Rosdahl Chapter 56

Stage 4 of general anesthesia (Danger Stage)

(Respiratory paralysis, toxic or extreme medullary depression) Danger stage: too much anesthesia has been administered. No reflexes, weak and thready pulse, respiration completely flaccid, decreased BP, widely dilated pupils. Prompt intervention is required to prevent respiratory arrest, irreversible coma, and death.

stage 1 of general anesthesia (Beginning anesthesia)

(analgesia and amnesia) Reflexes present, heart rate normal, slower rate, and increased depth of respiration, normal BP, some dilation of eyes, with reaction to light.

Stage 2 of general anesthesia (Dreams and Excitement stage)

(delirium)Active reflexes, increased heart rate, irregular breathing, increased BP, pupils widely dilated and divergent.

Nursing diagnosis

-anxiety -ineffective coping -decisional conflict - fear -anticipatory grieving -deficient knowledge -powerlessness

Antibiotic and Cephalosporins

1. Amoxicillin trihydrate (Amoxicillin) 2. Ampicillin- used in some high-risk clients undergoing cesarean section 3. Cefotaxime Na+ (Claforan) 4. Ceftriaxone Na+ (Rocephin)- used especially in coronary surgery and in potentially contaminated procedures 5. Cefoxitin sodium (Mefoxin) 6. Cefuroxime axetil (Ceftin) 7. Ertapenem (Invanz)- used in adults to prevent infection after colorectal surgery 8. Erythromycin- used in clients allergic to penicillin, with valvular heart disease. 9. Penicillin (various forms) 10. Vancomycin HCL (Vancocin)- used in clients allergic to penicillin

What items are found in the PACU?

1. Breathing Aids 2. Circulatory Aids and Realted Medications 3. Drugs- Narcotics, sedatives and drugs for emergency situations 4. Surgical dressings - sandbags - warmed blankets -forced air warming blanket -extra pillows - crash cart -traction setup -back/neck brace

Sedatives used to assist clients to sleep

1. Chlorpromazine (used in Canada)- especially to relieve preoperative apprehension, also antiemetic 2. Secobarbital Na+ (seconal Na+)- also can be premedication 3. Temazepam (Restoril)- Used pre- or postoperatively 4. Trazodone HCL- antidepressant, with drowsiness side-effects 5. Colpidem (ambien)- used pre- or postoperatively

Narcotics (used for pain)

1. Fentanyl (Sublimaze) 2. Meperidine HCL (Demerol HCl) 3. Morphine SO4 Sulfate (Morphine)

Nursing Considerations when antibiotics are given

1. Instruct the client to inform the caregiver of any untoward effects, such as a rash, stomach upset, or diarrhea. 2. Instruct the client to drink plenty of water and other fluids. 3. Some antibiotics are to be taken on an empty stomach and some with food. Check the specific instructions. 4. Instruct the client to take all of the medication for the prescribed length of time. 5. If the client is taking an oral contraceptive, advise her to use another means of fertility control while taking antibiotics. 6. Avoid alcohol.

Nursing considerations when Atropine is given

1. Know that atropine is given cautiously to clients with glaucoma and certain other eye disorders and may be contraindicated. Atropine is also contrain- dicated in clients with certain GI conditions, such as achalasia, peptic ulcer, or pyloric obstruction, and with asthma, chronic obstructive pulmonary disease (COPD), heart conditions, symptomatic prostatic enlargement, Down syndrome, brain damage, and liver or kidney dysfunction. 2. Inform the client about the experience of a dry mouth; relieve with moistened cloth, ice chips, sips of water, and hard candy, as tolerated and allowed. Report if dry mouth does not gradually resolve post-operatively. 3. Observe for side effects such as dizziness, agitation, confusion, diarrhea, constipation, urinary retention, blurred vision, and sensitivity to light. 4. Be alert for other more serious side effects, including skin rash, eye pain, difficulty breathing, irregular heartbeat, hallucinations, and difficulty swallowing. Report any of these immediately

Nursing Considerations when sedatives and narcotics are given

1. Observe for respiratory distress or bradypnea (very slow respiration). These medications often are contraindicated in clients with severe respiratory disorders. 2. Observe for inability to arouse client, extreme lethargy or drowsiness, fatigue, or oversedation. 3. Observe for other CNS symptoms, such as dizziness, blurred vision, severe nightmares, ataxia (difficulty in coordination). 4. Keep in mind that the medications may potentiate (abnormally enhance) the action of oral anticoagulants and anti-hypertensive drugs. 5. Watch for paradoxical excitement in older adults or children (a reaction opposite the desired reaction). 6. Observe for constipation and/or bowel obstruction; routine medications, such as senna or colace are often prescribed.

Types of surgery

1. Optional/elective surgery 2. Required/not elective surgery 3. Urgent/non elective 4. Emergency surgery

Steps in teaching a patient

1. Organize your teaching 2. Explain what you are going to do. 3. Demonstrate the procedure 4. Have the client or family caregiver return the demonstration. 5. Supervise the client's practice until the client/caregiver can accurately perform it independently. 6. Reinforce successful behavior. 7. Review the procedure. 8. Provide written instructions, to reinforce the learning.

Sedatives used as premedication before anesthesia

1. Promethazine HCL (Phenergan)- used pre- or postoperatively, and in obstetrics. 2. Midazolam HCL- benzodiazepine, central nervous system depressant, anxiolytic; causes some amnesia, can be used alone for IV moderate sedation (conscious sedation)

preoperative phase

1. person prepared physically and emotionally, 2. preliminary studies, such as ECG, done. 3. Informed consent obtained

What is the order of steps that occur during the transport of a client from the PACU to the recovery room? 1. Notify the client's family that the client is back in the recovery room. 2. Check the client's vital signs and compare them with previous recordings for any significant discrepancies. 3. Place the bed in its highest position, and keep the head of the bed flat. 4. Arrange for all necessary equipment before the client arrives in the recovery room.

3 4 2 1

A neuroleptanalgesic is a combination of:

An opioid and a tranquilizer/sedative

What does the preoperative checklist identify?

Assessments, medications, and other physical preparations that must be completed before the client is anesthetized.

How long should a patient be NPO prior to undergoing spinal anesthesia, general anesthesia or moderate sedation?

At least 8-10 hours prior to surgery to minimize the risk of the patient having N&V during anesthesia.

intraoperative phase

Begins with the patient's entry into the operating room and ends with admittance to the postanesthesia care unite (PACU) or recovery room

General anesthetics

Block all body sensations and cause unconsciousness, relaxation, and loss of reflexes.

minimal sedation

Client can respond to commands

Why would a same-day surgery be cancelled?

Client does not have adequate transportation to take them home. Client did not adhere to preoperative instructions. Client did not sign preoperative consent prior to receiving sedation medications.

Common procedures done under local anesthetics

Dental work, plastic surgery and skin suturing and some types of eye surgery. Much brain surgery is done under local as well.

moderate sedation

Depressed level of consciousness; client can breathe without assistance, respond to pain, and follow some commands; protective reflexes are maintained

nursing diagnosis for perioperative care

Fear, deficient knowledge, anticipatory grieving, disturbed body image, risk for aspiration, ineffective airway clearance, pain, hyperthermia, hypothermia, altered tissue perfusion ( cerebral, peripheral) deficient fluid volume, impaired tissue/skin integrity, impaired physical mobility.

What is the goal of the preoperative checklist?

For the client is to be in the best possible physical and emotional condition for surgery. A well prepared client is more likely to have successful surgery and an uneventful course of recovery, leading to an optimal rehabilitation.

stage 3 of general anesthesia (Surgical anesthesia)

Four planes, ranging from light to deep, with third or fourth plane usually best for most types o surgery. Progressive loss of reflexes, decreased heart rate, progressively depressed respiration until apneic (not breathing), normal to decreased BP, constricted to slightly dilated and centrally fixed pupils.

What is an example of a polyethylene glycolelectrolyte solution?

GoLYTELY or Halflytely

Common medications given for general anesthesia

Halothane (fluothane), enflurane (ethrane), Isoflurane (forane), sevoflurane (Ultane), desflurane (suprane, and methoxyflurane (penthrane) and nitrous oxide N2O2.

In the case of ambulatory day surgery, where do clients recover?

In a special reclining lounge chair.

Where is surgery performed if a patient is deemed high risk, or if its extensive?

In an acute care facility such as a hospital

What is the most common route of general anesthesia is?

Inhalation

How is general anesthesia administered?

Inhalation agents, IV anesthetics, rectally

what is the most important thing you can do for a patient and their family and when is the best time?

Keep the client informed before the surgery as there is little time after the surgery.

Common local anesthetics

Lidocaine (Xylocaine), Procaine (Novocaine), Tetracaine (Pontocaine)

What is an example of a cathartic solution?

Magnesium citrate or Miralax

What is General anesthesia used for?

Major procedures, such as open-heart surgery and transplants of organs, and in some less complex situations.

Where is the prep and shave performed?

Most often in the Operating Room

Skin preparation

Must be cleansed thoroughly prior to surgery using an antibacterial soap.

What medications should a client d/c using prior to surgery?

NSAID's aspirin, ibuprofen, blood coagulation medications for 7-14 days

Local (infiltration and topical anesthesia) Anesthesia

Pain and sensation blocked in limited area, most often by injection of an anesthetic agent into a small local area or by topical application to the area (dental work or traumatic wound suturing).(Novocain)

What level of Maslow's needs to be met first when performing pre and postoperative care?

Physiological must be met first to sustain life. (oxygen, water, food, elimination, and sleep)

What is maslow's first level of needs and why is it important to nursing?

Physiological needs, oxygen is the most important basic human need. Meaning the airway must remain patent. If the client had local, spinal, or regional anesthesia, the sensory and motor functions must be monitored as well.

What is vital for the patient to receive in same-day surgery?

Preoperative and post operative teaching, and they must understand what needs to be done and what complications might occur. the client has to receive written as well as verbal instructions.

Drying Agents (Anticholinergic)

Prevents or reduces respiratory tract secretions

If a client is on a ventilator or otherwise unable to speak postoperative what should you do?

Prior to surgery arrange for a communication system. Allow the client to practice this system preoperatively.

perioperative

Refers to the time span that includes preparation for, the process of, and recovery from surgery.

Having been responsible for the monitoring of the client's condition what does the anesthesia nurse do when when handing over the client to the PACU?

Reports the clients condition to the PACU nurse and leaves the surgeon's postoperative orders and any required special instructions.

What are the 4 types of medications administered preoperatively?

Sedatives, antibiotics, narcotics, and drying agents

What is the goal of administering anesthesia?

Smooth progression in and out of the stages, with no definite demarcation between them and to provide anesthesia without progressing into stage 4.

True or False: All preoperative orders are null and void when the client enters the OR. Totally new orders must be written.

TRUE

True or False: The client under general anesthesia cannot be aroused and cannot breathe without assistance. A patent airway must be artificially maintained. In some cases, cardiovascular function is also impaired.

TRUE

Regional Anesthesia

Temporary interruption of sensory nerve conduction, is produced by injecting an anesthetic solution near the nerves to be blocked.

What does the patient do when they in a walk-in, ambulatory center, surgical center, or short stay, same-day surgery center?

The client does the preparation at home, enters the facility, has the surgery, and goes home to recover the same day.

What must be performed prior to administering any presedation medications to the client?

The client needs to sign the preoperative checklist as well as the surgical consent.

What makes the client and family more relaxed and cooperative going into surgery?

The client understanding pre and postoperative procedures. They know what to expect when the client returns from the OR. They are taught about the different machines and equipment that may be present. The client is taught how to perform breathing exercises. The client is taught how to splint an abdominal incision to help cough.

Who prepares sterile instruments for the surgeon's use?

The scrub nurse or surgical technician

Conduction Block Anesthesia

There are many types of conduction blocks, depending on the nerve group affected by anesthetic injection. The field block encircles the operative area with several injections. A nerve block is done by injecting the anesthetic near the nerves supplying the area. These are commonly used in obstetrics. Can also be used for chronic pain management (most often back pain).

What must a client have prior to going to the OR?

Two identification bands, allergy band, fall risk id band, two blood bands (if a transfusion may be necessary)

less complex of less dangerous procedures not requiring an overnight stay are most often performed where?

Walk in, or ambulatory center, often called a surgi-center, short-stay, or same-day surgery center

What happens during stage 1 of general anesthesia?

a client's pulse remains normal, increased RR and depth of respiration.

What medication is given to help inhibit body secretions, so the client produces less mucus, reducing the likelihood of aspiration and atelectasis?

a drying agent or anticholinergic, such as atropine sulfate (AtroPen, Sal-Tropine)

anesthesiologist

a health care provider trained in anesthesiology

registered nurse first assistant

a member of the operating room team whose responsibilities may include handling tissue, providing exposure at the operative field, suturing, and maintaining homeostasis

What medication is given the morning of surgery, to relax the client and enhance the anesthesia's effect?

a narcotic

post operative nursing care

after surgery (recovery from surgery)

spinal anesthesia

an extensive conduction nerve block produced by injecting medication into the subarachnoid space of the spinal cord. Administered by an anesthesiologist and the effect is achieved more slowly and resolves more slowly that with general anesthesia. Can be used for many types of surgery however the cost may be prohibitive.

Why do surgeons prescribe before surgery to help prevent postoperative infections? How long are they usually taken prior to surgery?

antibiotics, several days

Preoperative Nursing Care

before surgery, preparation for surgery

What herbal supplements should a client d/c using prior to surgery?

chamomile, cat's claw, feverfew, garlic, ginger, ginkgo, goldenseal, grape seed extract, green tea leaf, horse chestnut seed, and turmeric

What are the routine preoperative tests?

chest xray, complete blood count, urinalysis, ecg, BMP or CMP, toxicology screen, pregnancy test, type and cross match, bleeding-clotting test (prothrombin time), patient weight (in kg).

Deep sedation

client cannot be easily aroused, but can respond after repeated stimulation. respiration may need to be supported

What is atelectasis?

collapse of the tiny air sacs in the lungs usually caused by mucus plugs or blood clots that close the bronchi -involves all or part of a lung -post op client often is reluctant to breathe deeply due to incisional pain - S/Sx: fever and cyanosis

anesthesia

complete or partial loss of sensation.

Optional/elective surgery

condition is not life-threatening. client may choose whether or not to have the surgery. (plastic surgery, removal of a nonmalignant birthmark, tubal ligation or vasectomy for sterilization

surgery

considered to be invasive because it usually involved an incision into the body or removal of external structures (the client may understand the work operation rather than surgery)

Local, Regional, conduction blocks, or spinal anesthetics

disrupt sensation to specific body areas or parts, without causing unconsciousness; administered topically, by injection, and less commonly, by freezing with special substances such as ethyl chloride

What happens when a client is administered an anticholinergic medication?

given to help inhibit body secretions, so the client produces less mucus, reducing the likelihood of aspiration. Production of gastric and intestinal secretions is also reduced, so there is less abdominal distention postoperatively.

intraoperative nursing care

in the operating room, and post anesthesia recovery, or post anesthesis care unit (the process of surgery.

anesthetics

induce anethesia

circulating nurse

is an RN who works outside the sterile field. Duties include general management of the operating suite, including monitoring temperature, cleanliness, humidity, lighting, and fire safety. This nurse continually assists anesthesia personnel in monitoring the client and observes for breaks in technique by all personnel in monitoring the client and observes for breaks in technique by all personnel in the area, including ancillary personnel, such as laboratory or x-ray staff. They also assist by opening sterile packs, delivering medications to the scrub person, weighing and labeling specimens, and keep records during the surgical procedure.

which factors increase a clients surgical risk?

obesity, poor nutrition, malnutrition, anorexia, bulimia, exercise bulimia, dehydration, edema, electrolyte imbalance, elderly, children, infants, babies, smoking, use of chewing tobacco, vapor cigarettes, caffeine, abuse of chemicals/ abuse of illegal drugs, alcohol abuse, use of certain prescription drugs, pre-existing physical disorders, immune disorders, immunosuppression, excessive fear, intellectual impairment, depression, immobility, poor physical condition, lack of available care givers.

What is completed in the same-day surgery center?

only the immediate preoperative preparation and the surgery itself are completed.

What are the three phases of perioperative nursing?

preoperative, intraoperative, postoperative

post operative phase

prevention of complications

registered nurse anesthetists (RNA)

registered nurse trained in anesthesiology

What is medication is ordered as a one time only order the evening before surgery to promote a restful night's sleep?

sedative

IV moderate sedation (conscious sedation)

sedative medications are used either alone or in conjunction with local anesthetics. Depressed Level of consciousness, but continues to breathe and is able to respond to verbal stimuli. (example medications are: Midazolam HCL or another short-acting benzodiazepine(they induce sleepiness, and relieve anxiety))

Whose is responsible for monitoring a client under general anesthesia?

specially trained anesthesia personnel.

Common procedures done under spinal anesthesia

surgery of the lower extremeties, perineum, and lower abdomen.

Emergency surgery

surgery that must be performed immediately to save the person's life or a body organ. (example ectopic pregnancy with threat of rupture, severe internal hemorrhage, ruptured appendix, and angioplasty after a MI

What is informed consent?

the client must understand what is being done and why. The client and/or family must be able to verbalize the type of surgery being done, and this statement must agree with the records and consent forms.

surgical anesthesia

the degree of anesthesia at which an operation can safely be done and tolerated by the client

anesthesiology

the discipline of medicine that administers anesthetics

Sedation

the induction of a calm, relaxed, often sleepy state

Required/not elective surgery

the surgery is necessary at some time, the patient has some choice as to when the procedure will be done. Examples are hernia repair, prolapse, uterus, hip joint replacement

Urgent/non elective

the surgery must be performed with a short time to prevent further damage to the client. ( examples are removal of a malignancy, repair of an aneurysm, or removal of an inflamed appendix.

How is local anesthesia administered?

topically, injection, or less commonly freezing substances (ethyl chloride.

General Anesthesia

unconsciousness (severe nervous system depression, narcosis) is induced by anesthetic agents. This causes absence of pain (analgesia) and sensation over eh entire body and muscle relaxation, with loss of reflexes. The client cannot be aroused, and breathing must be maintained mechanically.