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

1. Care of the Surgical Patient (anesthesia to end of chapter) AizaEspanol 06-02-09

2. Words/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 procedures • Prosthesis: Artificial replacement for a missing body part • Surgical 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)

3. 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 membrane • Extubate: To remove an endotracheal tube from an airway • Dehiscence: Partial or complete separation of a surgical incision or rupture of a wound closure • Cachexia: General ill health and malnutrition marked by weakness and emaciation; usually associated with a serious disease such as cancer • Evisceration: Protrusion of an internal organ through a disrupted wound or surgical incision

4. 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 anabolism

5. Anesthesia

6. 3 Categories of Anesthesia • General Anesthesia • Regional Anesthesia • Local Anesthesia

7. General Anesthesia

8. General Anesthesia (cont) General Anesthesia results in an immobile, quiet patient who does not recall the surgical procedure. The patient’s 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

9. Stage I of General Anesthesia • Begins with the patient awake • This stage is completed once the patient loses consciousness

10. Stage II of General Anesthesia • Begins with the loss of consciousness and ends with the onset of regular breathing and loss of eyelid reflexes • Referred to as the excitement of the delirium phase • Often accompanied by involuntary motor activity • Patient must not receive any auditory or physical stimulation during this stage • Can result in an undesirable increase in heart rate and blood pressure

11. Stage III of General Anesthesia • Begins with the onset of regular breathing and ends with the cessation of respirations • Known as the operative or surgical phase

12. Stage IV of General Anesthesia • Begins with the cessation of respirations and must be avoided • Will necessitate the initiation of CPR • May lead to death **These stages were defined with the use of ether and are sometimes difficult to ascertain with new anesthetic agents**

13. Induction Phase of General Anesthesia • Administration of agents • Endotracheal intubation

14. Maintenance Phase of General Anesthesia • Positioning the patient • Preparation of the skin for incision • Surgical procedure itself • Appropriate levels of anesthesia are also maintained during this phase

15. Emergence Phase of General Anesthesia • Anesthetics decreased • Patient begins to awaken • Due to the short half-life of today’s medications, emergence is often in the OR

16. General Anesthesia (cont.) • To induce anesthesia, an IV agent is often given, although an inhalation agent may also be used • Unconsciousness is normally achieved 10 to 20 seconds after the dose is administered • Barbiturates provide sedation, amnesia, and hypnosis • Must be used with other agents to achieve pain relief and muscle relaxation • Anesthesiologist puts an endotracheal tube into the patient’s airway to prevent possible aspiration and other respiratory complications

17. General 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 intubation • Technique to reduce the risk of the aspiration of stomach contents during induction of general anesthesia: the esophagus is compressed to prevent passive regurgitation • This technique, however, cannot stop active vomiting • This technique is also begun when the patient is awake • Patient reassurance is important to provide support during this period of mild discomfort • Once initiated, pressure must be held constant

18. General Anesthesia (cont) • Upon completion of induction, anesthesia may be maintained through a combination of inhalation and IV meds • Continuous supply of oxygen is also given • Adjunct meds such as opioid analgesics (analgesia) and muscle relaxants are administered • Duration of anesthesia depends on the length of surgery • Emergence from anesthesia occurs when procedure is completed and reversal agents are given • Oropharynx is suctioned to decrease risk of aspiration and laryngeal spasm following extubation • Extubation is often accomplished before transfer to the PACU (postanesthesia care unit)

19. Risks of General Anesthesia • Side effects of anesthetic agents • Cardiovascular depression • Cardiovascular irritability • Respiratory depression • Liver damage • Kidney damage

20. Regional Anesthesia

21. Regional Anesthesia • Results in loss of sensation in an area of the body • Method of induction influences the portion of sensory pathways that is anesthetized • No loss of consciousness, however, the patient is usually sedated • Anesthesiologist gives regional anesthetics by infiltration and local application • Infiltration of agent may involve one of the following induction methods: • Nerve Block • Spinal Anesthesia • Epidural Anesthesia • Intravenous Regional Anesthesia (Bier Block)

22. Induction Method of Regional Anesthesia • Nerve Block: Local Anesthetic is injected into a nerve, blocking the nerve supply to the operative site • Spinal 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.*

23. 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 surgery

24. Induction 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.

25. Regional Anesthesia (cont) • Patient is awake throughout the surgery procedure with regional anesthesia unless the physician orders a tranquilizer that promotes sleep and/or amnesia • Use of endotracheal tube is unnecessary because the patient is responsive and capable of breathing voluntary • Necessary 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 aware • Topics discussed within the operating room should be done with caution

26. Risks of Regional Anesthesia • Postspinal headaches • In 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 affected • Patient 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 fibers • Also, if the level of anesthesia rises, respiratory paralysis may develop, requiring resuscitation by the anesthesiologist

27. Local Anesthesia

28. Local Anesthesia • Involves loss of sensation at the desired site • Agent inhibits nerve conduction until the drug diffuses into the circulation • May be injected or applied topically • Patient experiences a loss in pain sensation and touch, and in motor and autonomic activities • Commonly used for minor procedures performed in ambulatory surgery

29. *Examples of Local Anesthetics • Lidocaine hydrochloride (Xylocaine) • Bupivacaine hydrochloride (MarcaineHCl) • Tetracaine (Pontocaine) • Ropivacaine (Naropin)

30. *Risks of Local Anesthesia • Toxic effects caused by overdose • Initial s/sx are excitement and central nervous system stimulation followed by depression of the central nervous system and the cardiovascular system • Local tissue damage • Inflammation and edema • Abscesses and necrosis sometimes develop at injection site • Allergic responses

31. Local Anesthesia Nurse prepping patient with local anesthetics for suturing of laceration to right eyebrow.

33. Conscious Sedation • Routinely used for procedures that do not require complete anesthesia but rather a depressed level of consciousness • A patient under conscious sedation must independently retain a patent airway and airway reflexes and be able to respond appropriately to physical and verbal stimuli • Advantages 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 recovery

34. Conscious Sedation (cont) • Variety of diagnostic and therapeutic procedures are appropriate for conscious sedation • Burn dressing changes • Cosmetic surgery • Pulmonary biopsy and bronchoscopy • Nurses must have the knowledge of anatomy and physiology, cardiac dysrhythmias, procedural complications, and pharmacological principles related to the adminsitration of individual conscious agents • Nurses must also be able to assess, diagnose, and intervene in the event of untoward reactions and demonstrate skill in airway management and oxygen delivery • Resuscitation equipment must be readily available in conscious sedation is being used

35. Positioning the Patient for Surgery • During general anesthesia the nursing personnel and surgeon often wait to position patient until stage of complete relaxation is achieved • Choice of position is usually determined by the surgical approach • Position should provide good access to the operative site as well as sustain adequate circulatory and respiratory function • Should not impair neuromuscular structures • Patient’s comfort and safety must be considered • Although 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 injuries

36. Preoperative Checklist • Usually completed upon admission or before leaving the nursing unit • When a nurse endorses the checklist, the nurse assumes responsibility for all areas of care included on the list • If there are pre-op meds to be given on the nursing unit, the nurse completes the pre-op checklist before administering • Any prosthesis, contact lenses, dentures, jewelry, and other valuables are removed and either given to a family member or placed in a secure area • Disposition 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 procedure • Patient should be reminded to remain in bed after administration of pre-op meds and call light should be in reach

37. Transporting to Operating Room • Personnel in operating room will notify the nursing unit when it is time for the surgery • Transporter must check against patient ID against the medical records to make sure the correct patient is being transported to surgery • If patient is being transported via gurney the transporter and nurse should assist with transfer from bed to gurney • If patient is ambulatory they may walk to the operating room allowing for more control over the event • The trip to surgery should be as smooth as possible to avoid nausea and dizziness • Family members are usually provided with an opportunity to visit the patient before the procedure and patient is transferred to the operating room

38. Preparing for Post-Op Patient • If the patient is an inpatient, the nurse will prepare the bed and room for their return to the unit • Post-Op bedside shall include • Sphygmomanometer, stethoscope, and thermometer • Emesis basin • Clean gown • Washcloth, towel, and facial tissues • IV pole and pump • Suction equipment • Oxygen equipment • Extra pillows for positioning • Bed liners for protection against drainage • PCA pump and SCD machine

39. INTRAOPERATIVE PHASE Holding Area Role of the nurse

40. Intraoperative Phase • Centers on the care and protection of the patient • Nursing interventions should include warm, personal contact with the patient to humanize the often cold, aseptic, and highly technical environment of the operating room

41. Holding Area • Patient enters a preanesthesia care unit (holding area) where nurse completes the pre-op preparations • Nurses in this unit are usually part of the operating room staff and wear surgical scrub suits • Here the nurse or anesthesiologist will insert an IV catheter into patient’s vein to establish a route for fluid replacement and IV meds • Pre-Op meds are administered • Patient’s stay in the holding area is usually brief

42. Role of the Nurse • In the intraoperative phase the nurse assumes one of two roles: scrub nurse or circulating nurse • See Box 42-7 on page 1291 for responsibilities of each • Everyone in the OR must be alert to contamination of sterile items and must aid in maintaining aseptic conditions • Surgical asepsis is provided to prevent microbial contamination of the operative site • Goal of surgical asepsis is to prevent or minimize post-op wound infections • Standards and guidelines for surgical scrubs and skin prep should be strictly followed

43. Role of the Nurse (cont) • During the post-op phase the OR nurse assists in transferring the patient to the PACU • Report is also endorsed to the PACU nurse • Patient’s status • Review of IV fluids • Meds • Blood products administered • Surgical dressing • Nature of any complications in the OR • Unusual risks for hemorrhage or cardiac irregularities • The OR nurse is an important resource in planning the post-op care for the patient

44. POSTOPERATIVE PHASE

45. Immediate Postoperative Phase • Upon completion of surgery, patient is transferred to recovery room (PACU) or intensive care area • Eval of the patient follows the ABCs of immediate post-op observations: airway, breathing, consciousness, and circulation • Vital signs are assessed every 15 minutes and respiratory and GI functions are monitored • Wound 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 unit

46. Immediate Post-Op Phase (cont) • As patient regains consciousness, relief of pain is often the first need expressed • Frequently, meds are given in the PACU • Documentation from surgical suite and PACU is reviewed by staff on the nursing unit to assess how well the patient tolerated the surgical process • Body temperature is closely monitored for hypothermia • Occurs in 60-80% of all post-op patients • Body exposure in a cold OR • Effects of cold solutions • Consequence of some anesthetics

47. Later Postoperative Phase • Immediate postsurgical assessment • VS • “times four” factor • 15 minutes x4; 30 minutes x4; every hour x4;or until VS are within expected range • IV and incision site • Any tubes • Post-op orders reviewed • Review of each body system identifies when body functions return and provides a guideline for further assessment

48. Later Post-Op Phase (cont) • Nausea and vomiting are normal in the first 12 to 24 hours • An emesis basin should be left at bedside and amount should be measured and carefully described and documented • Red or coffee-ground emesis should be reported immediately • Usually patient remains NPO for a few hours after surgery • Fluids are introduced gradually • Usually begins with ice chips then gradually changed to clear or full liquids

49. Later Post-Op Phase (cont) • Post-op complications can occur suddenly • Changes in condition should always be noted • Sweating should never be induced with the post-op patient but another blanket should be provided for extra comfort • VS coupled with the patient’s behavior are first-line observations • Pulse that increases and becomes threadycoupled with a declining BP, cool and clammy skin, reduced urine output, and restlessness may indicate hypovolemic shock • Hypovolemic shock in the post-op period is frequently caused by internal hemorrhage which is a life threatening emergency

50. Later Post-Op Phase (cont) • Drop in BP slightly below a patient’s pre-op baseline reading is common after surgery • Significant drop in BP accompanied by an increased heart rate, may indicate hemorrhage, circulatory failure, or fluid shift • Do not diagnose impending hypovolemic shock on the basis of 1 low BP reading • Decreased BP can also mean that the anesthetics is wearing off or that the patient is experiencing severe pain • In addition to hypotension, manifestations of shock include tachycardia; restlessness and apprehension; and cold, moist, pale, or cyanotic skin