Intraop Phase
1. sign in
2. time out
3. sign out
surgery
anesthsia
- 2 components of intra-op phase
WHO Guidelines - Surgical Safety Checklist
1. Sign In - before induction
2. Time out - before skin incision
3. Sign out - before patient leaves OR
Sign In: Before induction (PSPC)
right
- patient
- site
- procedure
- consent
- patient risks
Time Out: Before skin incision
right
- patient
- site
- procedure
critical events
- nursing focus on sterility, antibiotics within last hour?
Sign Out: Before the patient leaves the OR
- documentation
- count correct
- specimen labeled correctly
- any problems/concerns?
During Sign in, is the patient awake or out?
the patient is still awake
everyone makes sure we have
- right patient
- right site
- right procedure
- consent ready
patients risks are assessed BEFORE the pt is put under anesthesia
During Time Out is when the pt is
under anesthesia, no longer awake
BEFORE the skin is cut
- after anesthesia before surgery
before the skin is cut, the surgeon has to confirm with everyone that they have
- the right patient
- the right site
- the right procedure
everyone must agree
Time Out - Nursing Focus:
ensure sterile field so infection doesn't occur
pre-op: pts receive anti-biotics prophylactically (intended to prevent disease)
- given within the last hour
- should cover the surgery time
Sign Out
surgery is over
- before the pts incision is CLOSED, make sure count is correct.
- specimens are labeled correctly
- biopsy for cancer: make sure the right name is on the right sample (hard to get these samples so you want to ensure accuracy)
- all docume
during sign out, who counts all the equipment beforehand and after to make sure nothing is left in the pt.?
the circulating and scrub nurse
Surgery Risks
- physical systems
- infection
Anesthesia Risks
- unconsciousness
- drugs
Surgery Risks
cutting into the pt
- general risks associated with surgery is based on the physical system that's cut into
Ex. heart surgery, cardiac bypass
- risks associated = MI
Ex. carpal tunnel surgery
- risks associated = hand paralysis
Infection
- cutting into th
Anesthesia Risks
controlled poison
- risks associated with it in terms of the drugs used and unconciousness
- most ppl under would be unconscious and paralyzed
Anesthesia Purpose / Effects
- amensia
- analgesia
- hypnosis
- relaxation
Anesthesia - Amnesia
- you don't remember what happened
Ex. Benzodiazipine: Versed
Anesthesia - Analgesia
pain management
- all anesthetics should provide analgesia
Anesthesia - Hypnosis
altered mental state
- patient remembers, it just changes the way the pt perceives things
Ex. Narcotic: Fentanyl
Anesthesia - Relaxation
- muscle relaxation
- body relaxation
Ex. surgery appendectomy
- you can get a really big hole from a small incision because the muscles have relaxed so much and the skin can be stretched
Ex. coronary bypass graft
- pt had CAD, angina
- they bypass the bl
Types of Anesthesia
1. general
2. Regional
- local
- epidural
- spinal
- blocks
General Anesthesia
Produces a state of unconsciousness. It may be brought about by inhalation of gases such as ether, nitrous oxide, & ethylene or by drugs administered intravenously; such as sodium pentothal.
reversible unconsciousness
Regional Anesthesia - Local
ex. lidocaine
small area that's anesthetized
Regional Anesthesia - Epidural
injected in the epidural SPACE
(over large region, can move with low doses)
LOWER portion of the body
ex. see this in OB
Regional Anesthesia - Spinal
injected in the CSF
bigger block, cant move
anesthesia produced by injection of an anesthetic into the subarachnoid space of the spinal cord.
Regional Anesthesia - Blocks
extremities, paralysis
- creating a mini circulation around peripheral extremities, usually the arms
ex. carpal tunnel surgery
anesthesia of an area supplied by a nerve NOUN
EX. produced by an anesthetic agent applied to the nerve
works on a local nerve
General Anesthesia
Provider
induction phase
- pre-op to unconsciousness
maintenance phase
- surgery performed
emergence
- surgery over to extubation
General Anesthesia
Patient
Stage 1: onset
Stage 2: Excitement (muscle jerking)
Stage 3: surgical anesthesia
Stage 5: danger (death)
General Anesthesia
Provider
Induction Phase
point of pre-op
to
OR
to point when pt is unconscious
Ex. Fentanyl, Versed = induction agents
General Anesthesia
Provider
Maintenance Phase
surgery can start once the pt is unconscious
maintaining the anesthesia so the patient doesn't feel the procedure
General Anesthesia
Provider
Emergence Phase
- when the surgery is over and the pt is extubated
- after the surgeon sutures up the pt
- anestehsia is removed and the pt wakes up
General Anesthesia
Patient
Stage 1: Onset
Ex. Fentanyl and Versed
- start getting loopy to the point when the pt falls asleep
General Anesthesia
Patient
Stage 2: Excitement
- when the body falls asleep
- involuntary release of ATP in muscles that causes contraction
- very dramatic for pts
- some pts have a very pronounced excitement phase when that they can shake so hard they fall off the table
****monitor for that in the OR
General Anesthesia
Patient
Stage 3: Surgical Anesthesia
the nurse anesthetist usually maintains the anesthesia
General Anesthesia
Patient
Stage 4: Danger (death)
danger death
General Anesthesia
onset of anesthesia
- induction IV drugs
- inhalation drugs
- neuromuscular blocking agents
excitation
surgical anesthesia
- maintenance
emergence
- reversal agents
induction is from
pre-op to fallin asleep
pts are started with IV meds
Ex. fentanyl and versed
most ppl are nervous when they go to the OR and their energy levels are very high
- so the induction agents bring them down so they can fall asleep easily
- its not a quick drop
inhalation drugs
Nitrous oxide
Forane
Ultane
- mask is put on the pt
- ask to count back from 100 or 10
- 2 seconds and the pt is out
intubation occurs AFTER and BEFORE
AFTER the pt is asleep and excitation occurs
- tube is placed into the trachea and attached to a respirator to breathe for the pt
- this occurs BEFORE neuromuscular blocking agents because those are paralytic agents
- you don't want the diaphragm paralyze
Reversing the Anesthetic Agents
most drugs are reversed just by not administering them anymore
inhalation drugs are easier to monitor blood levels with
or by the IV to maintain the blood levels
as soon as the meds are stopped being administered, the body will metabolize them and it will
General Anesthesia Drugs
Induction
- IV rapid onset, short duration
(doesn't last very long)
- LOC within 3 - 10 seconds
- given prior to inhalation drugs (so they can calm down so excitation isn't so dramatic)
can be given alone for minor / local procedures to calm them down
IV Induction Agents (Drugs) cause what?
- unconsciousness
- amnesia/hypnosis
- decreases reflexes (to calm pt.)
IV Induction Agents (Drugs) Examples
Sodium Thiopental (Pentothal) - barbiturate
Fentanyl (Imnovar) most common - opioid
Ketamine (Ketalar) - analgesic / amnesic
(asthmatics - bronchodilator, trauma - increases HR, hallucinations, street drug)
Versed - benzodiazipine
(also with conscious sed
The drugs will respond a little differently depending on the type of drug.. - most common are
Fentanyl and Versed (2 most common)
- Fentanyl is an opioid narcotic
- Versed is benzodiazipine
so there are different classes of drugs - but they're both used as induction agents
Ketamine (Ketalar) - analgesic/amnesic (asthmatics-bronchodilator, trauma - � HR, hallucinations, street drug)
used for asthmatics
- bc its also a bronchodilator, people who have asthma can cause their bronchiles to constrict and can cause an asthma attack
SURGERY = trigger for asthma
this drug works as an induction agent AND a bronchodilator
HOWEVER:
- it can inc
IV Induction Agents (Drugs)
Nursing Care
monitor vitals
- you want to see a decrease in VS
- BP to decrease a bit (HR is up because of stress, tachypnea)
PROBLEM: you dont want to slow VS too much
- make sure pt is breathing
- make sure IV site is okay, check it
- strap to table, esp. during exc
3 types of intubation (anesthetic delivery methods)
1. oral
2. intranasal
3. Laryngeal Mask
oral intubation
- anesthesiologist intubates pt
- circulating nurse ensures the ET tube is in correct position and is inserted into the mouth, past the larynx
- inserted into trachea
- NOT in esophagus
- in lungs and NOT in GI system
- tube is in position with cuff infla
intranasal intubation
- only used for 1 type of surgery
- oral surgery (cant put it in the mouth)
laryngeal mask
psych (electro shock therapy)
- sometimes they'll put this mask in to ensure the pt. doesn't aspirate
- for very short term procedures
- plugs esophagus to prevent aspiration
NOT in the trachea
Maintenance Phase:
Inhalation agents allow for more control over the blood levels and they leave the body quicker
examples:
NO (nitrous oxide)***most common
Halothane (Flurothane)
Isoflurane (Forane)
Suphane
Maintenance Phase - Inhalation Agents
Nursing Care: monitor what?
VS
- ensure they're not depressed too much
breathing
- they're on a respirator
- diapharagm isn't working
****ensure respirator works
laryngospasms
- muscles around the larynx spazz and they may block off the ET tube or dislodge it
- involuntary
****monit
Maintenance Phase - Neuromuscular Blocking Agents
- Pancuronium (Pavulon)
- Vecuronium (Norcuron)
- Succinylcholine chloride (Anectine) sometimes abbreviated as SUX (common)
Succinylcholine chloride (Anectine), sometimes abbreviated as SUX (common)
- very commonly used because its a very clean drug
- works very well
- only problem with it: associated with malignant hyperthermia
****genetic predisposition
Emergence Phase
withdrawal of anesthetic agents
drugs are given to reverse effects
reversal agents during Emergence Phase
Romazicon (reverses benzodiazipines)
Neostigime (reverses paralysis)
Narcan (reverses opioid) not given unless overdoses
Romazicon reverses what?
benzodiazipines
Neostigime reveres what?
patalysis
Narcan reveres what?
opioids
not given unless overdosed
Emergence phase occurs when
during Time Out
and the anesthesiologist will withdrawal the anesthetic agents and give some drugs to reverse the effects
they may give the Romazicon
- but they don't usually do that because benzodiazipines aren't usually used at such high levels where i
Neostigime reverses what?
paralysis
Narcan
would never give to the pt unless the pt has overdosed on opioid narcotics
- when people OD on opioids, they end up in the ED
- narcan is a reversal agent
- stays in the system for a long time
- but if this is given, pain meds wont work for the remainder
GOAL = balance between
inhalation agent + muscle relaxant + benzodiazipine + opioid
NURSE MONITORS
- if anesthesia is working
- pt is still alive
- no complications (recognize complications early)
Care Team - Peri-operative Nurse
- circulating nurse
- scrube role (nurse or tech)
- RN First Assistant (based on NPA)
Care Team - Peri-operative Nurse
Circulating Nurse
most important nurse role
- manager for the room
- person is not sterile
- not around the sterile field
- responsible for ensuring that the sterile field is STERILE
- gather equipment
- set up room
- tell you where to stand in the OR
Care Team - Peri-operative Nurse
Scrub Role (nurse or tech)
- person who is IN THE STERILE FIELD
- hands the equipment to the surgeon
Care Team - Peri-operative Nurse
RN First Assistant
- in some states, an RN can be a 1st Assistant
- may assist with surgery
RN First Assistant
special training or certification must be documented; if something happens to the surgeon, RN can stabilize; can close wound, punch biopsy but no actual surgery
Anesthesia Care Providers
Anesthesiologist
- is available for the nurse anesthetist incase they need help
Nurse Anesthetist
Intra-Op Assessment
- psychosocial assessment
- physical assessment
- chart review
- allergies (latex)
- WHO surgical check list "sign in" before anesthesia
p. 455
Nurse Psychosocial Assessment
- the nurse does this before the pt is under
holding area:
- very imp. bc patients are very stressed at the time
- try to minimize the stress and get a handle of who's outside waiting for them, how they're doing, are they worried?, what's on their mind?
e
Physical Assessment / Chart
- most of that info would be in the chart
- dont usually do this in the holding area there's Hx and physical in the chart
- must find out the baseline
- bc if anything happens, you'd want to compare it to the baseline
Allergies
- esp. latex allergy
- latex allergies can be lethal
- if the pt is allergic to latex, then everyone on the team needs to know that
NANDAs
- risk for infection
- risk for injury
(patient / procedure id)
(electrical shocks)
(hemodynamic instability)
- risk for perioperative positioning injury
- deficient / excess fluid volume
- ineffective breathing pattern
- hypothermia/hyperthermia
Risk for Infection
NOC
- infection status
NICs
infection control: intra-op
- principles of sterility
- sterile/aseptic technique (room prep)
- circulating nurse (monitor breaks in the sterile field
- maintain asepsis of surgical suite (restricted areas)
Risk for Infection
scrub nurse
opens the packages and holds it in a certain way not to break sterile technique
- sterile
- pulls equipment out to set up the table
Risk for Infection
circulating nurse
- monitors sterile field
- your back is never sterile so dont turn your back on the sterile field
if it's contaminated, then the whole thing needs to be broken down and re-set regardless of where you are
Risk For Injury
NOCs
- risk control
NICs
surgical precautions
- patient / procedure identification guidelines "time out"
- eye protection / blood & body fluid exposure
- grounding / fire hazards
- laser safety
- vitals
Eye protection/blood & body fluid exposure
- usually surgeons and nurses have shields around their face so nothing splashes into your eyes and infect you
Grounding/fire hazards
- nurses job to set up the equipment and the nurse does that
Laser safety
- look at the book
- you never want to look inside of a laser, it will burn out your optic nerve
Vitals
- u always want to monitor the pt
- VS to make sure nothing is depressed
- or if there is no reaction to meds that elevate the VS once they become depressed
- VS can go either high or low depending on the situation
Risk for Injury
surgical assistance
- sponge, sharp instrument count
- equipment / supply management
- specimen collection
- anesthesia administration
- administer drugs / fluids
Risk for Injury
surgical assistance
- sponge, sharp instrument count
all need to be counted before and after the procedure
Risk for Injury
surgical assistance
- equipment / supply management
nurses manage the equipment, they get whatever sutures the surgeon needs
- sometimes the nurse will need to run out to supply room to get additional equipment and hand it to the scrub nurse using sterile procedure
Risk for Injury
surgical assistance
- specimen collection
circulating nurse will manage the specimens and document, label them
Risk for Injury
surgical assistance
Administer drugs/Fluids
the nurse anesthetist or the nurse will hang additional drugs and fluids
Monitor for Anaphylaxis
- due to medications
- foreign objects (sutures, sealants, tissue adhesives)
foreign objects (sutures, sealants, tissue adhesives) left in the body
***Most common allergic reaction that could happen
- particularly for ortho procedures, foreign objects that are supposed to be left in the body
ex. orthoplasty (joint replacement) artificial joint
ex. sealants
ex. adhesives
can all cause anaphylaxix
moni
Risk for Perioperative Positioning injury
NOCs:
- circulation status
- neuro status
- respiratory status
- tissue perfusion: peripheral
NICs
- transport
- positioning: intraop
who's job is it to position the pt?
the nurse's
- very complex bc it affects circulation
- you can cause nerve damage if its not done right
- it can affect breathing and cause skin damage
transport
- whne ppl are medicated, they may not feel pain
- pts on peripheral blocks, epidurals, spinals (no pain)
- when when transporting the pts, you want to make sure their legs and arms arent caught in the side rails
- you can break someones bones or cause ti
positions on the OR table
SUPINE
patient in position on the OR table for a laparotomy
note the strap ABOVE the knees
- the arms are at the sides sos they arent' hanging off the table
- legs are tied into place so the legs dont roll out and cause undue pressure on the hip joint
(may cause
positions on the OR table
Trendelenburg Position
padded shoulder braces in place
be sure that the brace doesn't press on the brachial plexuses
there's a padding under the lower back to ensure the iliac crest isn't damaged
- seat belt
- on the shoulders, there are braces to keep the patient from falling
positions on the OR table
Lithotomy Position
the hips extended over the edge of the table
for rectal and gym surgeries
- make sure legs are padded and are positioned appropriately so the buttocks isn't hanging off the table and causing pressure on the lower back
Patient position for Thoracotomy
- focus on pt alignment
- one knee is brought up to decrease pressure on back
- left arm is on the side arm board
- right arm is hanging over with a trapeze
- very imp how the pt is positioned bc you can dislocated the shoulder if not careful
NANDA: Decreased/Excess Fluid Volume
NOCs:
fluid balance - be careful elderly/CHF
VS status
NICs:
fluid management
- IVs
- Foley
Hemodynamic Regulation
- VS
- blood
Shock Prevention/Management
when a pt is undergoing surgery, the most important thing to maintain is what?
cardiovasculature
- you're always going on a fluid hunt
- a lot of fluid shifts bc of the normal stress response
- you must be careful w/ fluid balance esp with elderly bc their adrenal glands may not respond as quickly as a young person's because they've
- so you have to monitor where the fluid is in the different compartments of the body, but how?
how do you know what's in the vasculature?
1. vital signs
- low vasculature fluid - low BP, high HR
2. urine output
- if you don't have enough fluid in your vasculature, the urine output will go down
- because the fluid in the urine is pulled out of the vasculature
- the body is going to be shifti
so during surgery, the most important thing to make sure is if there's enough fluid in the vasculature
what type of fluid is hung the most?
- isotonic
- hypotonic
- hypertonic
isotonic fluid
Lactated RIngers
- It has an electrolyte concentration (same concentration as blood)
why do they use Lactated RIngers and not normal saline (isotonic)?
because it has too much saline in it
- lactated ringers has less saline but has other electrolytes that maintains the same concentration as blood
so you're always monitoring how much fluid is in the vasculature
- and the nurse will administer IV fluids appropriately
- and it would be titrated based on the vital signs and the urine output
Hemodynamic Regulation
for vital signs
blood - you may be hanging blood if you have a very bloody procedure
you're always monitoring for shock you need to know what the S/S of shock are
for VS
blood
- you may be hanging blood if you have a very bloody procedure
- always monitor for SHOCK
- you must know the s/s of shoc
SHOCK
not enough oxygen gets to the tissues for whatever reason
- hypovolemic shock - not enough vasculature to feed the tissues
- monitor how bloody the procedure is
- this will let you know if you will need to hang blood or if additional fluids are needed
S/S of shock
- pulse: decreased
- HR: increased
- BP decreased
- tachypnea
- cold clammy skin = 1st indication
FLUID SHIFTING
- maintain CV
- kidney perfusion
- pitting edema leads to cell lysis
NANDA: Ineffective Breathing Pattern
NOC:
- respiratory status: airway patency
NIC
airway management
- monitor airway
- respirations
- treat n/v
monitor ABCs
Ineffective Breathing Pattern
during intra-op phase, usually intubated so the respirator will manage the breathing
- if the patient is NOT intubated, what will the nurse monitor for?
- check respirations
- check pulse ox
- always monitor for N/V bc if someone vomits during surgery, they will aspirate very easily
****this is why pts are on NPO before the procedure
= make sure their stomach is empty
- but the stomach is always secreting
NANDA: Hypothermia
NOC
- thermoregulation
NIC
temperature regulation: intraop
- monitor temp
- equipment
- blood warmer
- blankets
what is the most important system of the body that is for temperature regulation?
integumentary system (skin)
- keps the heat in and regulates body heat
- bc they cut into the skin, pts can get very cold
- also due to the stress response, the shifting goes to the vital organs, away from the periphery
- this will also stimulate a stress
the nurse must monitor temperature
- usually the equip is heated to regulate the temp
- if you administer blood, sometimes its through a blood warmer to warm the blood because if you infuse the blood, its usually cold
- so its nice to warm it up as it enters the pts body
immed. after the procedure, the pt will
- be shaking
- get very cold
- the pt tried to warm the body by shivering to generate heat
- but you dont want them using their ATP for generating heat, so you usually put warm blankets on them
- in the OR, there are cabinets with warm blankets and they s
NANDA: Hyperthermia
NOC:
- thermoregulation
NIC:
- malignant hyperthermia precautions
hyperthermia can happen, is this an emergency situation?
yes
- usually people dont get hot postop or intraop
- this is a disease/condition called malignant hyperthermia
****life threatening
Malignant Hyperthermia
- life threatening, medical emergency
- genetic predisposition
- causes an increase in Ca+, K+ and metabolic and respiratory acidosis
- can occur anytime in the OR or during recovery period
- linked to some inhalation anesthetics (halothane) and depolariz
Ca+ and K+ levels in pts who have malignant hyperthermia are increased or decreased?
increased
pts who have malignant hyperthermia are have metabolic and respiratory alkalosis or acidosis?
metabolic and respiratory acidosis
which inhalation anesthetic is malignant hyperthermia linked to?
halothane
which depolarizing muscle relaxant is malignant hyperthermia linked to?
succinylcholine
malignant hyperthermia
- it's an electrical electrolyte cascade that can kill a patient
- it can cause respiratory and metabolic acidosis
malignant hyperthermia - genetic predisposition
- if there's a family hx of this, the anesthesiologist must avoid using those drugs
- we still use these drugs bc their very good but we dont use them if the person has a genetic predisposition
(halothane and succinylcholine)
Malignant Hyperthermia manifests in bradycardia or tachycardia? and what happens to the BP?
tachycardia
with unstable BP
Malignant Hyperthermia manifests in
hypoxia
Malignant Hyperthermia manifests in hypokalemia or hyperkalemia?
HYPER kalemia
what are the first signs of malignant hyperthermia?
tachycardia and unstable BP
Malignant Hyperthermia: Muscle Rigidity (rigid jaw and chest)
- malignant hyperthermia pts bite down on the ET tube
- but if the pt is paralyzed, they wouldn't be able to bite down on the ET tube
- so they don't voluntarily bite down, its instead caused by the muscle rigidity
- so if you see that, immed. you would t
malignant hyperthermia temperature
46 degrees C
108 degrees F
the nurse moves very quickly
to keep the pt from dying
primary prevention is always best
- identify the pt of having this genetic predisposition and avoid the meds
malignant hyperthermia Rx
IV fluids, Dantrolene (dantrium - muscle relaxant)
- helps slow down the electrical cascade
if the patient becomes tachycardia and the BP remains unstable, what should the nurse suspect and do?
suspect malignant hyperthermia
tell the anesthesiologist and surgeon know right away'
- and the anesthesiologist monitors for muscle rigidity
- circulating room nurse monitors as well
- as soon as the early signs occur, the surgery is stopped because they
Regional / Local Anesthesia - is the patient awake and what's the status of their LOC?
patient is awake
but no LOC
which drug (induction agent) is used with Regional/Local anesthesia to calm the patient down?
versed or fentanyl
Regional/Local anesthesia does what to the transmission of the sensory nerve impulses?
it numbs the area so it doesnt hurt when they cut into it
Regional anesthesia covers how much of the body?
over a large specific area
Local anesthesia covers how much of the body?
over a small area
Blocks anesthesia
some of nearby nerves affected (peripheral)
Regional - Anesthetic over large specific area
Ex.
epidural and spinal
Regional/Local Anesthesia
NANDAS
- ineffective individual coping
- acute pain
- vasoconstriction
NICs
- coping enhancement
- pain management
- no epinephrine with extremities
NOCs:
- coping
- pain level
- local circulation
pleuropericarditis
excess fluid in the pleural cavity
- fluid accumulation in the pericardial sac around her heart
- very painful
- angina, SOB
Tx: tap the lungs
tap the lungs - local anesthesia
- ultrasound to see where the fluid is in the lungs
- numb area btw the ribs
-insert the probe
- remove the fluid
- cant feel it
Vasoconstriction and local anesthesia
- when people have local anesthesia, you must pay attention to what area is being anesthetized
ex. lidocaine meds
- epinephrine and without epinephrine
if you take epinephrine with lidocaine. what will happen to the bleeding?
minimizes bleeding (good thing)
- except for peripheral areas, (hands, fingers), then the vasoconstriction can cut off circulation to those areas
why would you never use lidocaine with epinephrine ?
because you can end up causing decreased circulation to the area and tissue damage
no epinephrine for extremities
- you need to recognize that local circulation for those areas
bc the local can decrease circulation to those areas
or there's epinephrine in the lidocaine
Epidural Anesthesia
inject narcotics in the epidural space near spine
- usually continuous infusion
is epidural anesthesia continuous or intermittent?
continuous infusion
- thats the big difference between an epidural and a spinal
what is epidural anesthesia used for?
- ortho cases, vaginal, rectal
- post op analgesia
where does the epidural infect the narcotics?
inside or outside of the spinal cord?
outside the spinal cord
between the vertebrae
doesn't pop into the spinal cord
- numbs the area from that point down
- from dermatomes from that point down
usually used for the following cases (below the waist)
- ortho
- vaginal
- rectal
Epidural Procedure
- insert the epidural using needle with a catheter
on the OUTSIDE
- they remove the needle and keep the catheter in place
- nurse's job: assist in positioning the patient for this, the patient is usually on their side or sitting up, and bending over to spread the vertebrae so the anesthesiologist could put the catheter in the right place
- assist in positioning the pt for this
- the pt is usually on their side or sitting up and bending over to spread the vertebrae so the anesthesiologist could put the catheter in the right .
Epidural Anesthesia
Additional NANDAs
- Disturbed Sensory Perception
- Impaired Physical mobility
- Impaired Urinary Elimination
- Risk for Infection
Additional NICs:
- self care assistance
- fall prevention
- tube care: urinary (keep Foley in 2 - 3 hour)
- tube care: epidural
Additional NOCs
- neurological status: spinal sensory/motor function
- urinary elimination
- infection status
Epidural Anesthesia
- affects sensory
reason: relieves pain
at high doses, Epidural Anesthesia may affect what?
what does the nurse always monitor for?
mobility
- epidurals aren't supposed to affect mobility but at high doses it could
- so you're always monitoring for movement
obviously if you decrease sensory perception below the waist, the pt would have to have a Foley
why?
because they cant control their urine or they wont feel the need to urinate
- usually you keep the Foley in for awhile
- after the epidural is removed because you want to make sure that sensory and motor are back to normal before you remove the Foley
- yo
the pt could also be at risk for infection when they're under Epidural Anesthesia because
you have a catheter next to the spine
- make sure the catheter is maintained and that there are no breaks in the system
- ensure that you don't end up with an infection next to the spine
what are you always monitoring for when pts have epidurals and spinals?
neuro stats and CNS checks
urine elimination
- to ensure Foley is patent and removes urine
- imp. bc the nurse uses URINE OUTPUT to determine fluid status
nurse must differentiate if this is
- a bladder issue (patent?)
- or CV fluid management issue
no S/
Spinal Anesthesia
where is the needle placed?
subarachnoid space, L3-L4
what type of injection is the Spinal Anesthesia?
continuous
single
or
intermittent?
continuous or single injection
the Spinal Anesthesia produces no feeling where?
no feeling / motor below the injection
used for below the waist procedures
the big difference between an epidural and a spinal is that:
***with a spinal - the anesthesiologist is actually injecting the narcotics INTO THE SPINAL CANAL
- into the canal, next to the spinal cord to numb the area
- inject and remove
NO CATHETER
- higher doses
- the anesthesiologist will insert it between L3 an
is EPIDURAL sensory or motor paralysis?
only sensory
NO paralysis
is the SPINAL anesthesia sensory or motor paralysis?
both
sensory and motor paralysis
what does a SPINAL do that an epidural doesn't?
- it causes paralysis
when a pt codes, the legs are propped up, this helps the blood pooled in the legs to travel back to the heart from the feet
- little valves in the veins
- muscle contraction
help to do this
this would occur if spinal anesthesia doesn
Spinal Anesthesia
Additional NANDAs
- decreased CO
- respiratory depression
- acute pain (spinal headache)
Additional NICs
- shock prevention
- monitor vitals / breathing
- pain management ( 1 - 2 liters of fluid)
Additional NOCs
- circulation status
- oxygenation
- pain level
downside - the spinal anesthesia can cause
blood pooling and can affect the cardiac output
what the nurse should have done:
- get orthostatic BPs post-spinal because you need to make sure the patient can withstand changes in position post-spinal
- in this case it caused BP drop and respiratory de
nurse must monitor oxygenation with a pt with spinal anesthesia
- ensure breathing is ok
- esp with pts who have a spinal
- depending on the site of the spinal bc it can cause paralysis,
sometimes the med thats injected into the spinal cord, although it iwll numb and paralyze from that point down, it sometimes seeps U
spinal anesthesia - pain management
spinal headache
- leakage of CSF fluid
- for a spinal, you prin prick a little hole into the spinal canal
- and in that canal is the CSF
- if you think of the canal as a little balloon, if you prick and deflate it, you stretch it and can see the hole
what position should the post-spinal anesthesia pt be in to avoid a spinal headache?
the pt must STAY FLAT (15-30 degrees)
- they cannot sit up or bend or have their head be up too high
- it will bend the spine and increase the hole so CSF will lead and this causes a horrible headache
how long should the post-spinal anesthesia pt remain flat for?
6 hours
and push fluids so they're well hydrated
so if there's leakage it can replace the CSF with fluid shifting
major 3 nursing things to monitor post-spinal anesthesia
1. monitor CO
- esp. post spinal when they get up for the 1st time
2. during the spinal, make sure the diaphragm isnt affected
- check for oxygenation and breathing
3. positioning is very important
- remain flat for 6 hours to prevent spinal headache
Blocks Anesthesia - Bier Block
is for what type of surgeries?
peripheral surgeries
- upper extremities
Blocks Anesthesia - Bier Block
Tourniquet
Local anesthetic circulation
VS monitoring in case anesthetic becomes systemic
for short procedures
what is very important to monitor when a pt has
Blocks Anesthesia - Bier Block?
Vital Signs to ensure the anesthetic doesn't become systemic
Peripheral nerve blocks
where is the anesthetic injected?
injects the anesthetic over nerve to block the pain
Bier Block
peripheral surgeries
for upper extremities
- you're trying to create a micro circulation around the extremity so you don't need as many drugs
- it would be injecting the medication in the arm to minimize circulation in the body
- when the tourniquet is re
Peripheral nerve blocks
the doctor can block the pain for the nerves that innervated his penis so he didn't feel that horrible pain
- there are areas that can get blocked peripherally
Moderate Sedation is used by itself for what type of procedures?
short term procedures
in addition to other local anesthesia
Minimally depressed LOC
used in situations where someone is going to have a procedure that will make them very nervous
and it's usually associated with local anesthesia
if a pt is going to have a procedure and they're very scared, they will receive the what to cause minimal depression of LOC ?
Fentanyl and Versed
- so it would make them loopy so they can endure the local anesthesia
Ex. for tapping a pt's lungs
Moderate Sedation
NANDAs
- ineffective breathing pattern / cardiac
- acute confusion (agitation, combative)
NICs
- respiratory monitoring: constant, vitals q 15-30 min
- reality orientation - responds to verbal commands
NOCs
- respiratory status: airway patency - vitals
- cognitive orientation
moderate sedation
a decreased level of consciousness in which the patient is not completely asleep
sedated, but still aware , and can follow directions
Moderate Sedation
the issue here is that the medications that are given are induction agents... so the most important thing is to make sure of what?
that you don't cause general anesthesia
so you're always prepared in monitoring their
breathing and cardiac status
because you're depressing
them enough that they can go into respiratory arrest
so always monitor their airway and check their VS
NICs for Moderate Sedation
- monitor VS every 15 - 30 min
while they're being medicated
also some of these meds can cause a great deal of confusion and delirium
- must Tx that
- sometimes ppl can get very combative depending on the medication that's used
- make sure you maintain th
Moderate Sedation and for delirium
you want to always re-orient them, remind them that you're taking care of them
because they may think they're in a different place
so you need to constantly re-orient them to treat the confusion or delirium
You are the circulating room nurse. What is your responsibility?
circulatory nurses
- help put pts to sleep for surgery
- when the surgery starts, they remain in the non-sterile function
they venture outside the OR if theres a need for supplies
- they also open packages as necessary so doctors can grab the sterile supp
The perioperative nurse encourages a family member or a friend to remain with the patient in the pre-operative holding area until the patient is taken into the operating room primarily to
A. Ensure the proper identification of the patient before surgery.
D. Help relieve the stress of separation for both the patient and significant others.
Answer: D social supports relieve stress. Also, that sense of connectedness improves spiritual well-being.
The patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. At the completion of the surgery, it is most important that the nurse monitor the patient for:
A. Nausea and vomiting.
B. Agitation and seizures.
C. Laryng
D. Adequacy of respiratory muscle movement
Answer D OK even if you did not know all the side effects of all the drugs, think about it. A neuromuscular blocking agent paralyzes the patient.
The diaphragm is paralyzed by this medication. It just makes sense