Title: The Peri-operative and Post-operative Patient
1The Peri-operative and Post-operative Patient
2Anxiety
3Anesthesia Man
4Types of Anesthesia
- General-unconscious state
- Regional-reversible loss of sensation in area to
block nerve fibers (includes spinal, epidural) - Monitored Anesthesia Care- local IV drugs for
sedation - Conscious Sedation/Analgesia- sedation
- Local Anesthesia- anesthetic agent by local
infiltration or topical application.
5General Anesthesia
6Open Drop Ether Anesthesia
7ASA Classification
- Class I- Normal, healthy patient
- Class II- Patient with mild systemic disease
- Class III-Patient with systemic disease that is
not incapacitating - Class IV- Patient with an incapacitating systemic
disease that is a constant threat to life - Class V- Moribund patient not expected to survive
for 24 hours with or without surgery - See page 23 in handout in binder.
8Typical Sequence leading up to Induction
ofAnesthesia
- Admission after pre-work up
- Anesthesiologist sees patient in pre-op holding
and has talked with the patient the night before
to review history and plan for anesthesia. Chart
and patient checked for consents, ID, labs, HP.
Sedation. - In OR-Monitors applied, Time-out occurs
- Sedation, Induction
9The Three Phases of General Anesthesia
- Induction- begins with placing of monitors
through intubation. - Maintenance- begins after intubation to near
completion of the procedure (titrated doses of
anesthetic agents) - Emergence- begins with turning off the
maintenance agent(usually a volatile gas in the
Ether family) and culminates with the patient
regaining consciousness.
10Process of Induction
- Monitors applied (EKG, Pulse Oximetry, Blood
Pressure) - Meds given IV for beginning sedation
- Pt pre-oxygenated with 100 O2 for 3-5 minutes
to supply pt with reserve supply of oxygen in the
lungs. - Sleep dose of induction agent given. Usually
Propofol, Sodium Pentothal or Etomidate. - Followed by a Neuromuscular Blocking Agent.
11Visualizing Vocal Cords Prior to Intubation
12Endotracheal Tube with Cuff
13Vocal Cords with Endotracheal Tube
14Maintenance of Anesthesia
15Maintenance of Anesthesia
- Maintenance of anesthesia is usually
accomplished with one of several volatile gasses
which are related to Ether. - During the maintenance phase we monitor end tidal
Carbon Dioxide as a means of determining how well
we are ventilating the patient and end tidal
anesthetic gas which gives us one indicator of
anesthetic depth. - Total Intravenous Anesthesia or TIVA can also be
used in the maintenance phase of anesthesia.
This is usually accomplished with a combination
of Versed, Propofol, which is a sedative
hypnotic, a narcotic and muscle relaxant.
16Emergence
- Emergence from anesthesia usually includes
extubation and continues in the PAR. Where the
drugs used for anesthesia gradually wear off . - The patients postsurgical pain is also addressed
at this time.
17Regional Anesthesia
- Accomplished by injecting a local anesthetic
anywhere along the pathway of a nerve from the
spinal cord. - Examples Spinal, Epidural, Peripheral Nerve
Blocks - Patients need to be monitored appropriately while
receiving these medications. Pulse oximetry,
EKG, BP, supplemental O2 prn. - Provide reassurance and possibly sedation as
ordered.
18Spinal/Epidural Anesthesia
19Epidural Space
20Spinal/Epidural Anesthesia
21Physiologic Responses to Spinal Anesthesia
- Hypotension occurs secondary to sympathetic
nerves that control vasomotor tone are blocked.
Tx crystalloid bolus, 5 degree head-down
position to improve venous return, Vasopressor
(Ephedrine). - Total Spinal (inadvertently high block) may
result in paralysis of the respiratory muscles
and necessitate immediate intubation and
ventilation. - Spinal Duramorph Administered by the
anesthesiologist. Nursing needs to be aware of
effects on the respiratory rate and sedation as
this med is not broken down by the liver. Have
an ambu bag and Narcan available at the bedside
22Monitored Anesthesia Care
- Uses Procedures that combine MAC with a
peripheral nerve block or local anesthetic. - Useful for normal, healthy people and sicker,
unstable patients that are high risk for general
anesthesia. - Meds used may be local IV analgesic (fentanyl)
sedative and amnestic drugs (midazolam or
propofol). - Anesthesiologist monitors VS, respiratory and
cardiovascular status and positioning. May give
low flow supplemental oxygen. - Can quickly be changed into General Anesthesia.
23Conscious Sedation/ Analgesia
- Administration of IV medications to produce
sedation at a level that pt is able to maintain
airway and respond appropriately to verbal
commands or physical stimulation. - Performed by peri-operative nurses with
additional training under the direction of a
physician.
24Local Anesthesia
- Administration of an anesthetic agent to a
specific area of the body by the following
methods topical application, local
infiltration, regional nerve block or field
block. - Administered by the surgeon or anesthesiologist
if surgeon prefers.
25Considerations for Recovery
- Length of surgery/positioning of patient during
surgery. - Hydration status in relation to surgery.
- Blood glucose control pre-op, intra-op and
post-op (Optimal wound healing and decreased rate
of infection if maintained in the normal range
80-110). - Temperature control intra-op and post-op (Optimal
wound healing if gt96.8 maintained).
26Malignant Hyperthermia
- Rare, life-threatening complication triggered by
common anesthetic agents (Inhalational agents and
Succinylcholine). - May be induced by trauma, strenuous exercise or
emotional stress. - Genetic disorder Autosomal dominant trait.
- Syndrome is a hypermetabolic condition in the
skeletal muscle cells involving an altered
mechanism of calcium function at the cellular
level. - Usually presents in OR or PACU.
- Temperature increase is a late sign.
27Malignant Hyperthermia
28Malignant Hyperthermia
29Admission to PACU
- Immediately determine airway, breathing and
circulation. - Apply humidified O2, count RR and apply pulse
oximeter. - Apply cardiac monitor, assess cardiac rate and
rhythm. - Obtain VS, assess breath sounds.
- Peri-op nurse and Anesthesiologist give
report-pre-op vs, labs, O2 sat, allergies and
relevant hx, anesthesia technique and agents,
length of anesthesia, reversal agents, surgical
procedure, EBL and volumes in, complications and
ASA classification.
30Nursing Dx in PACU
- Ineffective breathing pattern
- Decreased Cardiac Output
- Risk for altered body temperature
- Altered thought processes
- Pain
31Postoperative Complications
- Airway obstruction- commonly the tongue secondary
to anesthetic agents and muscle relaxants (chin
lift, jaw thrust). - Laryngospasm-muscles of the larynx contract to
cause airway obstruction. Result of irritable
airway (remove irritating stimulus, suction,
hyperextend head, O2,aerosol with racemic
epinephrine, positive pressure ventilation per
mask and bag). May need succinylcholine.
32Post-Op Complications
- Bronchospasm-(bronchodilators)
- Cardiovascular-hypotension, hypertension,
dysrhythmias - Hypotension-usually caused by hypovolemia in this
setting, we will usually try a fluid bolus if it
isnt cardiac in etiology. - Hypertension- May be caused by volume overload,
pulmonary edema, pain, anxiety or reflex
vasoconstriction from hypothermia.
33Post-Op Complications
- Dysrhythmias- sinus tachycardia common. Causes
pain, hypoxemia, hypovolemia, increased
temperature and anxiety. Treat underlying cause.
- Bradycardia-hypoxemia, hypothermia,
- high spinal, vagal stimulation.
- PVCs-hypoxemia, hypokalemia.
34Post-Op Complications
- Hypothermialess than 36 degrees Celsius, or 96.8
degrees Fahrenheit. - 60 of PACU patients are hypothermic. Causes
physiologic stress, prolongs recovery time and
contributes to post-op morbidity. - Shivering increases oxygen needs by 300-400.
- Depresses CNS resulting in longer duration of
anesthesia.
35Post-op Complications
- Hyperthermia-may indicate infection, sepsis, MH
- Altered Thought Processes
- Nausea and Vomitting
- Aspiration
- Pain
36Discharge from PACU
37Discharge from PACU
- Discharge order written by anesthesiologist.
- Patient needs to meet discharge criteria
- Common scoring system Aldrete Score-factors in
activity, respiration, circulation, consciousness
and O2 saturation level. Need a total score of
8-10 to discharge.
38Discharge from PACU
- Report to nurse who will be assuming care of the
patient upon transfer. - Given via telephone or face-to-face.
- Includes pre-op history, pertinent information
about the surgery and recovery, meds the patient
received, physicians orders and other
information as appropriate.
39Transfer to Unit
- Maintain patient safety side-rails, PCA use.
- Nurse accepting report needs to do an immediate
assessment. Include head-to-toe and focused
assessment with consideration to UOP and bowel
sounds.
40Nursing Diagnosis
- Risk for infection
- Ineffective breathing pattern (secretions,
decreased lung expansion, RR, aspiration) - Pain
- Altered nutrition, less than body requirements
(wound healing) - Impaired physical mobility (venous stasis)
41References
- Meeker MH, Alexanders Care of the Patient in
Surgery, Mosby, 1999. - Bishop J., Sprague M., Gelber MS, Krol M,
Rosenblatt MA, Gladstone J, Flatow EL.
Interscalene Regional Anesthesia for Shoulder
Surgery. Journal of Bone and Joint Surgery. 2005
87-A,5974-979.