Download LWW PPT Slide Template Master

Chapter 13:
The Postanesthesia Patient
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Differences Between Sedation Levels
Moderate Sedation
Monitored Anesthesia
Care
• More responsive to
verbal or tactile
stimulation
• Responsive only to
deep stimulation
• Maintains airway on
own
• Able to breathe on
own
• May need an artificial
airway placed
• May need assistance
with breathing
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Anesthetic Options for Surgery
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Medication Choices for Anesthetic Options
See Figure 13-1.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Which of the following is expected in a patient under
moderate sedation?
A. Impaired coordination
B. Protective reflexes intact
C. Response to purposeful or painful stimuli
D. Loss of consciousness
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
B. Protective reflexes intact
Rationale: A client under moderate sedation responds
purposefully to verbal commands and has protective
reflexes intact. The client can manage his or her own
airway. Impaired coordination is seen with a client
under mild sedation. A client under deep sedation
responds only to purposeful or painful stimuli. A client
under general anesthesia has a loss of consciousness.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Anesthesia Provider-to-Nurse Report:
Information to Convey
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Oxygenation/Ventilation Care
Assessment
• Assess for clinical
signs of hypoxia or
hypoventilation
• Assess weaning
parameters before
extubation from
mechanical ventilation
Interventions
• “Stir-up” regimen
• Head of bed elevated,
unless contraindicated
• Position head in
neutral position
• Protect airway from
aspiration
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Circulation/Perfusion Care
Assessment
Compare baseline with
postop values in the
following areas:
• ECG rhythm, rate
• BP, heart rate
• Peripheral vascularsensory checks
• Estimated blood loss
Interventions
• Monitor VS and
ECG/protocol
• Monitor peripheral
vascular-sensory
checks
• Assess I&O
• Assess estimated
blood loss and Hgb/Hct
(assess wounds)
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Fluid/Electrolyte Balance
Hypervolemia
• Elevated blood
pressure
Hypovolemia
• Low blood pressure,
tachycardia
• Pulmonary crackles
• Neck vein distention
• Increased urine
specific gravity (if
measured)
• Decreased urine
specific gravity (if
measured)
• Decreased skin turgor,
dry mucous
membranes
• Potential for
electrolyte imbalance
• Potential for
electrolyte imbalance
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Mobility/Safety for the Postanesthesia
Patient
•
Assess level of consciousness
•
Reorient to surroundings and events
•
Maintain safety measures with bed and equipment
•
Assess motor/sensory function to determine whether
the neuromuscular blockade is wearing off
•
Assess level of local anesthesia, if used
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Skin Integrity Care for the Postanesthesia
Patient
•
Assess for skin breakdown
•
Protect skin from pressure, moisture, and shearing
forces
•
Reposition as soon as possible, considering any
limitations in positioning
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nutrition for the Postanesthesia Patient
•
Assess for nausea and treat with antiemetics
•
Assess for bowel sounds
•
Provide fluids once airway is patent and no risk of
aspiration
•
Provide enteral feeding once bowel sounds return
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Comfort/Pain Control for the
Postanesthesia Patient
•
Assess pain and treat with pharmacological and nonpharmacological interventions
•
Monitor epidural analgesia
–
Observe site of insertion and dressing for patency
–
Observe pain level, respiratory rate, BP, level of
consciousness, and sensation
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Psychosocial Care for the Postanesthesia
Patient
•
Include the patient’s support system as soon as possible
(as the patient has predetermined to be appropriate)
•
Explain the care being provided and the reasons on an
ongoing basis to the patient/support system
•
Assess for patient/support person understanding and
clarify any areas of misunderstanding
•
Get referrals to social service, clergy, etc. as needed
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Teaching/Discharge Planning for the
Postanesthesia Patient
•
Instruct patient’s support system on reason for
orientation and how to provide it
•
Instruct on proper use of incentive spirometer and
splinting when coughing
•
Instruct on mobility preparation exercises performed in
bed
•
Instruct on need to call the nurse for assistance before
ambulation, especially the first time
•
Instruct on pain control strategies
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Management of Laryngospasm
• Brief spasm (involuntary contraction of muscle) of
vocal cords interrupting speech and breathing for 30
to 60 seconds
• Causes: General anesthesia, inhalation injury,
hypocalcemia, severe GERD
• Treatment: establish airway, give 100% O2 via bagvalve mask with tight seal, inhalation of racemic
epinephrine, paralysis and ventilator if needed
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Management of Airway Obstruction
• Signs/Symptoms
– Wheezing and stridor
– Use of accessory muscles and paradoxical
breathing
– Change in level of consciousness
• Treatment
– Head tilt/chin lift; jaw thrust
– Establish airway - intubation
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Which of the following is the first action the critical care
nurse should take when a postanesthesia client has a
laryngospasm?
A. Prepare client for intubation.
B. Administer succinylcholine as ordered.
C. Administer racemic epinephrine via inhalation as
ordered.
D. Apply 100% FI02 via a bag-valve mask with a tight seal.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
D. Apply 100% FI02 via a bag-valve mask with a tight seal.
Rationale: First establish the airway by the head-tilt/chinlift maneuver. Next give 100% FI02 via a bag-valve
mask with a tight seal. That will usually resolve the
laryngospasm. If it doesn’t, the nurse could give the
racemic epinephrine via inhalation. If that doesn’t work,
then the nurse should prepare for intubation and the
patient would receive the succinylcholine to relax the
airway so the bag-valve mask with 100% oxygen can be
used effectively, and if needed the patient is intubated.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Actions to Take When a Client Has
Residual Neuromuscular Blockade
• Assess for inability to raise head from bed for 5 seconds,
air hunger, weak chest rise or fall, weak use of
abdominal muscles, anxiety, tachycardia (Rogovin,
2008).
• Monitor temperature: hypothermia prolongs
neuromuscular blockade.
• Provide airway/breathing support until reversal agents
take effect.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Which of the following is the reversal treatment for a
nondepolarizing muscle relaxant?
A. Edrophonium and atropine
B. Naloxone (Narcan)
C. Flumazenil (Romazicon)
D. Dantrolene sodium (Dantrium)
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
A. Edrophonium and atropine
Rationale: To reverse the effects of a nondepoloraizing
muscle relaxant, an anticholinesterase, such as
edrophonium, and an anticholinergic, such as atropine,
are given. Other possible combinations include
neostigmine and glycopyrrolate, or pyridostigmine and
glycopyrrolate. Narcan is the reversal agent for opioid
overdose. Romazicon is the reversal agent for
benzodiazepine overdose. Dantrium is used to reverse
malignant hyperthermia.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Conditions and Medications That Increase
the Effects of Neuromuscular Blocking
Agents
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Postanesthesia Hypotension
• Defined as a 25% to 30% decrease in systolic BP from
baseline
• Assess for orthostatic hypotension, supine and with head
of bed at 60 degrees (unless contraindicated)
• Determine underlying causes and provide treatment
accordingly
– Reverse anesthetic agents
– Improve venous return
– Avoid vasovagal reactions
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Risk Factors That Precipitate
Dysrhythmias
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Temperature Regulation Problems
Hypothermia
• Body temp <35
degrees C
Hyperthermia
• Body temp >39
degrees C
• Due to heat loss and
blockage of motor and
sensory nerve fibers
during anesthesia
• Due to anticholinergic
drugs, thermal drapes,
inhalation anesthetics
• Warm the patient
using passive heat at
1-2 degrees C/hr
• Pyrogenic response
due to septicemia
• Allergic reactions could
cause hyperthermia
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Management of Malignant Hyperthermia
• Due to a hypermetabolic state triggered by anesthesia in
a sensitive person
• Occurs during surgery until 12 hours after surgery.
• Report increase of 0.5 degrees C, muscle rigidity,
diaphoresis, and instability of BP
• Treat with dantrolene sodium (Dantrium) and 100% O2,
avoid triggering events, and correct any acid-base
abnormalities
• Cool externally and provide cold fluids
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Factors Influencing Pain
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Safe Administration of Epidural Analgesia
• Use only preservative-free medications.
• Use infusion sets without injection ports.
• Infusion pump, bag, and tubing should be labeled
“epidural.”
• Monitor VS, respiratory status, oxygen saturation, level
of sedation, motor assessment, and sensory level.
• Inspect epidural catheter insertion site dressing and
report any drainage.
• Keep naloxone (Narcan) and ephedrine on hand.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Side Effects From Epidural Analgesia
See Box 13-12.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins