Surgical Experience - Nursing lecture
OUTLINE OF NURSING LECTURES
- IV line inserted
- Receiving a sedating agent prior to induction
- Losing consciousness
- Being intubated; if indicated
- Receiving a combination of anesthetic agents
- Has no recall of events
- Concurrent medications
- Optimization of medical treatment for:
- Diabetes Mellitus (DM) – glycemic control
- Nutritional status – malnourishment
- Smoking – cessation
- Obesity – weight loss
- COPD – respiratory status, postop exercises
- • class 1 - able to visualize soft palate, fauces, uvula, ant and post tonsillar pillars
- • class 2 - able to visualize all of the above, except anterior andposterior tonsillar
- pillars are hidden by the tongue
- • class 3 - only the soft palate and base of the uvula are visible
- • class 4 - only the soft palate can be seen (uvula not visualized)
- Common classification of physical status
- at the time of surgery
- ASA 1 : healthy fit patient
- ASA 2 : with mild systemic disease
- ASA 3 : with severe systemic disease that limits activity
- ASA 4 : with incapacitating disease that is a constant threat to life
- ASA 5 : a moribund patient not expected to survive 24 hours with/without surgery
- nursinglectures.blogspot.com Levels Findings Minimal Sedation Patient responds normally to VERBAL commands, Cognitive & Coordination Fxn may be impaired, but Ventilatory & Cardiovascular Fxns Unaffected Moderate Sedation Midazolam(Versed)/Diazepam(Valium) used often. Depressed LOC that does not impair patient’s ability to maintain a patent airway Deep Sedation Patient cannot be easily aroused but can respond purposefully after repeated stimulation. IV or Inhalation. NO2 most commonly used GAS Anesthetic ANESTHESIA State of Narcosis (severe central nervous system depression produced by pharmacologic agents), analgesia, relaxation, and reflex loss. Not arousable.
- nursinglectures.blogspot.com Stages of ANESTHESIA Findings Beginnning Anesthesia / Induction Patient feels DIZZY,WARMTH and DETACHED . May have ringing, roaring, or buzzing in the ears. AVOID NOISE Excitement PR is rapid. Respirations maybe IRREGULAR. SAFETY of the patient is the PRIMARY CONCERN. Surgical Anesthesia Unconscious patient. RR is regular . PR and BP is normal . SKIN is PINK and slightly Flushed. Continuous administration of Anesthetic agent. Medullary Depression Too much Anesthesia. Pulse is weak and thready. Pupil become WIDELY DILATED .Respiratory and Cardio Support. DEATH rapidly follows.
- Inhalation – administered with mixing the vapors with OXYGEN. Via ET TUBE or MASK
- Injection – no buzzing, roaring, or dizziness. THIOPENTAL, agent of choice. Useful in EYE surgery(low Nausea and Vomiting)
- Rectal – obsolete but sometimes used in Pediatric patients.
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- Tranquilizers and Sedative – Hypnotics
- a. Benzodiazepines
- 1. Midazolam ( Versed ) – Monitor Respiratory Status
- 2. Diazepam ( Valium ) –
- - may produced Thrombophlebitis
- - Central vein is preferred
- 3. Chlordiazepoxide ( Librium ) – hypnosis(induction)
- 4. Droperidol ( Inapsine ) – Extramidal rigidity
- 5. Lorazepam ( Ativan ) – Hepatoxic/Nephrotoxic
- Flumazenil (ANEXATE) – benzodiazepine antagonist
- b. Opiods
- 1. Morphine ( High Doses ) –
- - not a myocardial depressant
- - orthostatic hypotension(decreasing systemic vascular resistance)
- 2. Meperidine HCl ( Demerol ) –
- - “ Spasmolytic effect ”
- - DOC for bile duct , distal colon , and rectum surgery . - Ready diphenhydramine (benadryl) for Allergic reaction.
- - refers to combination of short-acting synthetic opiod agent ( fentanyl ) and a butyrophenone ( droperidol )
- 1. Fentanyl (Sublimaze )
- 75%-100% more potent than morphine
- little Cardio effect
- Respiratory depression
- 2. Sufentani l (Sufenta)
- Onset extremely rapid
- 1/3 duration of fentanyl
- The patient appears to be asleep or anesthesized, but rather dissociated from surroundings.
- Ketamine (Ketalar;Ketaject)
- useful when Hypotension can be hazardous
- may experience hallucinations
- AVOID Verbal, Visual, or TACTILE stimulation .(triggers psychic aberration )
- Droperidol or Diazepam may eliminate such psychic phenomena.
- Thiopenthal sodium ( Pentothal )
- not for children
- Rapid induction
- Powerful depressant for breathing
- Methohexital sodium ( Brevital )
- rapid onset
- seizures
- necrosis if IV infiltrates
- Etomidate (Amidate)
- Useful for FRAIL patients
- Transient ADRENAL suppression
- Involuntary muscle movements
- Propofol (Diprivan)
- Rapid induction
- May have antiemetic effect
- Pain on injection
- Myocardial depression
- Contraindicated in patients with allergy to EGGS and Soybean Oil
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- Anesthetic agent is injected around nerves .
- Motor fibers have the thickest myelin sheath
- Sympathetic fibers are the smallest and have minimal covering
- Sensory fibers are intermediate
- An anesthetic is worn off until all three are no longer affected.
- A QUIET environment is THERAPEUTIC
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- Epidural Anesthesia – injection of local anesthetic into the spinal canal in the space surrounding the dura mater.
- Absence of spinal headache
- Difficult to introduce anesthetic agent into the epidural rather than the subarachnoid space.
- HIGH spinal can result(subarachnoid injection) – causes severe hypotension, respiratory depression and arrest (TREATMENT: Airway, IV, Vasopressor)
- Spinal Anesthesia – local anesthetic is introduced into the subarachnoid space at the lumbar level, usually between L4 and L5.
- Anesthesia of the lower extremities, perineum and lower abdomen
- Lumbar puncture procedure – KNEE-CHEST(side)
- Procaine,tetracaine (Pontocaine), lidocaine (Xylocaine), and bupivacane (Marcaine).
- Respiratory Paralysis (Temporary/Complete) – High concentrations of med reached the upper thoracic and cervical spinal cord
- Risk Factors
- Size of spinal needle used
- Leakage of CSF from the subarachnoid space
- Patient’s hydration status
- Decreasing Cerebrospinal pressure
- TREATMENT
- 1. Keep patient LYING FLAT
- 2. QUIET
- 3. Well hydrated
- Brachial plexus block – anesthesia of the arm
- Paravertebral anesthesia – anesthesia of nerves supplying the Chest, Abdominal wall & Extremities .
- Transsacral (caudal) block – anesthesia of the perineum, and occasionally, the lower abdomen.
- The injection of a solution containing the local anesthetic into the tissues at the planned incision site
- Advantages
- Simple, Economical, non-explosive
- Equipment needed is minimal
- Post-operative recovery is brief
- Undesirable effects of GA are avoided
- Ideal for SHORT and SUPERFICIAL operations
- Usually given with EPINEPHRINE
- maximum dose usually expressed as (mg of LA) per (kg of lean body weight) and as a total maximal dose (adjusted for young/elderly/ill)
- lidocaine maximum dose: 5 mg/kg (with epinephrine: 7mg/kg)
- chlorprocaine maximum dose: 11 mg/kg (with epinephrine: 14 mg/kg)
- bupivicaine maximum dose: 2.5 mg/kg (with epinephrine: 3 mg/kg)
- Occurs by accidental IV injection, Overdose or unexpectedly rapid absorption
- CNS effects
- N umbness of tongue, P erioral tingling
- D isorientation, d rowsiness
- T innitus
- V isual D istrubances
- M uscle twitching, tremors
- C onvulsions, seizures
- G eneralized CNS d epression, c oma, r espiratory arrest
- CVS effects
- V asodilation, hypotension
- D ecreased myo cardial contractility
- D ose-dependent delay in cardiac impulse transmission
- P rolonged PR, QRS intervals
- S inus bradycardia
- C VS collapse
- Early recognition of signs
- 100% O2, manage ABCs
- Diazepam may be used to increase seizure threshold
- If seizures are not controlled by diazepam, consider using :
- Thiopental (increases seizure threshold)
- SCh (stops muscular manifestations of seizures, facilitates intubation)
- Nausea & Vomiting
- Turn to side, head lowered, provide basin
- Pre-op Antiemetic drugs
- Suction for Saliva and vomited gastric contents
- Aspiration of Vomitus can lead to Pneumonitis and Pulmonary Edema leading to HYPOXIA.
- Anaphylaxis
- Reaction of the body to foreign substances
- Meds common cause of anaphylaxis
- Latex reaction can also occur
- Life-threatening – vasodilation, hypotension, and bronchial constriction
- Fibrin sealants and cyanoacrylate adhesives – can also cause anaphylactic reaction
- Hypoxia and Respiratory Complications
- Patient’s oxygenation status is the PRIMARY FUNCTION of the ANESTHESIA PROVIDER and the CIRCULATING NURSE .
- Pulse Oximetry Values are monitored continuously.
- Anatomic variation, ET tube may be inserted
- Surgical POSITIONING (Trendelenburg)
- Hypothermia
- Glucose metabolism is reduced, TEMP decreases results in METABOLIC ACIDOSIS
- Below 36.6°C[98.0°F] – below Normal core temp
- Low temp in OR (Set at 25 to 26.6 Celsius)
- Infusion of cold fluids (Warm to 37.6 Celsius)
- Warming should be gradual
- Malignant Hyperthermia – inherited MUSCLE DISORDER chemically induced by anesthetic agents.
- Susceptible People
- Those with strong and bulky muscles
- History of muscle cramps or muscle weakness
- Unexplained temperature elevation
- Unexplained death of a family member after surgery
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- Tachycardia – (150 beats/min), early sign
- Ventricular dysrhytmia
- Hypotension
- Decreased Cardiac Output
- Oliguria
- Cardiac Arrest
- Rigidity , tetanus-like movements
- Rise in temp , usually a late sign, develops fast
- 1° to 2° C every 5 mins, can exceed 40°C
- Trismus (masseter spasm) – common not specific for MH, occurs 1% in children given SCh w/ Halo
- Death / Coma
- Disseminated intravascular coagulation (DIC)
- Muscle Necrosis / weakness
- Myoglobinuric renal failure
- Electrolyte abnormalities (i.e. iatrogenic hypokalemia)
- Suspect possible MH with family history of problems/death with anesthetic
- Dantrolene prophylaxis no longer routine
- Avoid all triggers
- Central Body temp and ET CO2 monitoring
- Use regional anesthesia if possible
- Use equipment “clean” of trigger agents
- Discontinue inhaled anesthetic agent and SCh, terminate procedure
- Hyperventilate with 100% O2
- Dantrolene 1mg/kg, repeating until stable or 10mg/kg maximum reached
- Treat metabolic/physiologic derangements accordingly
- Control body temperature
- Diligent monitoring (especially CVS, lytes, ABGs, urine output)
- Life-threatening, characterized by thrombus formation and depletion of select coagulation proteins, Idiopathic
- Predisposing factors:
- Emergency surgery
- Massive trauma
- Head Injury
- Massive transfusion
- Liver/kidney involvement
- Embolic events or shock
- AVOID Derogatory comments
- Patient is treated as a person
- Respecting cultural and spiritua l values
- Providing physical privacy
- Maintaining Confidentiality
- 1. A patient in the holding area awaiting surgery indicates that he had not received instructions not to take his usual medications ( antihypertensive agent, diuretic, digoxin, potassium chloride, and insulin injection ); as a result, he took them a few hours ago . What implications does this have for the patient’s care and well-being while awaiting surgery, during surgery, and in the immediate postoperative period?
- 2. What are the differences in responsibility of the operating room nurse for care of patients who receive general anesthesia, conscious sedation, spinal anesthesia, and regional anesthesia ?
- 3. While she is being transferred from the stretcher to the operating table, a female patient says she is very anxious about her surgery because of previous negative experiences . What assessment and interventions are indicated at this time?
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