Care of the Surgical Patient (anesthesia to end of chapter)

Care of the Surgical Patient (anesthesia to end of chapter)Aiza Espanol06-02-09Words/Vocab to know.Anesthesia: Absence of sensation (pain)Conscious Sedation: Administration of central nervous system depressant drugs and/or analgesia to relieve anxiety and/or provide amnesia during surgical, diagnostic, or interventional proceduresProsthesis: Artificial replacement for a missing body partSurgical Asepsis: A group of techniques that destroy all microorganisms and their spores (sterile technique)Drainage: Free flow or withdrawal of fluids from a wound or cavity by some sort of system (such as a catheter or T-tube) Words/Vocab to know (cont.)Exudate: Fluid, cells, or other substances that have been slowly exuded or discharged from body cells or blood vessels through small pores or breaks in cell membraneExtubate: To remove an endotracheal tube from an airwayDehiscence: Partial or complete separation of a surgical incision or rupture of a wound closureCachexia: General ill health and malnutrition marked by weakness and emaciation; usually associated with a serious disease such as cancerEvisceration: Protrusion of an internal organ through a disrupted wound or surgical incision

Words/Vocab to know (cont.) Atelectasis: Collapse of lung tissues, preventing the respiratory exchange of carbon dioxide and oxygen Paralytic Ileus: Most common type of intestinal obstruction; a decrease in or absence of intestinal peristalsis that may occur after abdominal surgery Singultus: hiccup Catabolism: Breakdown or destructive phase of metabolism. Catabolism occurs when complex body substances are broken down to simpler ones; opposite of anabolismAnesthesia

3 Categories of Anesthesia General Anesthesia

Regional Anesthesia

Local AnesthesiaGeneral Anesthesia

General Anesthesia (cont)General Anesthesia results in an immobile, quiet patient who does not recall the surgical procedure. The patients amnesia acts as a protective measure from the unpleasant events of a procedure. Surgery using general anesthesia involves major procedures requiring extensive tissue manipulation.

Four Stages of General Anesthesia Stage I Stage II Stage III Stage IV

An anesthesiologist gives general anesthetics by either IV or inhalation routes through these four stages.

A more useful designation of stages includes the three phases Induction Maintenance Emergence Stage I of General AnesthesiaBegins with the patient awakeThis stage is completed once the patient loses consciousness

Stage II of General AnesthesiaBegins with the loss of consciousness and ends with the onset of regular breathing and loss of eyelid reflexesReferred to as the excitement of the delirium phaseOften accompanied by involuntary motor activityPatient must not receive any auditory or physical stimulation during this stageCan result in an undesirable increase in heart rate and blood pressure

Stage III of General AnesthesiaBegins with the onset of regular breathing and ends with the cessation of respirations Known as the operative or surgical phase

Stage IV of General AnesthesiaBegins with the cessation of respirations and must be avoided Will necessitate the initiation of CPRMay lead to death

**These stages were defined with the use of ether and are sometimes difficult to ascertain with new anesthetic agents**

Induction Phase of General AnesthesiaAdministration of agentsEndotracheal intubationMaintenance Phase of General AnesthesiaPositioning the patientPreparation of the skin for incisionSurgical procedure itselfAppropriate levels of anesthesia are also maintained during this phaseEmergence Phase of General AnesthesiaAnesthetics decreasedPatient begins to awakenDue to the short half-life of todays medications, emergence is often in the ORGeneral Anesthesia (cont.)To induce anesthesia, an IV agent is often given, although an inhalation agent may also be usedUnconsciousness is normally achieved 10 to 20 seconds after the dose is administeredBarbiturates provide sedation, amnesia, and hypnosisMust be used with other agents to achieve pain relief and muscle relaxationAnesthesiologist puts an endotracheal tube into the patients airway to prevent possible aspiration and other respiratory complicationsGeneral Anesthesia (cont)For those who are at high risk for aspiration, cricoid pressure can prevent silent regurgitation and aspiration of gastric contents during induction and intubationTechnique to reduce the risk of the aspiration of stomach contents during induction of general anesthesia: the esophagus is compressed to prevent passive regurgitationThis technique, however, cannot stop active vomitingThis technique is also begun when the patient is awakePatient reassurance is important to provide support during this period of mild discomfortOnce initiated, pressure must be held constant

General Anesthesia (cont)Upon completion of induction, anesthesia may be maintained through a combination of inhalation and IV medsContinuous supply of oxygen is also givenAdjunct meds such as opioid analgesics (analgesia) and muscle relaxants are administeredDuration of anesthesia depends on the length of surgeryEmergence from anesthesia occurs when procedure is completed and reversal agents are givenOropharynx is suctioned to decrease risk of aspiration and laryngeal spasm following extubationExtubation is often accomplished before transfer to the PACU (postanesthesia care unit)Risks of General AnesthesiaSide effects of anesthetic agentsCardiovascular depressionCardiovascular irritabilityRespiratory depressionLiver damageKidney damageRegional Anesthesia

Regional AnesthesiaResults in loss of sensation in an area of the bodyMethod of induction influences the portion of sensory pathways that is anesthetizedNo loss of consciousness, however, the patient is usually sedatedAnesthesiologist gives regional anesthetics by infiltration and local applicationInfiltration of agent may involve one of the following induction methods:Nerve BlockSpinal AnesthesiaEpidural AnesthesiaIntravenous Regional Anesthesia (Bier Block)Induction Method of Regional AnesthesiaNerve Block: Local Anesthetic is injected into a nerve, blocking the nerve supply to the operative siteSpinal Anesthesia: The anesthesiologist performs a lumbar puncture and introduces local anesthetic into the cerebrospinal fluid in the spinal subarachnoid space. Positioning of the patient influences movement of the anesthetic agent up or down the spinal cord. This type of induction is often used for lower abdominal, pelvic, and lower extremity procedures; urologic procedures; or surgical obstetrics. *Spinal anesthesia pose a less risk for respiratory, cardiac, and gastrointestinal complications then general anesthesia. One of the complications of spinal anesthesia is postspinal headache. This is caused by the leakage of cerebrospinal fluid at the puncture site.* Induction Method of Regional Anesthesia (cont)Epidural Anesthesia: This is known to be safer than spinal anesthesia because the anesthetic agent is injected into the epidural space outside the dura mater and the depth of anesthesia is not as great as that with spinal anesthesia. This method is often used with obstetric procedures. The epidural catheter may be left in so that the patient may receive meds via continuous epidural infusion following surgeryInduction Method of Regional Anesthesia (cont)Intravenous regional anesthesia (bier block): Local anesthetic is injected via IV line into an extremity below the level of a tourniquet after blood has been withdrawn. The extremity is pain free while the tourniquet is in place. Advantages include a short onset and a short recovery time. The tourniquet may only be inflated for 2 hours or else tissue damage may occur.Regional Anesthesia (cont)Patient is awake throughout the surgery procedure with regional anesthesia unless the physician orders a tranquilizer that promotes sleep and/or amnesiaUse of endotracheal tube is unnecessary because the patient is responsive and capable of breathing voluntaryNecessary for the nurse to frequently observe the position of extremities and condition of the skin because the patient can be injured on the anesthetized body part without being awareTopics discussed within the operating room should be done with cautionRisks of Regional AnesthesiaPostspinal headachesIn particularly with spinal anesthesia, levels of anesthesia may rise, which means that the anesthetic agent had travelled upward in the spinal cord and breathing may be affectedPatient may experience a sudden drop in BP which results from extensive vasodilation caused by the anesthetic block to sympathetic vasomotor nerves and pain and motor nerve fibersAlso, if the level of anesthesia rises, respiratory paralysis may develop, requiring resuscitation by the anesthesiologistLocal Anesthesia

Local AnesthesiaInvolves loss of sensation at the desired siteAgent inhibits nerve conduction until the drug diffuses into the circulationMay be injected or applied topicallyPatient experiences a loss in pain sensation and touch, and in motor and autonomic activitiesCommonly used for minor procedures performed in ambulatory surgery*Examples of Local AnestheticsLidocaine hydrochloride (Xylocaine)Bupivacaine hydrochloride (Marcaine HCl)Tetracaine (Pontocaine)Ropivacaine (Naropin)*Risks of Local AnesthesiaToxic effects caused by overdoseInitial s/sx are excitement and central nervous system stimulation followed by depression of the central nervous system and the cardiovascular systemLocal tissue damageInflammation and edemaAbscesses and necrosis sometimes develop at injection siteAllergic responses

Local AnesthesiaNurse prepping patient with local anesthetics for suturing of laceration to right eyebrow.

Conscious SedationRoutinely used for procedures that do not require complete anesthesia but rather a depressed level of consciousnessA patient under conscious sedation must independently retain a patent airway and airway reflexes and be able to respond appropriately to physical and verbal stimuliAdvantages of conscious sedation include adequate sedation and reduction of fear and anxiety with minimal risk, amnesia, relief of pain and noxious stimuli, mood alteration, elevation of pain threshold, enhanced patient cooperation, stable vital signs, and rapid recoveryConscious Sedation (cont)Variety of diagnostic and therapeutic procedures are appropriate for conscious sedationBurn dressing changesCosmetic surgeryPulmonary biopsy and bronchoscopyNurses must have the knowledge of anatomy and physiology, cardiac dysrhythmias, procedural complications, and pharmacological principles related to the adminsitration of individual conscious agentsNurses must also be able to assess, diagnose, and intervene in the event of untoward reactions and demonstrate skill in airway management and oxygen deliveryResuscitation equipment must be readily available in conscious sedation is being usedPositioning the Patient for SurgeryDuring general anesthesia the nursing personnel and surgeon often wait to position patient until stage of complete relaxation is achievedChoice of position is usually determined by the surgical approachPosition should provide good access to the operative site as well as sustain adequate circulatory and respiratory function Should not impair neuromuscular structuresPatients comfort and safety must be consideredAlthough it may be necessary to place patient in an unusual position, the nurse should attempt to maintain correct alignment and protect the patient from pressure, abrasion, and other injuriesPreoperative ChecklistUsually completed upon admission or before leaving the nursing unitWhen a nurse endorses the checklist, the nurse assumes responsibility for all areas of care included on the listIf there are pre-op meds to be given on the nursing unit, the nurse completes the pre-op checklist before administeringAny prosthesis, contact lenses, dentures, jewelry, and other valuables are removed and either given to a family member or placed in a secure areaDisposition of personal items should always be charted The patient should be instructed to void before pre-op meds are administered or at least 1 hour before the procedurePatient should be reminded to remain in bed after administration of pre-op meds and call light should be in reachTransporting to Operating RoomPersonnel in operating room will notify the nursing unit when it is time for the surgeryTransporter must check against patient ID against the medical records to make sure the correct patient is being transported to surgeryIf patient is being transported via gurney the transporter and nurse should assist with transfer from bed to gurneyIf patient is ambulatory they may walk to the operating room allowing for more control over the eventThe trip to surgery should be as smooth as possible to avoid nausea and dizzinessFamily members are usually provided with an opportunity to visit the patient before the procedure and patient is transferred to the operating room

Preparing for Post-Op PatientIf the patient is an inpatient, the nurse will prepare the bed and room for their return to the unitPost-Op bedside shall includeSphygmomanometer, stethoscope, and thermometerEmesis basinClean gownWashcloth, towel, and facial tissuesIV pole and pumpSuction equipmentOxygen equipmentExtra pillows for positioningBed liners for protection against drainagePCA pump and SCD machineINTRAOPERATIVE PHASEHolding AreaRole of the nurseIntraoperative PhaseCenters on the care and protection of the patientNursing interventions should include warm, personal contact with the patient to humanize the often cold, aseptic, and highly technical environment of the operating room

Holding AreaPatient enters a preanesthesia care unit (holding area) where nurse completes the pre-op preparationsNurses in this unit are usually part of the operating room staff and wear surgical scrub suitsHere the nurse or anesthesiologist will insert an IV catheter into patients vein to establish a route for fluid replacement and IV medsPre-Op meds are administeredPatients stay in the holding area is usually briefRole of the NurseIn the intraoperative phase the nurse assumes one of two roles: scrub nurse or circulating nurseSee Box 42-7 on page 1291 for responsibilities of eachEveryone in the OR must be alert to contamination of sterile items and must aid in maintaining aseptic conditionsSurgical asepsis is provided to prevent microbial contamination of the operative siteGoal of surgical asepsis is to prevent or minimize post-op wound infectionsStandards and guidelines for surgical scrubs and skin prep should be strictly followedRole of the Nurse (cont)During the post-op phase the OR nurse assists in transferring the patient to the PACUReport is also endorsed to the PACU nursePatients statusReview of IV fluidsMedsBlood products administeredSurgical dressingNature of any complications in the OR Unusual risks for hemorrhage or cardiac irregularitiesThe OR nurse is an important resource in planning the post-op care for the patientPOSTOPERATIVE PHASEImmediate Postoperative PhaseUpon completion of surgery, patient is transferred to recovery room (PACU) or intensive care areaEval of the patient follows the ABCs of immediate post-op observations: airway, breathing, consciousness, and circulationVital signs are assessed every 15 minutes and respiratory and GI functions are monitoredWound is evaluated for any drainage and/or exudate When patient has patent airway and stable vitals, in conscious, and responds to stimuli, the anesthesiologist or surgeon approves the transfer of the patient to the nursing unitImmediate Post-Op Phase (cont)As patient regains consciousness, relief of pain is often the first need expressedFrequently, meds are given in the PACUDocumentation from surgical suite and PACU is reviewed by staff on the nursing unit to assess how well the patient tolerated the surgical processBody temperature is closely monitored for hypothermiaOccurs in 60-80% of all post-op patientsBody exposure in a cold OREffects of cold solutionsConsequence of some anestheticsLater Postoperative PhaseImmediate postsurgical assessmentVStimes four factor15 minutes x4; 30 minutes x4; every hour x4;or until VS are within expected rangeIV and incision siteAny tubesPost-op orders reviewedReview of each body system identifies when body functions return and provides a guideline for further assessment

Later Post-Op Phase (cont)Nausea and vomiting are normal in the first 12 to 24 hoursAn emesis basin should be left at bedside and amount should be measured and carefully described and documentedRed or coffee-ground emesis should be reported immediatelyUsually patient remains NPO for a few hours after surgeryFluids are introduced graduallyUsually begins with ice chips then gradually changed to clear or full liquids

Later Post-Op Phase (cont)Post-op complications can occur suddenly Changes in condition should always be notedSweating should never be induced with the post-op patient but another blanket should be provided for extra comfortVS coupled with the patients behavior are first-line observationsPulse that increases and becomes thready coupled with a declining BP, cool and clammy skin, reduced urine output, and restlessness may indicate hypovolemic shockHypovolemic shock in the post-op period is frequently caused by internal hemorrhage which is a life threatening emergencyLater Post-Op Phase (cont)Drop in BP slightly below a patients pre-op baseline reading is common after surgerySignificant drop in BP accompanied by an increased heart rate, may indicate hemorrhage, circulatory failure, or fluid shiftDo not diagnose impending hypovolemic shock on the basis of 1 low BP readingDecreased BP can also mean that the anesthetics is wearing off or that the patient is experiencing severe painIn addition to hypotension, manifestations of shock include tachycardia; restlessness and apprehension; and cold, moist, pale, or cyanotic skinLater Post-Op Phase (cont)Nursing Interventions for patient who are going into shock:Administering oxygen or increasing its rate of deliveryRaising patients legs above the level of the heartIncreasing the rate of IV fluids (unless contraindicated because of fluid excretion problems)Notify the anesthesia provider and the surgeonProvide meds as orderedContinuing to assess the patient and response to interventionsLater Post-Op Phase (cont)Incision:Dressing is always monitored because bleeding or excessive drainage may also signal post-op hemorrhageDressings are normally only reinforced during the first 24 hoursA surgical incision may also separate (dehiscence)- may occur within 3 days to over 2 weeks postoperativelyWound separation occurring after 2 weeks is usually associated with metabolic factors such as cachexiaIf internal organ protrudes through incision site then wound evisceration has occurredBoth wound dehiscence and evisceration should be given prompt attentionNurse should contact physician immediatelyLater Post-Op Phase (cont)Ventilation:Immediate post-op hypoventilation can result from drugs, incisional pain, obesity, chronic lung disease, or pressure on the diaphragmInadequate ventilation leads to hypoxemiaBecause lung ventilation is vital, the nurse assists the patient to turn, cough, and breathe deeply every 1 to 2 hours until the chest is clearEarly mobility and frequent position changes facilitate secretion clearance and improve the distribution of ventilation and perfusion in the lungsIf the patient feels chest pain or has a fever, productive cough, or dyspnea, atelectasis or pneumonia may be developingFrequently oxygen therapy is instituted to assist with respirationsWhenever air exchange is slow post-op recovery slowsIf respiratory complications develop, the physician may order respiratory therapy to provide intermittent positive pressure breathing treatments to deliver a mixture of air and oxygen; meds can be added to enhance respirationsPatients are not left unattended during postural drainage treatments, since they may experience respiratory distressLater Post-Op Phase (cont)Pain:Normal postoperatively; nurse should offer patients prescribed analgesicsNurse should ask patient every 3 to 4 hours if something is needed for pain Acute pain begins to subside within 24 to 48 hoursPain meds are subsequently adjusted to meet the patients needsPatients level of pain can be difficult to assess therefore request for patient to use a pain scaleObjective pain factors:Vital sign changesRestlessnessDiaphoresispallorLater Post-Op Phase (cont)Pain:Patients description of discomfort represents subjective pain factorsPain behaviors are influenced by the patients culture and past experiencesMoaningGrimacingFavoring a body partEffectiveness of analgesic measures differs with each personSuccess of pain management depends on the nature of the surgery, emotional state of patient and post-op complications