provider/surgeon
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| 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
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| 4. Intubation problems | injury to teeth, lips, vocal cord during intubation, neck injury, sore throat
-TX. nurse assist, have available tracy set-up
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| Local anesthesia: 3 main methods | Topical, local infiltration, regional nerve block
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| Topical local anesthesia; | Applied directly to the skin or mucous membranes
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| Local infiltration; | Injected directly into the tissues through which the surgical incision is to be made
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| Regional nerve block; | Injected into or around specific nerves; four types
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| The different types of regional nerve blocks; | Spinal, epidural, nerve block, field block, peripheral
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| 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
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| 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
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| 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
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| Field block; | Injection of anesthetic around the operative field commonly used for procedures of the chest, plastic surgery, dental, and hernia repairs
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| Peripheral; | Injection of anesthetic into a specific nerve for analgesic and anesthetic use
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| Procaine (Nocovain) and lidocaine (xylocaine) | i.e. of local anesthetics
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| 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
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| 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.
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| 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
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| 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
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| Who can administer moderate sedation? | Qualified provider; anesthesiologists, CRNAs, attending providers, RNs certified in ACLS
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| 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
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| Opioids, anesthetics, benzodiazepines are for | Moderate sedation
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| Morphine, fentanyl (sublimaze), alfentanil (alfenta) | opioids
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| Propofol (diprivan) | anesthetics
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| Midazolam (versed), diazepam (valium), lorazepam (ativan) | benzodiazepines
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| What is used to reverse the adverse reactions to opioids? | Naloxone hydrochloride (Narcan)
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| Benzodiazepines, to reverse the effects use ____ | Flumazenil (Romazicon)
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| NPO guidelines; | no eating or drinking up to 6 hours before
-clear liquids okay up to 2 hours before
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| 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
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| 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
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| 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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