Chapter 56 Anesthesia PART 2

Types of Anesthetics

*Lidocaine- dental anesthesia *Procaine- dental anesthesia *Nitrous Oxide- Laughing gas -anxiolytic, adjunct to local anesthetic *Propofol - reduces anxiety and tension, and promotes relaxation/sleep or loss of consciousness *Diethyl Ether- (one of the first general anesthetics

Blood patch

*involves injecting 15-20mL of clients own blood into the epidural space -when blood clots in forms a seal over the hole in the dural membrane

Nerve Blocks

*local anesthetic injected more deeply into body and/or directed at specific nerves -ulnar nerve block -brachial plexus block -often use lidocaine, mepivacaine, or bupivacaine lasts 1 to 12 hours

Residual Sensory Block

*normal sensation not returning completely on discharge from recovery -as block wears off, sensation will gradually return -patient may have prickling, tingling sensation in the area that has been blocked -until complete sensory perception has returned the patients needs to be protected from injury. -sensory function can be assessed by touching the skin and asking the if he can feel the sensation.

Complete Motor Block

*the patient is totally incapable of moving the blocked part -a patient with a block involving the legs should not be allowed out of bed without assistance until you can be certain complete recovery of motor strength. -motor function can be assessed by having the patient move the effected part.

Administration of Scheduled medications

-Anesthesia provider will usually write an order specifying if routine medications should be administered the morning of surgery -heart meds, antihypertensives, diabetic meds

Anesthetics

-Drugs that interfere with the conduction of nerve impulses to produce loss of sensation, muscle relaxation, and/or complete loss of consciousness.

Anesthesia

-absences of normal sensation -loss of feeling or sensation -may be induced by drugs that are able to bring about partial or complete loss of sensation

Topical Anesthesia

-achieved with direct application of local anesthetic to tissue -takes form of an ointment, lotion, solution,viscous lidocaine, or spray -prevent choking and aspiration after oral local anesthetic, fluids and foods must be withheld until gag reflex returns

When sedation becomes general anesthesia all the risks are present:

-airway obstruction -respiratory arrest -aspiration

Residual Sympathetic Block

-aka orthostatic hypotension -sympathetic motor function is more difficult to detech -orthostatic hypotension can occur after motor and sensory function have returned -have patient change positions slowly and with assistance

Emergence (waking up)

-allowing drugs to wear off -timing must be exact -initial phase is quick- patent aroused just enough to respond to verbal instructions and maintain an airway -ET tube can generally then be removed and the client taken to PACU

(recovery) oxygenation and ventilation

-almost all anesthetics are CNS depressants and thus respiratory depressants. -monitor oxygen saturation by pulse ox -give supplemental oxygen to a client whose rate or depth of respiration is decreased to add extra oxygen postoperatively -highest priority for the nurse in the PACU is maintenance of patent airway.

The vital functions are controlled by the anesthesia provider

-anesthesia provider monitors oxygenation and gas exchange -client is at risk for aspiration because of general anesthesia eliminates protective airway reflexes

Preanesthetic care/Anesthesia provider

-assess clients health -explains risk and benefits of anesthesia -plans type of anesthetic appropriate for the client and procedure -ensures adequate levels are administered throughout procedure -monitors and controls physiological functions -administers meds to ensure the client is comfortable as possible after the procedure

Post-dural puncture headache

-csf leaks out through a hole made in the dural membrane -caused by loss of fluid from around the brain -relieved by lying flat -returns when head is higher than feet -pain occurs in the front and back of the head -often accompanied by neck and shoulder stiffness may take 1 to 2 days to occur

Sedation is used to

-decreases awareness of events -relieve anxiety *if due to pain, opioid analgesics are best -control physiologic changes that often accompany anxiety -ease induction of general anesthesia

Duration of anesthesia produced is based on :

-drug used and amount injected -party of the body in which the drug is injected

Treatment of Post-dural puncture headache

-hydration to allow for normal production of CFS -analgesics -bed rest in supine postition -blood patch

Preanesthetic care

-if client responds abnormally to preoperative meds, notify anesthesia department immediately -be sure client's chart complete when going to operating room with client -make sure client consents are in order and included in chart

Spinal Blocks

-injected into cerebrospinal fluid (CSP) -anesthetic bathes uninsulated spinal nerves as they exit to the periphery of the body -lasts 1 to 3 hours

Epidural blocks

-injected into epidural space near spinal cord -anesthetizes several spinal nerves at once -can be continued as long as local anesthetic injected through catheter into epidural space

Fluid balance

-large volumes of IV fluid are infused -fluid moves out of vascular space to interstitial and intracellular spaces -fluid loss through trauma -direct blood loss -evaporation during surgical wound -fluid shift -major abdominal surgery can result in loss of up to 10ml/kg/hr of fluid by evaporation

region of body temporarily rendered insensible to pain by injection of local anesthesia:

-local -nerve blocks -spinal -epidural

maintenance

-maintaining anesthesia with combination IV and inhaled drugs -provides a dependable way to give oxygen and ventilation -helps prevent gas from entering stomach -may have protective eye moisturized applied or eyes taped closed . Do not allow client to rub eyes- mays cause corneal abrasions.

Skeletal Muscles relaxation

-may be required to completely paralyze the client -some surgeries require total muscles relaxation

Recovery

-may take days or weeks -the speed of the release of medications from the patient's body depends on: -amount of anesthetics given -the length of surgery

JACHO requires the following for procedural sedation:

-monitoring of HR and oxygenation by pulse oximetry -monitoring of respiratory rate and pulmonary ventilation -EKG -monitoring blood pressure -individual monitoring the sedation should not have any other responsibilities.

Recovery B Heart rate and blood pressure

-most HR and BP changes seen during recovery result from factors related indirectly to the anesthetic -HR AND BP increases as a result of sympathetic stimulation -pain, hypoxia, and fear can cause an increase in HR and BP

As a regional block begins to wear off

-motor function returns first -sensation returns next -sympathetic nervous function returns last

nursing staff of preanesthetic care

-obtains clients consent forms -completes preoperative checklist -make sure all preoperative orders executed -checks, verifies, and documents allergies -administer regular oral meds with small sip of water as ordered -remind client of importance of eating and drinking restrictions -administer preoperative meds -immediately inform MD/anesthesia of abnormal results -review test results & have in medical record

sedation

-reduction of stress, excitement, or irritability -central nervous system depression

induction and Airway management

-short but critical period during -client is made unconscious, , vital functions are controlled and enough anesthetic is given keep the patient asleep during surgery. -in adults, IV sedation is given quickly to produce unconsciousness the the patient inhales anesthetic gases -going to sleep -inserting oral airway

Residual Motor Block

-temoporary condition caused when local anesthetics block nerves that carry instructions to skeletal muscles resulting in the inability to move a part of the body -usually the last effect to develop and the first to wear off

Sedatives are administered based on

-the clients physical condition -procedure being performed -weight -mental state *observe client closely for sedative effects

Synergistic Effect/Synergism

-when given in combination some sedative produce effects that are greater than if the drugs were given alone -makes the CNS depression more likely or more enhanced

Insulin and oral hypoglycemics

-will depend on the severity of the disease and DR. Preference

Temperature Regulation

-with general anesthesia -body loses its natural ability to regulate body temperature -blood vessels close to the skin surface dilate -client mostly uncovered and or cold -surgical area is clean with cold solutions -skin is open- warm internal heat escapes -IV fluids are infusing -cool gases are being breathed -when blood levels of the anesthetic agent becomes low during emergence from general anesthesia, shivering occurs -teats hypothermia with warm blankets

4 stages of general anesthesia

1)Induction and Airway Management 2)Maintenence 3)Emergence/Recovery 4)Fuild Balance

5 types of pre-op meds

1)Opioid 2)Prophylactic antibiotics 3)Sedatives 4)Antiemetics 5)Cholinergic Blocking agents (anticholinergics)

How long does the NPO status usually range from?

2 to 12 hours infants and small children for 4 hours or less

Sedation usually persists beyond duration of surgical procedure....

=health of the client =properties of the drugs used =other drugs the client may be taking =amount of sedative drugs administered

Cholinergic Blocking Agents

Anticholinergics -decrease secretions of the upper respiratory tract -some anesthetic gases adn volatile liquids are irritating to the lining of the respiratory tracts and increase mucus secretions -cough and swallowing flexes are lost during anesthesia -excessive secretions can cause a pool in the lungs resulting in ATELECTASIS(a reduction of air in the lungs) -Robinul dires up secretions of the UPT and lessens the possibility of excessive mucus production

Anticoagulants

Herapin and Coumadin -low does of herapin may be given in some cases to prevent post operative thromboembolism, blood work often ordered.

analgesia

a lessening of pain without loss of consciousness examples: Demerol, Morphine, Dilaudid, fentanyl (sublimaze) -analgesics given prior to anesthesia or in combination with anesthesia to decrease anxiety and ease induction of anesthesia

Spinal&Epidural blocks produces anesthesia sufficiently for surgery of the:

abdomen pelvis perineum lower extremities

During sedation, client must remain conscious and in control of own _______ and _________.

airway, breathing

meds that can be continued until the time of surgery are

antihypertensive agents and cardiac drugs

Sedation is often used to alleviate _______ and _________ during local anesthesia

anxiety, discomfort

brachial plexus block

blocks all nerves in arm

Procedural/conscious sedation

decreases the perception of physical and mental discomforts

how to deeply the patient is breathing-

inhalation anesthetics are eliminated from the body through the lungs

amount of medication needed depends on:

intensity and type on pain size of client client's age (elderly need lower doses of opioids) patient controlled analgesia regional analgesia -local anesthetics -opioids

Steriods

may be held due to side effects such as increased risk for GI bleed,post operative infection, delayed wound healing

Opioid Analgesics

morphine, demerol, antianxiety meds -ease induction -decrease anxiety and apprehension

Antiemtics

opiate adjuvant enhances effects of narcotics prophylactically to prevent nausea

Amnesia

partial or total loss of memory -common (may appear totally recovered) -may no remember if procedure ends suddenly -Monitor client until medications wear off enough for client to wake and become oriented.

oral intake

removes persons ability to guard the air way by coughing and closing of the vocal cords with the epiglottis. -aspiration of stomach contents in the respiratory tract can cause severe illness or death -make sure the stomach is empty to help prevent this.

There is a fine like between __________ and general anesthesia

sedation

Pavulon

skeletal muscles relaxant that completely paralyzes the body

Small amount of anesthetic drug injected either into ____ and _____________ tissues around cut or at site of needle puncture for _______ _____ placement

skin subcutaneous central line

Nonsteriodal Anti-inflammatory agents

such as ASA -in some cases no NSAIDS are allowed for 10 to 14 days pre-op

General Anesthesia

the blockage of all body sensations, causing un-consciousness and loss of reflexes. -body loses the ability to maintain an airway, control breathing and heart rate, and regulate body temperature.

The most dangerous result of sedation is

the inability to breathe

Sedatives

the night before surgery to enhance rest/sleep Valium,Versed

when opioid analgesics are administered via epidural catheter:

the nurse should have NALOXONE HCl (NARCAN) readily available to reverse respiratory depression

pain results from:

tissue injury release of local and hormonal substances inflammation mental outlook

Endotracheal ET tube

tube is usually in place. it makes it more difficult for gastric contents to enter the lungs while under anesthesia

C temperature regulation and shivering

when blood levels of the anesthetic agent becomes low during emergencies shivering occurs

Common use Lidocaine

with preservatives or epineprine are use only for locals and never for dyrhythmias -last approximately ONE HOUR