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The Peri-operative and Post-operative Patient

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The Peri-operative and Post-operative Patient Post-Op Complications Hypothermia=less than 36 degrees Celsius, or 96.8 degrees Fahrenheit. 60% of PACU patients are ... – PowerPoint PPT presentation

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Title: The Peri-operative and Post-operative Patient


1
The Peri-operative and Post-operative Patient
2
Anxiety
3
Anesthesia Man
4
Types 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.

5
General Anesthesia
6
Open Drop Ether Anesthesia
7
ASA 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.

8
Typical 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

9
The 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.

10
Process 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.

11
Visualizing Vocal Cords Prior to Intubation
12
Endotracheal Tube with Cuff
13
Vocal Cords with Endotracheal Tube
14
Maintenance of Anesthesia
15
Maintenance 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.

16
Emergence
  • 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.

17
Regional 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.

18
Spinal/Epidural Anesthesia
19
Epidural Space
20
Spinal/Epidural Anesthesia
21
Physiologic 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

22
Monitored 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.

23
Conscious 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.

24
Local 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.

25
Considerations 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).

26
Malignant 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.

27
Malignant Hyperthermia
28
Malignant Hyperthermia
29
Admission 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.

30
Nursing Dx in PACU
  • Ineffective breathing pattern
  • Decreased Cardiac Output
  • Risk for altered body temperature
  • Altered thought processes
  • Pain

31
Postoperative 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.

32
Post-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.

33
Post-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.

34
Post-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.

35
Post-op Complications
  • Hyperthermia-may indicate infection, sepsis, MH
  • Altered Thought Processes
  • Nausea and Vomitting
  • Aspiration
  • Pain

36
Discharge from PACU
37
Discharge 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.

38
Discharge 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.

39
Transfer 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.

40
Nursing 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)

41
References
  • 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.
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