Intraoperative Nursing Management

Intraoperative Nursing Management

Safety and advocacy for the client during surgical inter­ventions are the primary concerns of perioperative nurses. Outcomes and numerous hazards can be managed, prevented, reduced, and controlled by deliberate actions and observations. The client entering the perioperative environment is at risk for infection, impaired skin integrity, increased anxiety, altered body temperature, and injury related to positioning and other hazards present. The intraoperative phase begins with unfa­miliar experiences involving uncertain or nonguaranteed out­comes. Nursing care during the intraoperative period is criti­cal, because all of the client’s physical needs, comfort, safety, dignity, and psychologic status are dependent on the perioper­ative nurse. Specific procedures and policies may differ among agencies, but similarities are evident and reflect the standards and recommended practices for perioperative nursing, as pub­lished by AORN, the Association of periOperative Registered Nurses (formerly the Association of Operating Room Nurses).

1 OVERVIEW

I Members of the Surgical Team

The surgical team consists of the surgeon, one or more surgi­cal assistants, the anesthesiologist and/or nurse anesthetist, and perioperative staff.

Perioperative, or operating room (OR), nurses include the holding area nurse, circulating nurse, scrub nurse, and any specialty nurses. The number of assistants, circulating nurses, and scrub nurses depends on the complexity and projected length of the surgical procedure. For some minor diagnostic or outpatient procedures, only a scrub nurse or a circulating

nurse may be required in addition to the surgeon. The more complex procedures may require additional nursing staff to either circulate or scrub.

■ SURGEON AND SURGICAL ASSISTANT

The surgeon is a physician who assumes responsibility for the surgical procedure and any surgical judgments about the client. The surgical assistant might be another surgeon (or physician, such as a resident or intern) or a physician’s assis­tant, nurse, or surgical technologist. Under the direction of the surgeon and within the legal scope of practice within each state, the assistant may hold retractors, suction the wound (to allow visualization of the operative site), cut tissue, suture, and dress wounds. Regulating agencies determine who may qualify to be a surgical assistant and delineate the functions of the surgical assistant.

ANESTHESIOLOGIST AND NURSE ANESTHETIST

The anesthesiologist is a physician who specializes in the administration of anesthetic agents. A certified registered nurse anesthetist (CRNA) is a specially trained registered nurse with additional credentials who administers anesthetic agents under the supervision of an anesthesiologist, surgeon, dentist, or podiatrist. The anesthesiologist or CRNA adminis­ters anesthetic drugs to induce and maintain anesthesia and administers other medications as indicated to support the client’s physical status during surgery.The anesthesiologist or nurse anesthetist usually monitors the client intraoperatively by measuring, assessing, and mon­itoring the following:

•  The level of anesthesia (i.e., by using a peripheral nerve stimulator or bispectral analysis)

•  Cardiopulmonary function (using electrocardiographic [ECG] monitoring, pulse oximetry, end-tidal carbon dioxide monitoring, arterial blood gases, and hemody-
namic monitoring via arterial lines and/or pulmonary ar tery catheters)

•  Vital signs

•  Intake and output

Depending on the client’s needs, anesthesia personnel ad­minister intravenous (IV) fluids, including blood and blood components, to maintain physiologic homeostasis.

■ PERIOPERATIVE STAFF

Perioperative, or OR, staff assume several roles within the op­erating suite, depending on their education, experience, skill, and job responsibilities.

HOLDING AREA NURSE. Some operating suites fea­ture a presurgical holding area next to the main ORs. The client waits in this area until the OR is ready. The holding room nurse manages the client’s care while he or she is in this area. This nurse greets the client on arrival, reviews the med­ical record and preoperative checklist, and ensures that the operative consent forms are signed. The nurse assesses the client’s physical and emotional status, gives emotional sup­port, answers questions, and provides additional education as needed. The nurse initiates documentation on a perioperative nursing record (Figure 18-1).

The holding area can be very busy, with many staff mem­bers performing a number of preoperative procedures (e.g., establishing IV lines or inserting epidural catheters). The holding area nurse maintains an atmosphere conducive to the client’s overall well-being and intervenes on his or her behalf to maintain comfort, privacy, and confidentiality. Depending on the facility’s policy, family members may be invited to wait with the client.

CIRCULATING NURSE. The circulating nurse, or circulator (who should be a registered nurse), coordinates, oversees, and participates in the client’s nursing care while he or she is in the OR. The circulating nurse’s actions are vital to the smooth flow of events before, during, and after the opera­tion. This nurse is responsible for the activities within that particular OR. The circulator sets up the OR and ensures that necessary supplies, including blood products, are available asneeded. All anticipated equipment is gathered and inspected by the circulator to make certain that all equipment is safe and functional before the surgery. Depending on the procedure and position required, the circulator makes up the operating bed (formerly called the OR table) with gel pads (to prevent pressure sores) and heating pads (to prevent hypothermia) un­der the sheets as indicated.

If there is no holding room nurse, the circulator assumes the responsibilities of that nursing role as well. Even when there is a holding room nurse, the circulator also greets the client and reviews findings with the holding area nurse, be­cause the circulator is responsible for continuity of care.

Once the client is ready to move into the OR, the circulat­ing nurse assists the OR team in the transfer to the operating bed. The nurse then positions the client, protecting bony prominences with extra padding as indicated while providing comfort and reassurance. While comforting and observing the client, the circulating nurse also assists the anesthesiologist or CRNA with the induction of anesthesia. The circulator then may “prep” (scrub) the surgical site before the client is draped with sterile drapes.

Throughout the surgery, the circulating nurse:

•   Monitors traffic in the room

•   Assesses the amount of urine and blood loss

•   Reports findings to the surgeon and anesthesia personnel

•   Ensures that the surgical team maintains sterile tech­
nique and a sterile field

•   Anticipates the client’s and surgical team’s needs, pro­
viding supplies and equipment as needed

•   Communicates information regarding the client’s status
with family members during long and unique procedures

•    Documents care, events, interventions, and findings
Depending on facility policy, the circulating nurse may ob­
tain and record medications, blood, and blood components.
(This may be partially a function of anesthesia personnel.)

Before the surgical procedure is over, the circulating nurse completes documentation (Figure 18-2; see also Figure 18-1). The nurse notes drains or catheters in place, the length of the surgery, and a count of all sponges, “sharps” (needles, blades), and instruments. The nurse notifies the postanesthe-sia care unit (PACU) of the client’s estimated time of arrival and any special needs.

SCRUB NURSE AND SURGICAL TECHNOLO­GIST. The scrub nurse and/or the surgical technologist sets up the sterile field (Figure 18-3), assists with draping the client, and hands sterile supplies, sterile equipment, and in­struments to the surgeon and the assistant. Knowledge of anatomy and physiology, as well as familiarity with the surgi­cal procedure, allows the scrub nurse to anticipate the pro­gression of the procedure and determine which instruments and types of sutures the surgeon will need. The nurse’s ability to anticipate these needs reduces the duration of anesthesia for the client. Furthermore, the surgeon’s anxiety and tension can be minimized with a scrub nurse who is familiar with the procedure and demonstrates the ability to anticipate and re­spond accordingly. Throughout the surgical procedure, the scrub nurse (with the circulating nurse) maintains an accurate account of the sponges, sharps, instruments, and amounts of irrigation fluid and medication used.

A specially trained person who is not a nurse may perform the scrub role. Such people are called operating room tech­nicians (ORTs) or surgical technologists. Increasingly, cer­tified surgical technologists (CSTs) are used in the periopera­tive environment.

SPECIALTY NURSE. The specialty coordinator nurse

is educated in a particular type of surgery (e.g., orthopedic, cardiac, ophthalmologic) and is responsible for intraoperative nursing care specific to clients needing that type of surgery. The specialty coordinator nurse serves a critical role by as­sessing, maintaining, and recommending equipment, instru­ments, and supplies used in that specialty. They also typically are responsible for orienting and evaluating staff members

Figure 18-3    •    Setting up the sterile table.

this service. During surgery the specialty nurse may function as the scrub or circulating nurse.

If the facility has laser technology, nurses specially trained in the use, care, and maintenance of the laser should be on hand. Such a nurse may be called a laser specialty nurse or a laser nurse coordinator. Laser is an acronym for /ight amplifi­cation by the stimulated emission of radiation. A laser emits a high-powered beam of light that cuts tissue cleaner than do scalpel blades. This process produces intense heat for rapid co­agulation of blood vessels or tissue and can turn tissue (such as a tumor) into vapor. It is essential for all personnel to observe safety measures (e.g., eye shields, door signs) during laser pro­cedures. Improper laser use and inadequate safety measures in­crease the risk for injury to both the client and staff.

Preparation of the Surgical Suite and Team Safety

During the intraoperative phase, when the client is unable to protect himself or herself, all members of the surgical team must provide protection. The operating room (OR) layout is designed to prevent infection by limiting the source of con­taminants by air exchanges in the room and limiting the traf­fic and extraneous activities in the OR. Safety straps are used for the client, and the operating bed is locked in place. Heat­ing pads are used to prevent hypothermia, and interventions are instituted to prevent skin breakdown.

The nurse ensures electrical safety through proper place­ment of grounding pads and use of electrical equipment that meets safety standards. All equipment that might be used dur­ing surgery must be functional and in proper working condi­tion, checked per safety procedure of that facility, and appro­priately cleaned and, when required, sterilized so that it can be used as a part of the procedure. The scrub and circulating nurses together ensure a correct count of surgical instruments, sharps, and sponges immediately before the beginning of the procedure, during the procedure, and immediately after the close of the surgical incision.

Fire prevention is of utmost concern to OR personnel, as is prevention of complications associated with the use of hazardous and potentially toxic substances. A cool room temper­ature (between 68° and 73° F [20° to 30° C]), with a low rel­ative humidity of 30% to 60% is optimal, and staff and clients must be protected against thermal or chemical burns caused by fire or spills. The nurse is aware of appropriate emergency measures to take in the event of a fire or spill.

LAYOUT

The surgical suite should be located out of the mainstream of the hospital or facility and adjacent to the postanesthesia care unit (PACU) and support services (e.g., blood bank, pathol­ogy and laboratory departments). Traffic flow should be pat­terned to ensure minimal contamination from outside the suite. Within the suite, clean and contaminated areas must be separate. According to AORN, the Association of periOpera-tive Registered Nurses, designation of the surgical area into three zones as unrestricted, semirestricted, and restricted fa­cilitates appropriate movement of clients and personnel.

The size of a surgical suite depends on the size and surgi­cal capabilities of the facility. The average suite contains staff changing rooms (staff locker rooms) and staff lounges, an ad­mission or preoperative holding area, a scrub area for staff, a number of ORs, designated cabinets for sterile supplies, sep­arate utility rooms for clean and soiled equipment, and a clean linen room.

Figure 18-4 shows a typical OR. The exact number of ta­bles and specialized equipment used in the room is based on the needs of each client. A reliable communication system links the OR and the main desk of the surgical unit or suite to ensure safe client care. The system should include an inter­com and the capability to differentiate between routine and emergency calls.

і HEALTH AND HYGIENE OF THE SURGICAL TEAM

People are a major source of bacteria in the surgical setting. Everyone has a large number of potentially pathogenic bacte­ria on the skin and hair and in the respiratory tract. Because these pathogens can be transmitted to the client, special health standards and dress are required. Every surgical environment has written policies and procedures regarding personnel and acceptable attire. Health standards require that all members of the surgical team and other support personnel in the surgical suite be free from communicable diseases. Anyone who has an open wound, cold, or other infection should not participate in surgery.

Good personal hygiene aids in the prevention and control of infection, as does frequent and appropriate handwashing. Shedding of microorganisms and skin debris is greatest imme­diately after showering, so surgical staff should bathe a few hours before changing into OR attire. Jewelry, which can carry multiple microorganisms, should be minimal. In preparing for surgery, all personnel must wash their hands between proce­dures and more frequently when indicated. Microbial speci­mens from the hands of surgical personnel may be obtained for culture periodically to maintain an awareness of the potential for nosocomial (hospital-acquired) infections and to identify the source of pathogenic invasion. Further interventions or cul­tures are necessary if quality reports (e.g., through the facil­ity’s quality improvement program or quality reviews) indicate Chapter 18   Interventions for Intraoperative Clients

 

 

Monitor screen displayingclient’s heart rate and rhythm, blood pressure, and other hemodynamicparameters

Printer to accompanythe monitor

Ventilator bellows

Nitrous oxide, air, and oxygen flow meters Anesthesia circuit

Airway equipment(under sterile towel) – Extra supply of air (yellow) and oxygen (green)

Carbon dioxide absorber

Anesthesia breathing bag

Suction –canister

Pulse oximeter

Blood

pressure

monitor

Ventilator

Laboratory results

Vaporizers

Hazardous waste (“red bag” trash)

Figure 18-4    Ф    A, A typical operating room. B, A typical anesthesia station with an anesthesia machine.

 

Figure 18-5    •    An example of a hood-type hair covering that ad­equately covers facial and scalp hair.

a problem. The average time between routine cultures is 3 to 6 months. Surgical attire and the surgical scrub are additional in­terventions that help to prevent contaminations.

і   SURGICAL ATTIRE

All members of the surgical team and all OR personnel must wear scrub attire. Scrub attire is clean, not sterile. It is worn to decrease contamination from microorganisms. The basic attire of personnel entering the operating suite consists of a shirt and pants, a cap or hood (Figure 18-5), and shoe cover­ings. Staff change into clean surgical attire in the operating suite locker rooms, not at home. All members of the surgical team must cover their hair, including facial hair when present. In addition to basic attire, everyone must wear appropriate protective body attire depending on the situation. This includes a mask, eyewear, gloves, gown, and shoe covers. Everyone who enters an OR where a sterile field is present must wear a mask. Members of the surgical team who are scrubbed to be at the bedside of the client during the surgical procedure must also be in a sterile fluid-resistant gown, with sterile gloves and eye protectors (Figure 18-6). Members of the surgical team in the OR who are not scrubbed (e.g., anesthesiologist and circu­lating nurse) usually wear cover scrub jackets to prevent shed­ding of organisms from bare arms and eyewear, as warranted.

■   SURGICAL SCRUB

The surgeon, all assistants, and the scrub nurse perform a sur­gical scrub after putting on a mask and before putting on the sterile gown and gloves (Figure 18-7). The scrub does not make the hands and forearms sterile; however, when it is ef­fectively carried out, it reduces the number of microorganisms from the hands, arms, and nails. Rings, watches, and bracelets are removed before scrubbing.

A disposable scrub brush or sponge, impregnated with an antimicrobial solution, and a nail cleaner are used. As with handwashing, the effectiveness of the scrub depends on the application of friction from the fingertips to the elbow. The

Figure 18-6 • Typical attire for all scrubbed personnel. Note complete hair covering, eye shields, mask, sterile gloves over the sleeves of the sterile gown, and shoe coverings. Note that wheot in use, the hands are typically folded in front of the body, never below the waist.

surgical scrub usually continues for 3 to 5 minutes, followed by a rinse. During the rinse, surgical personnel position their hands and arms in such a way that water runs off, rather than up or down, their arms. After scrubbing, personnel enter the OR with their hands held higher than the elbows and thor­oughly dry their hands and forearms with a sterile towel. The scrubbed staff member is then assisted into a sterile gown (“gowning”) and puts on sterile gloves (“gloving”).

Gowns, gloves, and materials used at the operative field must be sterile and are changed between surgical procedures and as they become contaminated. The areas of the surgical gown considered sterile are the front of the gown from 2 inches below the neck to the waist area, and the elbow to the wrist area. Only when they are properly scrubbed and attired should members of the surgical team handle sterile drapes and other equipment.

■ Anesthesia

The word anesthesia comes from the Greek word anesthesis, meaning “negative sensation.” Administration of anesthesia is an exact and sophisticated science. It requires the skill of a li­censed anesthesiologist, a certified registered nurse anes­thetist (CRNA) working under the direction of an anesthesi­ologist or another physician, or an anesthesiologist’s assistant (AA)—which is similar to a physician’s assistant—working under the direction of an anesthesiologist.

Figure 18-7 • The scrubbing, gowning, and gloving process. A, The surgical scrub. B, Rinsing. Note the water falling off the hands and arms. Also note the foot-operated handle that controls the water flow. (After scrubbing and rinsing, the scrub nurse dries his hands and arms with a sterile towel inside the operating room and then is assisted into a sterile gown.) C, The scrub nurse prepares sterile gloves. Note that the scrub nurse’s hands are inside the sleeves of the gown and that he is touching the sterile gloves only with the sterile sleeves. D, The scrub nurse puts on his first sterile glove while the sterile gown is be­ing tied in the back. Note again that his hand never emerges from under the sterile sleeve. E, The scrub nurse puts on his second sterile glove.Anesthesia is an artificially induced state of partial or to­tal loss of sensation, occurring with or without loss of con­sciousness. The purpose of anesthesia is to block the trans­mission of nerve impulses, suppress reflexes, promote muscle relaxation, and in some cases, achieve a controlled level of unconsciousness. Anesthesia providers use a separate anes­thesia record for documentation (Figure 18-8).

Usually the anesthesia provider determines the choice of anesthesia after consultation with the client and surgeon, and af­ter consideration of specific client-related factors. The nurse or client or both communicate the preference and fears related to a particular type of anesthesia to the anesthesia provider. Specific problems noted in the client’s history or preoperative physical examination are major factors in the selection and dosage of anesthesia. Selection is also influenced by the following:

•  Type and duration of the procedure

•  Area of the body being operated on

•  Whether the procedure is an emergency

•  Options for management of postoperative pain

•  How long it has been since the client ate, had any liq­
uids, or any medications

•  Client position needed for the surgical procedure

The administration of anesthesia begins with the selection and administration of preoperative medication, if any (see Chapter 17). The nurse must know the pharmacologic char­acteristics of commonly used agents and their effects during and after surgery. Anesthesia produces multiple systemic ef­fects, which can affect the client’s care and can compound other coexisting problems. For example, most anesthetics aremetabolized by the liver and excreted by the kidneys. Liver or kidney impairment can increase anesthetic effects and the risk for toxicity. In addition, drug interactions may occur be­tween the anesthetic agents and other medications the client has been receiving.

The state of anesthesia may be produced in a number of ways (Table 18-1):

•  General or balanced anesthesia

•  Local or regional anesthesia

•  Hypnosis or hypnoanesthesia

•  Cryothermia

•  Acupuncture

Hypnosis or hypnoanesthesia (which induces a passive, trancelike state), cryothermia (use of cold [e.g., ice] to lower the surface temperature of the surgical site), and acupuncture are not commonly used in theUnited States or Canada. Interest in the use of these methods, however, is growing

Most controllable method

Induction and reversal accomplished with pulmonary

ventilation Few side effects

Rapid and pleasant induction

Low incidence of postoperative nausea and vomiting

Requires little equipment

Minimal disturbance to physiologic function

Minimal side effects

Can be used with older and high-risk clients

Gag and cough reflexes stay intact

Allows participation and cooperation by the client

Less disruption of physical and emotional body

functions

Decreased chance of sensitivity to the agent Decreased intraoperative stress

Must be used in combination with other agents for

painful or prolonged procedures Limited muscle relaxant effects Postoperative nausea and shivering common Explosive

Must be metabolized and excreted from the body

for complete reversal Contraindicated in presence of hepatic or renal

disease

Increased cardiac and respiratory depression Retained by fat cells

Drug interactions can occur Pharmacologic effects on the body may be unpredictable

Difficult to administer to an uncooperative or upset

client

No way to control agent after administration Absorbs rapidly into the blood and causes cardiac

depression (hypotension) or overdose Increased nervous system stimulation (overdose) Not practical for extensive procedures because of

the amount of drug that would be required to

maintain anesthesia

.

■ GENERAL ANESTHESIA

General anesthesia is a reversible state in which the client loses consciousness as a result of the inhibition of neuronal impulses in the several areas of the central nervous system (CNS). The administration of a single agent or a combina­tion of chemical agents achieves this state. The anesthetic agents used induce CNS depression, characterized by anal­gesia (pain relief or pain suppression), amnesia (memory loss of the surgery), and unconsciousness, with loss of mus­cle tone and reflexes. The client is unconscious, unaware, and anesthetized. Indications for general anesthesia include surgery of the head, neck, and upper torso; extensive ab­dominal surgery; and situations in which clients are unable to cooperate.

STAGES OF GENERAL ANESTHESIA. Four stages of general anesthesia are classically described. Table 18-2 presents the client’s physiologic responses and nursing inter­ventions for each stage.

The speed of emergence, or recovery from the anesthesia, depends on the type of anesthetic agent, the length of time the client is anesthetized, and whether a reversal agent for the neuromuscular blocking agent has been administered. Al­though they are not as common as they once were (because of advances made in the pharmacology of anesthesia), retching, vomiting, and restlessness may occur during emergence. The nurse has suction equipment available to prevent aspiration.During recovery, shivering, rigidity, and slight cyanosis are not uncommon. These phenomena may reflect a temporary disturbance in the body’s temperature control. The nurse provides the client with warm blankets, radiant light, and oxygen to decrease the undesirable effects of emergence.

ADMINISTRATION OF GENERAL ANESTHESIA.

The two methods of administering general anesthesia are in­halation and IV injection.

INHALATION. Inhalation is the most controllable method of administering general anesthesia because intake and elimi­nation of the anesthetic are accomplished primarily by respi­ration. The lungs act as a passageway for entrance and exit of the anesthetic agent. The client inhales the anesthetic vapor of a volatile liquid or the anesthetic gas via a mask. The anes­thetic then passes across the alveolar membrane to the general circulation. The agent is transported through the bloodstream to the various tissues, where it is metabolized.

To improve ventilation and control the anesthesia, respira­tion may be assisted or controlled. With assisted respiration, an endotracheal (ET) tube is inserted. The ET tube is then connected to a reservoir (breathing) bag of the anesthesia ma­chine (see Figure 18-4). The anesthesiologist overrides, or “assists,” the client’s own respiratory effort to initiate the res­piratory cycle by manually compressing the reservoir bag.

Controlled respiration is accomplished with the use of a mechanical device, such as a mechanical ventilator, that auto­matically and rhythmically inflates the lungs with intermittent positive pressure; the client is not required to participate. Controlled ventilation is initiated after the anesthesiologist has produced apnea (absence of spontaneous respiratory ef­fort) either through hyperventilation or by administering a respiratory depressant or neuromuscular blocking agent.

The anesthesiologist or certified registered nurse anes­thetist (CRNA) inserts the ET tube with the assistance of the circulating nurse. A laryngoscope is used to visualize the vo­cal cords, and the tube is placed in the trachea (Figure 18-9).

TTHE FOUR STAGES OF GENERAL ANESTHESIA AND RELATED NURSING INTERVENTIONS

Stage                 Description                  Nursing Interventions Rationale

Stage 1 (Analgesia and sedation, relaxation)

Stage 2 (Excitement, delirium)

Stage 3 (Operative anesthesia, surgical anesthesia)

Stage 4 (Danger)

Begins with induction and ends with loss of consciousness.

Client feels drowsy and dizzy, has a reduced sensation to pain, and is amnesic.

Hearing is exaggerated.

Begins with loss of conscious­ness and ends with relax­ation, regular breathing, and loss of the eyelid reflex.

Client may have irregular breathing, increased muscle tone, and involuntary move­ment of the extremities dur­ing this stage.

Laryngospasm or vomiting may occur.

Client is susceptible to external stimuli.

Begins with generalized muscle relaxation and ends with loss of reflexes and depression of vital functions.

The jaw is relaxed, and there is quiet, regular breathing.

The client cannot hear.

Sensations (i.e., to pain) are lost.

Begins with depression of vital functions and ends with res­piratory failure, cardiac ar­rest, and possible death.

Respiratory muscles are para­lyzed; apnea occurs.

Pupils are fixed and dilated.

Close operating room doors, dim the lights, and control traffic in the operating room.

Position client securely with safety belts.

Keep discussions about the client to a minimum.

Avoid auditory and physical

stimuli.

Protect the extremities. Assist the anesthesiologist or

CRNA with suctioning as

needed. Stay with client.

Assist the anesthesiologist or

CRNA with intubation. Place client into operative

position. Prep (scrub) the client’s skin

over the operative site as

directed.

Prepare for and assist in treat­ment of cardiac and/or pul­monary arrest.

Document occurrence in the client’s chart.

Avoiding external stimuli in

the environment promotes

relaxation. Using safety measures in stage

1 prepares for stage 2. Being sensitive to the client

maintains his or her dignity.

Sensory stimuli can contribute to the client’s response.

Safety measures help to pre­vent injury.

Staying with the client is emo­tionally supportive.

Providing assistance helps promote smooth intubation and prevent injury.

Performing procedures as soon as possible promotes time management to mini­mize total anesthesia time for the client.

Cuff inflating tube

Vocal cords

Teamwork and preparedness help decrease injuries and complications, and promote the possibility of a desired outcome for the client.

Endotrachealtube Trachea

Inflatedcuff

Esophagus

Anesthesia port

Figure 18-9 • An oral endotracheal tube in position. The cuff of the tube was placed just below the vocal cords, then inflated to seal off the airway.

With the ET tube safely in place, the client has an open air­way (through the tube) and an avenue for the safe administra­tion of the inhaled anesthetic and oxygen.

Inhalation anesthetic agents are divided into two cate­gories: gases and volatile agents. Table 18-3 lists the advan­tages, disadvantages, and related nursing implications of var­ious inhalation anesthetic agents.

GASEOUS AGENTS. In the past, gaseous agents included ether and cyclopropane gas. Nitrous oxide (N₂O) is now the most commonly used gaseous anesthetic agent and is usually administered with oxygen. It is a colorless, odorless, nonirri-tating gas that provides analgesia equivalent to 10 mg of mor­phine sulfate.

VOLATILE AGENTS. Liquids vaporized for inhalation are considered volatile agents. Oxygen acts as a carrier, flowing over or bubbling through the liquid in the vaporizer system on the anesthesia machine. All volatile agents can produce post­operative shivering in the client because of their effect on the hypothalamus. Awakening is usually rapid, within 15 to 20 minutes.

Halothane (Fluothane). Halothane is a halogenated hy­drocarbon that depresses the cardiovascular system. The in­traoperative use of epinephrine to control bleeding may in­crease or precipitate a dysrhythmia when halothane is used.

TABLE 18-3	ADVANTAGES, DISADVANTAGES	AND RELATED NURSING IMPLICATIONS OF VARIOUS GENERAL INHALATION ANES
Agent	Advantages	Disadvantages	Nursing Implications	Rationale
Nitrous oxide	Rapid induction and	Relatively weak anes-	Assess oxygenation via	Ongoing assessment
(N2O)	recovery	thetic agent	pulse oximetry, physi-	leads to early de-
	Useful for short	May produce hypoxia if	cal assessment.	tection and treat-
	procedures	the concentration is		ment of potential
	When used with other	high		complications.
	agents, reduces the	Needs addition of other
	required concentration	agents for longer
	of the other agents	procedures
	Minimal cardiovascular
	and respiratory
	depression
Halothane	Rapid and smooth	Shivering common post-	Monitor heart rate for	Ongoing assessment
(Fluothane)	induction	operatively	bradycardia.	leads to early de-
	Low incidence of post-	Malignant hyperthermia	Monitor blood pressure	tection and treat-
	operative nausea and	is possible in suscep-	for hypotension.	ment of potential
	vomiting	tible clients	Provide warm blankets,	complications.
	Less irritating to the res-	Metabolized by the liver	radiant heat.	Warmth helps promote
	piratory tract than	Hypotension and brady-		client comfort and
	other inhalation agents	cardia may occur		decrease shivering.
	Sweet smell makes it	Can sensitize the
	easy to use in children	myocardium to
	Tolerated well by children	dysrhythmias
Enflurane	Rapid induction and	Respiratory depression	Monitor respiratory rate	Ongoing assessment
(Ethrane)	recovery	and hypotension may	and depth for	leads to early de-
	Does not alter heart rate	occur	hypoventilation.	tection and treat-
	or rhythm	Malignant hyperthermia	Assess oxygenation via	ment of potential
		is possible in suscep-	pulse oximetry, physi-	complications.
		tible clients	cal assessment.
		Lowers seizure threshold	Monitor blood pressure
			for hypotension.
Isoflurane	Rapid induction and re-	Respiratory depression	Monitor respiratory	Ongoing assessment
(Forane)	covery	may occur	rate and depth for	leads to early de-
	Has some muscle relax-	Malignant hyperthermia	hypoventilation.	tection and treat-
	ant properties	is possible in suscep-		ment of potential
	Stimulates the heart,	tible clients		complications.
	which helps keep a
	stable heart rate
	Is not significantly me-
	tabolized; no renal or
	hepatic damage
Desflurane	Rapid induction, recov-	May cause coughing	Monitor heart rate and	Ongoing assessment
(Suprane)	ery, and awakening	and excitement during	blood pressure.	leads to early de-
		induction	Caution client and family	tection and treat-
		Deep levels of anesthe-	that client should not	ment of potential
		sia may increase heart	drive or operate haz-	complications.
		rate and blood	ardous machinery until	Specific instructions
		pressure	mental status has re-	will help prevent
		Malignant hyperthermia	turned to preoperative	other injuries or
		is possible in suscep-	baseline.	accidents.
		tible clients
		May cause changes in
		mental function

 

Clients can have memory impairment for up to 24 hours after halothane is used.

Enflurane (Ethrane). Enflurane is an inhalation anes­thetic agent that reduces ventilations and decreases blood pressure as the depth of anesthesia increases.

Isoflurane (Forane). Isoflurane is another halogenated compound and appears to be a preferred inhalation agent.

Desflurane (Suprane). Desflurane produces a rapid in­duction of anesthesia but can cause coughing and excitation during the process. The rapid elimination of desflurane pro­duces awakening in 8 to 10 minutes. Cardiopulmonary de­pressant effects and malignant hyperthermia are the most common adverse effects.

Sevoflurane (Sevorane). Sevoflurane is like desflu­rane, except less coughing and laryngospasm occur with sevoflurane. Adverse effects are similar to those associated with desflurane.

INTRAVENOUS INJECTION. IV anesthetic agents are in­jected, usually through a peripheral IV line, into the circula­tion. A pleasant, rapid, and smooth dissipation of the agent occurs. The drug is diluted by the blood, but still travels in high concentration to the organs of high blood flow (brain, liver, and kidneys). The reversal and removal of the agent from circulation are not possible with IV injection, and the re­covery from the agent is directly related to the client’s metab-olism. Table 18-4 lists advantages, disadvantages, and related nursing implications of various IV anesthetic agents.

BARBITURATES. Barbiturates are often used for IV in­duction of anesthesia. These drugs act directly on the central nervous system (CNS), producing a reaction ranging from mild sedation to unconsciousness. The principal barbiturate used is thiopental sodium (Pentothal), which can also be used for rectal induction. Intravenously, it acts rapidly, resulting in unconsciousness within 30 seconds of administration. Be­cause thiopental is a potent respiratory and cardiovascular system depressant, the client’s vital signs must be monitored continuously during administration.

KETAMINE (KETALAR). Ketamine is a dissociative anes­thetic agent (one that promotes a feeling of dissociation from the environment). It acts by selectively interrupting various pathways in the brain. Rapid onset of a trancelike, analgesic state occurs. Ketamine is commonly used for diagnostic and short surgical procedures or to supplement weaker agents, such as nitrous oxide.

Emergence reactions are expected during recovery from ketamine. The operating room (OR) nurse reports the use of the drug to the postanesthesia nurse so that safety precautions can be implemented. If the client is combative or restless, the nurse pads the siderails of the bed to prevent injury. The nurse minimizes external stimuli until the client awakens naturally.NONBARBITURATES

Ketamine          Rapid induction

hydrochloride(Ketalar)

Short acting

Can be given IM or IV

No respiratory depres­sion or loss of mus­cle tone (protects the airway)

Protective reflexes re­main intact

Stimulates the cardio­vascular system

Can use for clients with respiratory or cardiac disorders

Good amnesic effect

Postoperative emer­gence reactions gen­erally last only 24 hr

Propofol(Diprivan)

Short acting

Rapidly metabolized

Client becomes re­sponsive quickly postoperatively

Minimal postoperative nausea, vomiting, or sedation

Emergence reactions— hallucinations, irra­tional behaviors, dis­torted images, unpleasant dreams, restlessness—are common

Increased heart rate

Increased blood pressure

Increased cardiac output

Poor muscle relaxant effect

Nausea, vomiting, and aspiration can occur

Allergic skin reactions have occurred

Client becomes aware of postoperative pain and discomfort sooner than with other anesthetics

Minimize external stim­uli: noise, light, touch, movement.

Speak in a calm, soothing voice.

Reassure client and family that emer­gence reactions are common and temporary.

Have suction equip­ment near.

Monitor blood pressure for hypertension.

Monitor heart rate for tachycardia.

Be prepared to admin­ister analgesic med­ications as ordered early in the postop­erative period.

Plan for nonpharmaco-logic pain interven­tions (see Chapter 7).

Stimuli increase the severity of the emer­gence reaction.

Quiet promotes com­fort, decreases anxiety.

Reassurance de­creases anxiety.

Suction may be needed in the event of vomiting to pre­vent aspiration.

Ongoing assessment leads to early detec­tion and treatment of potential complica­tions.

Awareness of pain very early in the postop­erative period can be frightening.

Pain can increase blood pressure and increase anxiety.

 

OPIOIDS (AS ADJUNCT)

Fentanyl(Sublimaze)

Excellent postoperative

analgesia Long-acting analgesia

Significant respiratory depression can oc­cur several hours af­ter administration

Cardiovascular depres­sion can occur

Monitor respiratory rate and depth for hy-poventilation.

Monitor blood pressure for hypotension.

Have atropine, nalox-one (Narcan), vaso-pressors, and resuscitative equip­ment nearby.

Ongoing assessment leads to early detec­tion and treatment of potential complica­tions.

Having necessary sup­plies and equipment available provides for prompt response to an emergency.

 For severe reactions during the recovery phase, small doses of diazepam (Valium, Vivol^, Novo-Dipam^) may be given as needed. The medical-surgical nurse continues interventions until the effects of the drug have worn off.

PROPOFOL (DIPRIVAN). Propofol is in a newer classifi­cation of IV anesthetic agents, the alkylphenols. Its short ac­tion makes it desirable as an anesthetic agent. Hypnosis oc­curs in less than 1 minute from the time of injection, and because the drug is so rapidly metabolized, it does not accu­mulate during maintenance of the anesthesia. The client be­comes responsive quickly after the infusion is ended (within 8 minutes). Propofol is also used to supplement nitrous oxide during short procedures and is used as a hypnotic agent with regional anesthesia.

ADJUNCTS TO GENERAL ANESTHETIC AGENTS. Other drugs, such as hypnotics, opioid anal­gesics, and neuromuscular blocking agents, may be used as part of the anesthesia regimen.

HYPNOTICS. The benzodiazepines may be used for vari­ous effects. Common drugs in this classification include mi-dazolam (Versed), lorazepam (Ativan, Novolorazem^), and diazepam (Valium, Vivol***, Novo-Dipam^). All have hyp­notic, sedative, antianxiety, muscle relaxant, and amnesic ef­fects. Generally, lower doses are ordered for preoperative se­dation. Each drug may be used as part of an IV conscious sedation regimen for diagnostic or endoscopic procedures. Higher doses of midazolam may be used to induce general anesthesia. The benzodiazepines may also be used intraoper-atively in conjunction with regional or local anesthesia. Ad­verse reactions include respiratory depression, apnea, and oversedation.

OPIOID ANALGESICS. Common opioid analgesics used to supplement inhalation anesthesia include morphine sulfate (Statex+0, meperidine hydrochloride (Demerol), fentanyl cit­rate (Sublimaze), and sufentanil (Sufenta). The use of opioids during surgery contributes to postoperative analgesia. All opi­oid analgesics are respiratory depressants and decrease alve­olar ventilation. The nurse monitors respirations and main­tains an open airway. Reduced dosages are prescribed for older clients, clients with a circulatory problem (e.g., heart failure), and debilitated clients.

Fentanyl and sufentanil induce analgesia in lower doses, but at higher doses they can be used as the anesthetic agent. Fentanyl has a potency 75 to 125 times greater than that of morphine. Sufentanil has five to seven times the analgesic po­tency of fentanyl and produces a more rapid onset of CNS ef­fects than does fentanyl. It is often used in open heart surgery when the sternum must be opened. The nurse monitors the client who has received sufentanil for bradycardia and de­creased cardiac output.

NEUROMUSCULAR BLOCKING AGENTS. The neuro-muscular blocking agents are used to relax the jaw and vocal cords immediately after induction so that the anesthesiologist or certified registered nurse anesthetist (CRNA) can place the endotracheal (ET) tube. These drugs are also used throughout the surgical procedure to provide continued overall muscle re­laxation. Neuromuscular blocking agents act on the skeletal

muscles of the body by interfering with impulse transmission at the neuromuscular junction. The drugs are administered in­travenously in small amounts and may cause circulatory al­terations, decreased respirations, or apnea from muscle paral­ysis. The nurse ensures the client’s safety by securing him or her on the operating bed with safety straps and assists the anesthesiologist or CRNA with intubation. Throughout the surgery, the anesthesiologist or CRNA checks the effective­ness of the blocking agent by using a peripheral nerve stimu­lator. There are two types of neuromuscular blocking agents: nondepolarizing and depolarizing.

NONDEPOLARIZING BLOCKING AGENTS. The non-depolarizing blocking agents block acetylcholine at the neu­romuscular junction. Only skeletal muscles are blocked, and the drug is easily reversed with an antidote of neostigmine and atropine. Examples of nondepolarizing blocking agents include pancuronium (Pavulon), atracurium (Tracrium), ve-curonium (Norcuron), doxacurium (Nuromax), tubocurarine (Tubarine¹*¹), and mivacurium (Mivacron). Pancuronium has a relatively long effect (45 to 60 minutes) compared with ve-curonium (25 to 30 minutes) or mivacurium (6 to 16 minutes). The longer the duration of drug action, the longer it takes forthe client to recover.

DEPOLARIZING BLOCKING AGENTS. The depolariz­ing blocking agents, also called “noncompetitive” blocking agents, depolarize the motor end plate at the neuromuscular junction. In the process, potassium is forced out of the mus­cle cells and into general circulation, which can cause hyper-kalemia. Clients often experience transient intraoperative muscle twitching, which can result in generalized muscle aches after awakening. Other side effects include increased salivation (increasing the risk for aspiration) and increased in­traocular pressure (thus the agents may be contraindicated with glaucoma). An example of a commonly used depolariz­ing blocking agent is succinylcholine (Anectine). There is no specific antidote for these agents.

BALANCED ANESTHESIA. In the past, the term bal­anced anesthesia was used when various combinations of IV medications were balanced to provide complete anesthe­sia. Today, the term is used to describe a combination of both IV medication and inhalation agents employed to obtain spe­cific effects. Balanced anesthesia provides a safe and con­trolled anesthetic experience, especially for older and high-risk clients. A combination is used to provide hypnosis, amnesia, analgesia, muscle relaxation, and relaxation of re­flexes with minimal disturbance of physiologic function. An example of balanced anesthesia is the use of a barbiturate (such as thiopental) administered intravenously for induc­tion, nitrous oxide administered by inhalation for amnesia, morphine for analgesia, and a muscle relaxant (such as pan­curonium) administered intravenously to provide additional muscle relaxation.

A second example of balanced anesthesia is the use of 70% nitrous oxide for induction and maintenance (to prevent awareness throughout the procedure and to prevent recall af­terward), 30% oxygen to maintain oxygenation saturation at greater than 90%, an opioid, and a muscle relaxant. Many combinations are possible, and selection reflects assessment of the individual client and the specific surgical procedure.

 COMPLICATIONS FROM GENERAL ANESTHE­SIA OR ANESTHESIA MANAGEMENT. Complications can range from minor and annoying (sore throat) to the most severe and irreversible—death. Despite surgical procedures being performed on increasingly sicker and higher-risk clients, however, there has been a significant decline in anes­thesia-related deaths during the last 30 years (Voelker, 1995).

MALIGNANT HYPERTHERMIA. Malignant hyperther-

mia (MH) is an acute, life-threatening complication of gen­eral anesthesia that may be triggered by drugs commonly used in anesthesia. Inhalational anesthetics and succinyl-choline are the most frequently implicated triggering agents. MH is a multifactorial disease and is genetically transmitted as an autosomal dominant trait. The client with a genetic pre­disposition for MH is at risk for this complication from agents such as halothane, enflurane, isoflurane, desflurane, sevoflu-rane, and succinylcholine. Stressors such as severe fatigue, strenuous exercise, trauma or muscle injury, and emotional stress may also trigger this crisis.

This rare but potentially deadly syndrome is most common in children and young adults. A biochemical reaction begins with a defect in skeletal muscle calcium regulation, and ex­posure to specific triggering stimuli results in intracellular hy-percalcemia leading to increased metabolism. This hyperme-tabolic condition results in an increase in the circulating calcium level, an increase in the metabolic rate, hyper-kalemia, metabolic and respiratory acidosis, cardiac dys-rhythmias, and rapid elevation of the body temperature.

Onset of MH may occur immediately after induction of anesthesia, several hours into the procedure, or rarely, once the anesthetic has been terminated. Clinical features reflect the increased intracellular muscle calcium concentration and the greatly increased body metabolism. Common manifesta­tions include tachycardia or other dysrhythmias; muscle rigid­ity (apparent in 75% of all MH cases), especially of the jaw and upper chest; hypotension; tachypnea; and skin mottling, cyanosis, and myoglobinuria (cola-colored urine). The most sensitive indication is an unexpected rise in the end-tidal car­bon dioxide level with a decrease in oxygen saturation (Dunn, 1997). The second indication may be unexplained sinus tachycardia. Extremely elevated temperature, perhaps as high as 111.2° F (44° C), is a late sign ofMH. Treatment and sur­vival of the client depend on early diagnosis and the coopera­tion of the entire surgical team. Time is crucial when MH is diagnosed. Dantrolene sodium, a skeletal muscle relaxant, is the medication of choice along with other interventions.

Once a client or family history of MH is known, close fam­ily members can undergo a muscle biopsy to determine whether they are at risk. In the case of a known history or pre­determination, the client can be treated preoperatively, intra-operatively, and postoperatively with dantrolene to prevent this complication. Chart 18-1summarizes best practices for care of the client with malignant hyperthermia.

OVERDOSE. An anesthesia overdose can occur if the client’s metabolism and drag elimination do not react or re­spond as expected. Drugs (e.g., antihypertensive medications) also alter anesthesia metabolism, and drug interactions can occur between the anesthetic agents and other regularly ad­ministered medications. Accurate, accessible information about the client, such as height, weight, and history, is vital in

BEST PRACTICE/or

Care of the Client with Malignant Hyperthermia

Stop all inhalation anesthetic agents and succinylcholine.

If an endotracheal (ET) tube is not already in place, intubate

immediately.

Ventilate the client with 100% oxygen, using the highest

possible flow rate.

Administer dantrolene sodium (Dantrium) intravenously at a

dose of 2 to 3 mg/kg.

If possible, terminate surgery. If termination is not possible,

continue surgery using anesthetic agents that do not trigger

malignant hyperthermia (MH).

Assess arterial blood gases (ABGs) and serum chemistries

for metabolic acidosis and hyperkalemia.

If metabolic acidosis is evident by ABG analysis, administer sodium bicarbonate intravenously.

If hyperkalemia is present, administer 10 units of insulin in

50 mL of 20% dextrose intravenously. Use active cooling techniques.

Administer iced saline (0.9% NaCI) intravenously at a rate of 15 mL/kg every 15 minutes for three doses.

Apply a cooling blanket over the torso.

Wrap or rub extremities with  cold,  wet towels or ice wrapped in towels.

determining the anesthetic type and dosage. Intraoperative death, however, is more often related to pre-existing health problems than to overdose of anesthetics.

UNRECOGNIZED HYPOVENTILATION. The respiratory system is most frequently involved when the client experi­ences an anesthesia-induced complication. Failure to ventilate adequately can lead to cardiac arrest, central nervous system (CNS) damage (e.g., permanent brain damage), and death. Monitoring standards include the use of an end-tidal carbon dioxide monitor to confirm carbon dioxide in the client’s ex-

(Novocain) Tetracaine

(Pontocaine) Lidocaine

(Xylocaine) Mepivacaine

(Carbocaine,

Polocaine) Bupivacaine

(Marcaine,

Sensorcaine)

Easily administered Rapid onset (4-17 min) Can be administered

topically or by

injection

Excellent muscle relax­ant effects Protective reflexes

(cough, gag) remain

intact Client does not lose

consciousness Many are available with

epinephrine added

Absorbs into the blood­stream

Can cause cardiac de­pression and dys-rhythmias with ab­sorption

Difficult to control dosage

Drug interactions with monoamine oxidase (MAO) inhibitors can cause hypertension

Tremors, twitching shiv­ering, respiratory ar­rest can occur with absorption

Assess for return of movement and sensa­tion in the area anes­thetized.

Monitor blood pressure and pulse.

Assess administration site for pallor, drainage.

Protect area anes­thetized until full sen­sation has returned.

Movement returns first,

then sense of touch,

pain, warmth, and cold,

in that order. Ongoing assessment

leads to early detection

and treatment

of potential

complications. Protection prevents injury

to the area. Duration of the anesthetic

is 3-6 hr.

 

pired gas and a breathing system disconnect monitor to detect any break in the breathing circuit equipment.

COMPLICATIONS RELATED TO SPECIFIC ANES­THETIC AGENTS. Specific complications are discussed earlier in the chapter. The older or debilitated client may be more susceptible to complications of anesthesia because of intolerance to the agent, decreased metabolism, or his or her general physical condition. (For preoperative risk factors, see Chapter 17.)

COMPLICATIONS OF INTUBATION. Many complica­tions can occur from intubation (e.g., broken or injured teeth and caps, swollen lip, or vocal cord trauma). Intubation may be difficult because of the individual anatomy or disease process (e.g., small oral cavity, tight mandibular joint, or pres­ence of tumor). Improper extension of the neck during intu­bation also may cause injury. The surgeon should be in the op­erating room (OR) during the intubation process in case an emergency arises (e.g., a tracheostomy is needed) when the endotracheal (ET) tube is placed. Placement of the ET tube causes some degree of irritation and edema of the trachea and accounts for the client’s sore throat postoperatively.

■   LOCAL OR REGIONAL ANESTHESIA

Local or regional anesthesia temporarily interrupts the trans­mission of sensory nerve impulses from a specific area or re­gion. Motor function may or may not be affected, and the client does not lose consciousness. Thus the client is able to follow instructions throughout the procedure. Because the gag and cough reflexes remain intact, there is little risk of aspira­tion or complications from hypoventilation. Local or regional anesthesia is typically supplemented with sedatives, opioid analgesics, and/or hypnotics to reduce anxiety and increase comfort.

The OR nurse provides the client with information, direc­tions, and emotional support before, during, and after the pro­cedure. Table 18-5 describes various local and regional anes­thetic agents and related nursing implications.

LOCAL ANESTHESIA. Techniques used to administer local anesthesia include topical anesthesia and local infiltra-

tion. Sometimes when the term local is used, it means any form of anesthesia that is not general anesthesia.

TOPICAL ANESTHESIA. Topical anesthesia involves use of an anesthetic agent applied directly to the surface of the area to be anesthetized. Often the anesthetic is an ointment or spray. This method is often used for respiratory intubation and for diagnostic procedures, such as laryngoscopy, bron-choscopy, or cystoscopy. The onset of action is 1 minute, and the duration is 20 to 30 minutes. Collapse or depression of the cardiovascular system is a potential complication of topicalanesthetic agents applied to the respiratory tract.

LOCAL INFILTRATION. Local infiltration is the injec­tion of an anesthetic agent intracutaneously and subcuta-neously into the tissue surrounding an incision, wound, or le­sion. The anesthetic agent blocks peripheral nerve stimulation at its origin. Local infiltration is commonly used during the suturing of superficial lacerations.

REGIONAL ANESTHESIA. Regional anesthesia, a type of local anesthesia, may be used as follows:

• When general anesthesia is contraindicated because of
the presence of medical problems (e.g., dysrhythmias
and respiratory disease)

« When the client has experienced previous adverse reac­tions to general anesthesia

•  When the client has a preference and a choice is possible

•  When pain management postoperatively is enhanced by
regional anesthesia

If the client has eaten and the surgery is an emergency, it may be possible to perform the procedure with the client un­der regional anesthesia (depending on the procedure) to de­crease the risks associated with gastric contents (e.g., aspira­tion). Types of regional anesthesia include field block, nerve block, spinal, and epidural.

FIELD BLOCK. A field block is produced by a series of injections around the operative field. Injecting around a spe­cific nerve or group of nerves depresses the entire sensory nervous system of a localized area. This type of blocking is used for thoracic procedures, herniorrhaphy (hernia repair), dental procedures, and plastic surgery.

 

I Cervical plexus—C-1, -2, -3, -4  (between jaw and clavicle) Brachial plexus—C-5, -6, -7, -8, T-1(upper arm)

Radial nerveMedial nerve Ulnar nerve

Intercostal nerves (chest and abdominal wall)

(Elbow,

wrist,

hands,

and

fingers)

Figure 18-1О    •   Nerve block sites.

NERVE BLOCK. A nerve block is achieved by injection of the local anesthetic agent into or around a nerve or group of nerves supplying the involved area. Nerve blocks inter­rupt sensory, motor, and sympathetic transmission. They are used surgically to prevent pain during a procedure, diagnos-tically to identify the cause of pain, and therapeutically to relieve chronic pain and increase circulation in some vascu­lar diseases.

Figure 18-10 shows commoerve block sites. Lido-caine (Xylocaine) or bupivacaine (Marcaine) is frequently the agent used. A nerve block takes effect within minutes after the injection, and the anesthesia lasts longer than that achieved with local infiltration. Epinephrine added to the anesthetic agent potentates the drug, causing a prolonged effect. Seizures, cardiac depression, dysrhythmias, and/or respiratory depression may occur if the nerve-blocking agent is injected accidentally into the bloodstream. The nurse observes for signs of systemic absorption, sensitivity, or overdose.

SPINAL ANESTHESIA. Spinal anesthesia—intrathecal block—is achieved by injection of the anesthetic agent into the cerebrospinal fluid in the subarachnoid space (Figure 18-11). The drug acts on the nerves as they emerge from the spinal cord and before they leave the spinal canal, thereby inhibiting conduction in the autonomic, sensory, and motor systems. The drag is rapidly absorbed into the nerve fibers and produces analgesia with relaxation, which is effective for lower abdom­inal and pelvic surgical procedures.

EPIDURAL ANESTHESIA. The anesthetic agent is in­jected into the epidural space so that the protective coverings of the spinal cord (dura mater and arachnoid mater) are never entered. Because the anesthetic can diffuse or float up the ver­tebral column, the client can achieve anesthetic effects as high as the T4 level; however, potential respiratory complications may make injection at this high a level undesirable.

Epidural anesthesia is used for anorectal, vaginal, and per-ineal procedures, as well as for hip and lower extremity oper-ations, such as total hip or knee replacements. Two important advantages are associated with this type of anesthesia:

•  Decreased cardiopulmonary complications,  which is
particularly important for the older client

•  Ability to retain the epidural catheter for postoperative
analgesic administration (see Chapter 7)

COMPLICATIONS OF LOCAL OR REGIONAL ANESTHESIA. Major intraoperative complications of local or regional anesthesia are usually related to client sensitization to the anesthetic agent (anaphylaxis), incorrect administration technique, systemic absorption, or overdosage. The nurse ob­serves for signs of a systemic toxic reaction, manifested by central nervous system (CNS) stimulation followed by CNS and cardiovascular depression. The nurse assesses for initial behaviors indicating a problem, such as restlessness, excite­ment, incoherent speech, headache, blurred vision, metallic taste, nausea, vomiting, tremors, seizures, and increased pulse, respirations, and blood pressure. Nursing interventions include establishing and maintaining an open airway, administering oxygen, and notifying the surgeon. Usually it is necessary to administer a fast-acting and short-acting barbiturate. If the client’s toxic reaction remains untreated, unconsciousness, hy­potension, apnea, cardiac arrest, and death may result.

A cardiac arrest may occur as a rare complication of spinal anesthesia, possibly related to unknown autonomic nervous system effects. Administration of epinephrine to a client who develops sudden, unexplained bradycardia may prevent car­diac arrest (Biddle, 1994).

Local complications include edema and inflammation, as early problems, with possible abscess, necrosis, and/or gangrene later. Inflammation and abscess usually result from a break in sterile technique occurring at the time of injection of the anes­thetic agent. Necrosis and gangrene are rare but may occur as a result of prolonged vasoconstriction in the area of the injection.

The nurse’s role in the administration of regional anesthe­sia consists of the following:

•  Assisting the anesthesia provider

 • Administration of spinal and epidural anesthesia. A, Spinal or epidural anesthesia is administered by inserting a spinal nee­dle between the second and third or the third and fourth lumbar vertebrae (L2-3 or L3-4). The client is placed in the flexed lateral (fetal) position (shown here) or seated on the edge of the operating bed with the back arched and the chin tucked to the chest. B, Spinal anesthesia (viewed from the side). A large needle is inserted to the surface of the dura mater, and a second, smaller needle is passed through the first to penetrate the dura mater and arachnoid mater. An anesthetic in injected, sometimes through an indwelling catheter, directly into the cerebrospinal fluid in the sub-arachnoid space. C, Epidural anesthesia (viewed from the side). The nee­dle is inserted to the surface of the dura mater, and the anesthetic is in­jected, usually through an indwelling catheter, into the epidural space.

Observing for breaks in sterile technique in which the client has a depressed level of consciousness but retains the ability to independently maintain a patent airway and respond appropriately to verbal commands or physical stimulation. A rapid, safe return to activities of daily living is usually achieved with some degree of amnesia with conscious sedation. Diazepam (Valium, Vivol⁴*, Novo-Dipam^), mida-zolam (Versed), meperidine (Demerol), fentanyl (Sublimaze), alfentanil (Alfenta), and morphine sulfate are the most com­monly used drugs. Conscious sedation is typically used for procedures such as endoscopy, cardiac catheterization, closed fracture reduction, percutaneous transluminal cardiac angiog-raphy (PTCA), cardioversion, and other special but relatively short procedures.

Selection of clients for conscious sedation is based on es­tablished criteria developed by an interdisciplinary team. The physician determines whether the client is a candidate. In most states, a credentialed registered nurse may administer conscious sedation under physician supervision and within the state-defined scope of nursing practice (Bryan, 1997). Recommended credentialing includes advanced training in IV medication administration, airway management, and ad­vanced cardiac life support (ACLS) (Landrum, 1997).

The nurse monitors the client during and after the proce­dure for his or her response to the procedure and drag admin­istration. Specific responsibilities include careful monitoring of the client’s airway, level of consciousness, oxygen satura­tion via pulse oximetry, electrocardiographic (ECG) status, and vital signs every 15 to30 minutes until he or she is fully awake, alert, and oriented, and vital signs have returned to preprocedural levels.

The client receiving IV conscious sedation may be dis­charged to go home with a responsible adult. If the client re­turns to the general medical-surgical nursing unit, the unit staff nurses continue to monitor him or her. The client is expected to be sleepy but arousable for several hours after the procedure. The nurse usually does not permit oral intake until 30 minutes after the client has received medication or according to the physician’s orders. When fluids are permitted, the nurse makes sure that the client is awake and positioned to avoid aspiration.

HISTORY

On arrival in the surgical suite, the client is taken to the hold­ing area or directly into the operating suite. The holding area nurse and/or the circulating nurse greets the client on arrival. Correct identification of the client is the responsibility of every member of the health care team. The nurse verifies the client’s identity with his or her identification bracelet and asks, “What is your name?” This practice prevents errors that may occur. For example, if a client is asked, “Are you Mr. James?” He may respond inappropriately if he is drowsy, anx­ious, or sedated. The nurse always validates the identification obtained using the medical record and the client’s name andidentificatioumber.

After completing the identification process, the nurse vali­dates that the surgical consent form has been signed and wit­nessed. The nurse asks the client, “What kind of operation are you having today?” to ascertain that his or her perception of the procedure, the operative permit, and the operative sched­ule coincide. This practice is especially important when the nurse is validating the side on which a procedure is to be per­formed (e.g., for amputation, cataract extraction, or hernia re­pair). Some facilities have the client and/or nurse initial the appropriate surgical site. Before proceeding, the nurse thor­oughly investigates any discrepancy in information and noti­fies the surgeon and anesthesia provider.

The nurse asks the client about any allergies and deter­mines if any autologous blood was donated. A red allergy bracelet on the client’s wrist and the medical record must be verified with what has been communicated.

The nurse checks the client’s attire to ensure compliance with facility policy. Dentures and dental prostheses (e.g., bridges and retainers), jewelry, eyeglasses, contact lenses, hearing aids, wigs, and other prostheses are removed for safety during surgery. The nurse pays special attention to the removal of dentures, because the denture plate could become loose and obstruct the airway during surgery. Occasionally the anesthesiology team may request that the dentures be left in place to ensure a snug fit of the anesthesia mask. In some facilities, clients may be permitted to retain their eyeglasses and hearing aids until after the induction phase of anesthesia.

■   MEDICAL RECORD REVIEW

The circulating nurse and anesthesia personnel review the client’s medical record in the holding area (or in the operating room [OR] if there is no holding area). The medical record provides informatioeeded to identify potential and actual needs of the client during the intraoperative period and allows the circulating nurse to assess and plan for his or her needs during and after surgery. The medical record is a primary source of information on the type and location of the planned surgical procedure. A check of the medical record ensures that all required data are present before the procedure is started.

ADVANCE DIRECTIVES AND DO-NOT-RESUS-CITATE ORDERS. The perioperative nurse is subject to ethical dilemmas in the surgical environment. As a client ad­vocate, the perioperative nurse may have to intervene on be­half of the client’s rights and wishes. The perioperative nurse must be familiar with the advance directives and do-not-resuscitate (DNR) orders for each client.

The 1990 Patient Self-Determination Act requires health care providers to ask clients if they have advance directives. These directives are to be honored in the surgical environment regard­less of the situation. It is difficult for some health care providers not to treat the client in the OR for an emergency situation, and they ignore advance directive or living will. In addition, it is a common practice to suspend DNR orders while a client is un­dergoing a surgical procedure. The position statement of AORN, the Association of periOperative Registered Nurses, regarding the perioperative care of clients with DNR orders states that au­tomatically suspending a DNR order during surgery undermines a client’s right to self-determination (AORN, 1999b). Many in­stitutions are addressing this issue along with advance directives in a way that protects the client’s rights in all environments.

ALLERGIES AND PREVIOUS REACTIONS TO ANESTHESIA OR TRANSFUSIONS. In reviewing the medical record, the nurse asks about allergies and previous re­actions to anesthesia or blood transfusions. Allergies or sensi­tivity to iodine products or shellfish may indicate the poten­tial for a reaction to the antimicrobial agents used to clean the

Intraoperative Autologous Blood Salvage and Transfusion

Be aware of the cell-processing method to be used.

Make sure that collection containers are labeled for the client.

Assist with sterile setup as necessary.

Assist with processing and reinfusing procedures as needed.

Document the transfusion process.

Monitor the client’s vital signs during the transfusion

procedure.

surgical area. Latex allergies or sensitivities must be assessed with all clients. Induced anaphylaxis accounts for about 10% of the life-threatening anaphylactic reactions that occur dur­ing surgery (see Chapters 20 and 23). Latex-free equipment and supplies must be used when allergies, sensitivity, or a fa­milial history of latex allergy exists and poses a potential risk to the client. The nurse clearly indicates the allergies in the medical record and notifies the OR team.

The client’s previous experience with anesthesia helps the nurse and anesthesia provider plan and anticipate needs. For example, if a client is restless or agitated as a reaction to anes­thesia, the nurse can have padding for the stretcher siderails and protective restraints available. The use of blood and blood products during surgery may be influenced by the client’s his­tory, religious beliefs or preferences, and type of transfusion reaction in the past.

AUTOLOGOUS BLOOD TRANSFUSION. Increas­ingly, autologous blood transfusion (reinfusing the client’s own blood) is being used for surgery. This method of blood transfusion eliminates the risk of acquiring bloodborne infec­tions, such as hepatitis В and human immunodeficiency virus (HIV), from another person. Chapters 17 and 40 discuss autolo­gous blood transfusion in more detail, and Chart 18-2 outlines best practices for intraoperative autologous blood transfusion.

LABORATORY AND DIAGNOSTIC TEST RE­SULTS. The OR nurse assesses the most recent preoperative laboratory and diagnostic test results to inform the surgical team about the client’s medical condition and to alert them to poten­tial intraoperative and postoperative interventions. The most re­cent results are usually obtained within 24 to 28 hours before surgery for hospitalized clients and within 4 weeks for ambula­tory surgery clients. The nurse reports all abnormalities to thesurgeon and anesthesia provider. Laboratory values significantly greater than or less than the normal range are potentially life threatening for any client, but are especially so for the client un­dergoing surgery (see Chapter 17). For example, if the hemo­globin concentration is less than 10 g/dL, oxygen transport ca­pacity is reduced, affecting the amount and type of anesthesia used as well as the potential impact of blood loss during surgery.

MEDICAL HISTORY AND PHYSICAL EXAMINA­TION FINDINGS. The OR nurse checks that the medical history and examination findings, including usual pulse and blood pressure, are recorded. This information provides the circulating nurse, surgeon, anesthesia provider, and postanes-thesia care unit (PACU) nurse with baseline data to assess the client’s reaction to the surgical procedure and anesthesia. Medications the client has routinely taken preoperatively may affect the reaction to surgery and wound healing.

A common collaborative problem for the intraoperative client is Potential for Hypoventilation.

Allow clients to retain eyeglasses and hearing aids until

anesthesia has been administered.

Use a small pillow under the client’s head if his or her

head and neck are normally bent slightly forward.

Lift clients into position to prevent shearing forces on

fragile skin.

Position arthritic and artificial joints carefully to prevent

postoperative pain and discomfort from strain on those

joints.

Pad bony prominences to prevent pressure sores.

Provide extra padding for those clients with decreased

peripheral circulation.

Use head caps to prevent heat loss through the scalp.

Place stockinette on extremities to conserve body heat.

Warm prepping solutions and IV and irrigation fluids as

indicated.

Follow strict aseptic technique.

Carefully monitor intake and output, including blood loss.

pie, aspirin has an anticoagulant effect and can cause in­creased clotting time and danger of hemorrhage.

Knowing the client’s medical history and age (Chart 18-3) al­lows the nurse to take special precautions and plan appropriate interventions for the care and safety of high-risk clients. The nurse carefully monitors older clients and those with cardiac dis­ease for potential fluid overload, which can be life threatening.

After completing the medical record review, the nurse may insert an IV catheter and perform a surgical shave. The circu­lating nurse provides additional emotional support and explains procedures to the client. The client is never left unattended. If the client is in the holding area, he or she is transferred to the OR after the preoperative routine is completed.

«*> CRITICAL THINKING CHALLENGE

vs: The client, a 69-year-old retired homemaker, has en­tered the surgical suite. The OR schedule lists that she is scheduled for a left total knee arthroplasty (total knee re­placement). As the anesthesiologist is inserting the client’s IV line, the client is questioned about which knee is being re­placed. As the perioperative nurse, you overhear her answer, “I think it is my right knee, but both of them hurt and need to be replaced. I don’t care which knee they do today.”

•  What should you do with the information?

•  What steps do you take to ensure that the correct knee is
operated on?

•  Does it matter if the wrong knee is operated on first, since
according to the client both knees need to be replaced?

•  How do you prevent this situation from occurring again?

http://www.wbsaunders.com/SIMON/lggy/.

Ш Analysis

W.   COMMON NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS

The following are commoursing diagnoses for intraopera­tive clients:

1.    Risk for Perioperative Positioning Injury related to im­
mobilization and effects of anesthesia

2. Impaired Skin Integrity and Impaired Tissue Integrity
related to the surgical incision

■ ADDITIONAL NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS

In addition to the common nursing diagnoses and collabora­tive problems, intraoperative clients may have one or more of the following:

•  Risk for Infection related to a break in skin integrity (i.e.,
incision, invasive lines)

•  Risk for Injury related to fire and electrical hazards
within the operating environment

•  Risk for Disuse Syndrome related to a decreased level of
consciousness or to immobilization

•  Hypothermia related to evaporation from skin and ex­
posed tissue in a cool environment, body heat loss, alter­
ation in the hypothalamus from anesthetic agents, inade­
quate body covering, or aging

•  Ineffective Thermoregulation related to sedation, fluctu­
ating environmental temperature, medications, or age
extremes

•  Fear related to the threat of death, actual or perceived, or
to anticipation of events posing a threat to self-esteem

•  Anxiety related to loss of control or the threat of death

•  Deficient Fluid Volume related to decreased intake,
evaporative fluid loss through the skin and exposed tis­
sue, or blood loss

•  Potential for Peripheral Neurovascular Dysfunction re­
lated to intraoperative positioning

ii Planning and Implementation

В RISK FOR PERIOPERATIVE POSITIONING

INJURY

PLANNING: EXPECTED OUTCOMES. The intra­operative client is expected to be free of injury.

INTERVENTIONS. Interventions are directed toward preventing injury resulting from intraoperative positioning. Because of preoperative medication, anesthetic agents, and the narrowness of the bed, the client’s normal defense mech­anisms cannot guard against nerve or joint damage and mus­cle stretch and strain. Proper positioning, therefore, is impor­tant. In addition, the incidence of pressure ulcer formation is greater in the postoperative client population than for those hospitalized clients who do not undergo surgery. The circu­lating nurse pads the operating bed with foam and/or silicone gel pads, properly places the grounding pads, coordinates the transfer to the operating bed, and helps th°- client obtain a comfortable position. The circulating nurse assesses the skin, especially of older clients, for bruising or injury, placing ex­tra padding as indicated. A newer product designed to reduce pressure injury in the operating room (OR) is a mattress over­lay made of urethane foam having a 25% indentation load de­flection (ILD) of 30 pounds. The effectiveness of this device in preventing pressure ulcers during surgery is not consistent (see the Evidence-Based Practice for Nursing box on p. 280).

The client is usually in a dorsal recumbent (supine) posi­tion after transfer to the operating bed. Anesthesia may be administered with the client supine, and he or she may be repositioned for surgery. When general anesthesia is used, the nurse assists with repositioning (Figure 18-12).

This large, prospective, experimental study sought to determine whether an operating bed mattress overlay, made of foam with a 25% indentation load deflection (ILD) of 30 pounds and a den­sity of 1.3, could reduce the incidence of pressure ulcer forma­tion in surgical clients. A total of 413 surgical clients were ran­domized to a control (standard care) group or a treatment (mattress overlay) group during routine surgical procedures. The groups were highly homogeneous for N (control = 207; experi­mental = 206), mean age (~65 years), gender, surgical proce­dure, admission Braden Scale scores, body mass, operating room (OR) time, and the coexisting condition of diabetes. The time of first position change after surgery was recorded. All clients were examined for evidence of skin changes on postop­erative days 1 through 6 by two research assistants blinded to the study groups. The research assistants received special train­ing in use of the Braden Scale, and interrater reliability was set initially at 0.90 and re-established midway through the study.

The results showed that the incidence of early-stage pres­sure ulcers was not decreased by use of the mattress overlay. The incidence of pressure ulcers in the population studied was consistent with that found by other investigators; however, sub­jects in the study overall had less severe pressure ulcers than those in other studies of surgical clients. More severe pressure ulcers were correlated with greater age, the presence of dia­betes, smaller body mass, and the use of the mattress overlay.

Critique. The study was well designed and implemented. Subjects were homogeneous and accrued from one setting, limiting the generalizability of the results. Pressure, as a vari­able, was not measured directly.

Implications for Nursing. Initially, it would seem that in­creased padding with the use of a mattress overlay would bet­ter protect clients from pressure ulcer development during surgical procedures when position cannot be changed. This study exemplifies the need to test all devices for effectiveness before changing standard procedures.

The circulating nurse coordinates repositioning of the client for surgery and modifies the position according to the client’s safety and special needs. Factors influencing the tim­ing of repositioning include the following:

• The surgical site

The age and size of the client

The anesthetic administration technique

•  Pain experienced by the conscious client on movement
Factors influencing the actual position include the following:

•  The specific procedure being performed

•  The surgeon’s request

•  The client’s age, size, and weight

Any respiratory, skeletal, or neuromuscular limitations, such

as rheumatoid arthritis, joint replacements, or emphysema Table 18-6 presents possible complications related to pro­longed surgical immobility and preventive nursing actions.

The dorsal recumbent, prone, lithotomy, and lateral posi­tions are commonly used for surgery. Figure 18-12 illustrates common surgical positions and the use of protective padding. When general anesthesia is used, the nurse positions the client slowly to prevent blood vessel dilation that may produce hy­potension. The nurse ensures proper positioning by assessing for the following:

Physiologic alignment

Minimal interference with circulation and respiration

•  Protection of skeletal and neuromuscular structures

•  Optimal exposure of the operative site and IV line

•  Adequate access to the client for the anesthesia provider

•  The client’s comfort and safety
Preservation of the client’s dignity

The nurse must be aware of potential complications related to specific positions and modify care as indicated. For exam­ple, clients in the lithotomy position may develop leg swelling, pain in the legs or back, and diminished sensation or pulses. The nurse ensures proper padding and position changes at reg­ular intervals. Throughout the intraoperative period, the nurse assists in preventing obstruction of circulation, respiratory ef­forts, or nerve impulse conduction caused by tight straps, im­properly placed pads and pillows, or the position of the bed.

 CRITICAL THINKING CHALLENGE

 The 69-year-old client about to have knee replacement surgery is brought into the OR. She weighs 96 pounds and has type 2 diabetes.

•  What areas on this client are most likely to be injured as a
result of poor positioning or inadequate padding?

•  In what position should you place this client for a left knee
replacement?

For suggested answer guidelines, go to ”;£ц*№ http://www.wbsaunders.com/SIMON/lggy/.

I.   IMPAIRED SKIN INTEGRITY AND IMPAIRED TISSUE INTEGRITY

PLANNING: EXPECTED OUTCOMES. The intra­operative client is expected to experience minimal skin and tissue impairment and contamination as a result of surgery.

INTERVENTIONS. Surgery is an invasive procedure that places the client at risk for complications related to the surgical wound (such as incisional tears and lacerations), bac­terial contamination, and loss of body fluids from the wound during and after surgery. Sterile surgical technique and the use of protective drapes, skin closures, and dressings help to minimize complications and promote wound healing.

PLASTIC ADHESIVE DRAPE. If a sterile plastic adhesive drape is used, the scrub nurse helps the surgical assistant ap­ply the drape after the surgical site has been cleaned and dried. The plastic drape is applied directly to the client’s skin to prevent shifting and exposure of skin edges. The surgeon makes the incision through the plastic drape. The cut edge sticks to the skin and keeps the surgical incision sealed from the movement of bacteria into the wound. The scrub nurse and surgical assistant gently remove the drape after closure of the surgical incision. The nurse pays special attention to older clients and those with fragile skin to prevent skin tearing when the adhesive drape is removed.

SKIN CLOSURES. Skin and tissue closures, such as su­tures and staples, are used to:

•  Approximate wound edges until wound healing is
complete

•  Occlude blood vessels, preventing hemorrhage and fluid
loss

•  Prevent wound contamination

•   

 

Lithotomy

Supin

Trendelenburg

Jacknife

 

 

 

Interrupted sutures

Continuous sutures (interlocking stitch)

Staples

 

Tapes

Retention bridge Figure 18-13    •    Common skin closures.

 

may be used to close the deep layers of an abdominal wound; 11-0 is the smallest-diameter suture and is used in plastic sur­gery and eye surgery. Other characteristics of the suture ma­terial, such as type (e.g., nylon, silk, Vicryl), color (e.g., green, blue, black, white, violet), and structure (e.g., twisted, braided), are listed on the package.

Suture material can be absorbable or nonabsorbable. Ab-sorbable sutures are digested over time by body enzymes. These sutures first lose strength and then gradually disappear from the tissue. Catgut suture, such as “plain gut” and “chromic gut,” is a type of natural absorbable suture material still in use today, although not as frequently as in the past. Other absorbable sutures are made of synthetic materials. The client’s physical status, the presence of inflammation, and the type of suture used all influence the time for absorption, which is usually up to about 2 weeks.

Nonabsorbable sutures become encapsulated in the tissue during the healing process and remain embedded in the tissue unless they are removed. These sutures are made of silk, cot­ton, steel, nylon, polyester, or other synthetic material. Body enzymes do not affect nonabsorbable sutures. Nonabsorbable sutures are used for vascular anastomosis, “wiring” the ster­num together after open heart surgery, and closing external wounds. The surgeon may use a double or interlocking stitch to increase the integrity of the closure. Retention (stay) sutures (see Figure 18-13) may be used in addition to standard suture material for clients at high risk for impaired wound healing (those having major abdominal surgery, obese clients, clients with diabetes, and clients taking steroids, which inhibit wound healing).

After the incision is closed, the physician may inject a lo­cal anesthetic or instill an antibiotic into the wound. A gauze or spray dressing may be applied to protect it from contami­nation. A variety of dressings may also be used to absorb drainage and provide support to the incision. A pressure dressing may be applied to prevent or stop a vascular area from bleeding postoperatively. One or more drains (see Chap­ter 19) may be inserted to prevent the accumulation of secre­tions and fluids within tissues around the surgical area. These secretions, if not drained, slow healing and promote bacterial growth, which could result in wound infection.

After the dressing is secure, the nurse coordinates the sur­gical team in repositioning and transfer. A roller board or a lift sheet is used for safe transfer from the operating bed to a stretcher or bed. Some clients are able to move themselves back over to the stretcher. The circulating nurse and anesthe­sia provider accompany the client to the postanesthesia care unit (PACU) and give a report of the client’s intraoperative ex­perience to the PACU nurse (see Chapter 19).

■ POTENTIAL FOR HYPOVENTILATION

PLANNING: EXPECTED OUTCOMES. The intraop­erative client is expected to be free of damaging events related to hypoventilation.

INTERVENTIONS. Interventions are directed toward preventing injury resulting from anesthesia (see earlier discus­sion). The nurse, physician, and anesthesia provider monitor the client according to official standards. These standards,

which have been adopted by both the American Society of Anesthesiologists and the American Association of Nurse Anesthetists, include continuous monitoring of ventilation, circulation, and cardiac rhythms; blood pressure and heart rate recordings every 5 minutes; and the continuous presence of an anesthesiology practitioner during the case (Biddle, 1994).

Evaluation: Outcomes

Ml The nurse evaluates the care of the intraoperative client on the basis of the identified nursing diagnoses and collaborative problems. The expected outcomes are that the client:

•  Is safely anesthetized without complications

•  Does not experience any injury related to intraoperative
positioning or equipment

•  Is free of skin or tissue contamination during surgery

•  Is free of skin tears, bruises, redness, abrasion, or mac­
eration over pressure points and elsewhere

 

ONLINE RESOURCES:

http://intranet.tdmu.edu.ua/data/kafedra/video/ims/ADN/second%20course/Adult%20Health%20I/index.php?name_film=Preoperative%20nursing%20care%20-%2012