question

Intraop Phase

answer

1. sign in 2. time out 3. sign out surgery anesthsia - 2 components of intra-op phase

question

WHO Guidelines - Surgical Safety Checklist

answer

1. Sign In - before induction 2. Time out - before skin incision 3. Sign out - before patient leaves OR

question

Sign In: Before induction (PSPC)

answer

right - patient - site - procedure - consent - patient risks

question

Time Out: Before skin incision

answer

right - patient - site - procedure critical events - nursing focus on sterility, antibiotics within last hour?

question

Sign Out: Before the patient leaves the OR

answer

- documentation - count correct - specimen labeled correctly - any problems/concerns?

question

During Sign in, is the patient awake or out?

answer

the patient is still awake everyone makes sure we have - right patient - right site - right procedure - consent ready patients risks are assessed BEFORE the pt is put under anesthesia

question

During Time Out is when the pt is

answer

under anesthesia, no longer awake BEFORE the skin is cut - after anesthesia before surgery before the skin is cut, the surgeon has to confirm with everyone that they have - the right patient - the right site - the right procedure everyone must agree

question

Time Out - Nursing Focus:

answer

ensure sterile field so infection doesn't occur pre-op: pts receive anti-biotics prophylactically (intended to prevent disease) - given within the last hour - should cover the surgery time

question

Sign Out

answer

surgery is over - before the pts incision is CLOSED, make sure count is correct. - specimens are labeled correctly - biopsy for cancer: make sure the right name is on the right sample (hard to get these samples so you want to ensure accuracy) - all documentation and logistical things must be done before the pt leaves the OR

question

during sign out, who counts all the equipment beforehand and after to make sure nothing is left in the pt.?

answer

the circulating and scrub nurse

question

Surgery Risks

answer

- physical systems - infection

question

Anesthesia Risks

answer

- unconsciousness - drugs

question

Surgery Risks

answer

cutting into the pt - general risks associated with surgery is based on the physical system that's cut into Ex. heart surgery, cardiac bypass - risks associated = MI Ex. carpal tunnel surgery - risks associated = hand paralysis Infection - cutting into the largest organ in the system (skin) - opportunity for infection

question

Anesthesia Risks

answer

controlled poison - risks associated with it in terms of the drugs used and unconciousness - most ppl under would be unconscious and paralyzed

question

Anesthesia Purpose / Effects

answer

- amensia - analgesia - hypnosis - relaxation

question

Anesthesia - Amnesia

answer

- you don't remember what happened Ex. Benzodiazipine: Versed

question

Anesthesia - Analgesia

answer

pain management - all anesthetics should provide analgesia

question

Anesthesia - Hypnosis

answer

altered mental state - patient remembers, it just changes the way the pt perceives things Ex. Narcotic: Fentanyl

question

Anesthesia - Relaxation

answer

- muscle relaxation - body relaxation Ex. surgery appendectomy - you can get a really big hole from a small incision because the muscles have relaxed so much and the skin can be stretched Ex. coronary bypass graft - pt had CAD, angina - they bypass the blockages in the heart (open-heart surgery) to increase blood flow - break sternum, retract the sternum to expose heart - cut into legs and pull the saphenous veins from them (long incisions) - patent was medication but part of the meds are paralytic agents. the pt was paralyzed but the meds for analgesia, amnesia, and hypnosis didn't work. - when the paralytics wore off, he started screaming in pain

question

Types of Anesthesia

answer

1. general 2. Regional - local - epidural - spinal - blocks

question

General Anesthesia

answer

Produces a state of unconsciousness. It may be brought about by inhalation of gases such as ether, nitrous oxide, & ethylene or by drugs administered intravenously; such as sodium pentothal. reversible unconsciousness

question

Regional Anesthesia - Local

answer

ex. lidocaine small area that's anesthetized

question

Regional Anesthesia - Epidural

answer

injected in the epidural SPACE (over large region, can move with low doses) LOWER portion of the body ex. see this in OB

question

Regional Anesthesia - Spinal

answer

injected in the CSF bigger block, cant move anesthesia produced by injection of an anesthetic into the subarachnoid space of the spinal cord.

question

Regional Anesthesia - Blocks

answer

extremities, paralysis - creating a mini circulation around peripheral extremities, usually the arms ex. carpal tunnel surgery anesthesia of an area supplied by a nerve NOUN EX. produced by an anesthetic agent applied to the nerve works on a local nerve

question

General Anesthesia Provider

answer

induction phase - pre-op to unconsciousness maintenance phase - surgery performed emergence - surgery over to extubation

question

General Anesthesia Patient

answer

Stage 1: onset Stage 2: Excitement (muscle jerking) Stage 3: surgical anesthesia Stage 5: danger (death)

question

General Anesthesia Provider Induction Phase

answer

point of pre-op to OR to point when pt is unconscious Ex. Fentanyl, Versed = induction agents

question

General Anesthesia Provider Maintenance Phase

answer

surgery can start once the pt is unconscious maintaining the anesthesia so the patient doesn't feel the procedure

question

General Anesthesia Provider Emergence Phase

answer

- when the surgery is over and the pt is extubated - after the surgeon sutures up the pt - anestehsia is removed and the pt wakes up

question

General Anesthesia Patient Stage 1: Onset

answer

Ex. Fentanyl and Versed - start getting loopy to the point when the pt falls asleep

question

General Anesthesia Patient Stage 2: Excitement

answer

- when the body falls asleep - involuntary release of ATP in muscles that causes contraction - very dramatic for pts - some pts have a very pronounced excitement phase when that they can shake so hard they fall off the table ****monitor for that in the OR to see how much muscle jerking happnes - make sure they dont fall off - involuntary - also indicates the pt is now asleep

question

General Anesthesia Patient Stage 3: Surgical Anesthesia

answer

the nurse anesthetist usually maintains the anesthesia

question

General Anesthesia Patient Stage 4: Danger (death)

answer

danger death

question

General Anesthesia

answer

onset of anesthesia - induction IV drugs - inhalation drugs - neuromuscular blocking agents excitation surgical anesthesia - maintenance emergence - reversal agents

question

induction is from

answer

pre-op to fallin asleep pts are started with IV meds Ex. fentanyl and versed most ppl are nervous when they go to the OR and their energy levels are very high - so the induction agents bring them down so they can fall asleep easily - its not a quick drop IV give inhalation drugs are given - usually give pre-excitation to make the pt fall asleep excitation occurs

question

inhalation drugs

answer

Nitrous oxide Forane Ultane - mask is put on the pt - ask to count back from 100 or 10 - 2 seconds and the pt is out

question

intubation occurs AFTER and BEFORE

answer

AFTER the pt is asleep and excitation occurs - tube is placed into the trachea and attached to a respirator to breathe for the pt - this occurs BEFORE neuromuscular blocking agents because those are paralytic agents - you don't want the diaphragm paralyzed before the respirator is put in (breathes for the pt) pt falls asleep excitation occurs pt is intubated neuromuscular blocking agents are given pt is paralyzed anesthesia is maintained during surgery

question

Reversing the Anesthetic Agents

answer

most drugs are reversed just by not administering them anymore inhalation drugs are easier to monitor blood levels with or by the IV to maintain the blood levels as soon as the meds are stopped being administered, the body will metabolize them and it will go away for some meds, the anesthesiologist will administer - reversal agents to counteract the drugs - esp. paralytic agents = pt wakes up then the pt is rolled out into PACU - pt is monitored in the PACU to stabilize

question

General Anesthesia Drugs Induction

answer

- IV rapid onset, short duration (doesn't last very long) - LOC within 3 - 10 seconds - given prior to inhalation drugs (so they can calm down so excitation isn't so dramatic) can be given alone for minor / local procedures to calm them down

question

IV Induction Agents (Drugs) cause what?

answer

- unconsciousness - amnesia/hypnosis - decreases reflexes (to calm pt.)

question

IV Induction Agents (Drugs) Examples

answer

Sodium Thiopental (Pentothal) - barbiturate Fentanyl (Imnovar) most common - opioid Ketamine (Ketalar) - analgesic / amnesic (asthmatics - bronchodilator, trauma - increases HR, hallucinations, street drug) Versed - benzodiazipine (also with conscious sedation) NURSING CARE: - monitor VITALS - monitor BREATHING - IV site check - strap to table

question

The drugs will respond a little differently depending on the type of drug.. - most common are

answer

Fentanyl and Versed (2 most common)

question

- Fentanyl is an opioid narcotic - Versed is benzodiazipine

answer

so there are different classes of drugs - but they're both used as induction agents

question

Ketamine (Ketalar) - analgesic/amnesic (asthmatics-bronchodilator, trauma - î HR, hallucinations, street drug)

answer

used for asthmatics - bc its also a bronchodilator, people who have asthma can cause their bronchiles to constrict and can cause an asthma attack SURGERY = trigger for asthma this drug works as an induction agent AND a bronchodilator HOWEVER: - it can increase the HR - cause hallucinations - also a street drug (seen in ED) causes hallucinations

question

IV Induction Agents (Drugs) Nursing Care

answer

monitor vitals - you want to see a decrease in VS - BP to decrease a bit (HR is up because of stress, tachypnea) PROBLEM: you dont want to slow VS too much - make sure pt is breathing - make sure IV site is okay, check it - strap to table, esp. during excitation stage

question

3 types of intubation (anesthetic delivery methods)

answer

1. oral 2. intranasal 3. Laryngeal Mask

question

oral intubation

answer

- anesthesiologist intubates pt - circulating nurse ensures the ET tube is in correct position and is inserted into the mouth, past the larynx - inserted into trachea - NOT in esophagus - in lungs and NOT in GI system - tube is in position with cuff inflated ****make sure its in the trachea and both lungs expand after intubation neuromuscular agents are administered to the pt

question

intranasal intubation

answer

- only used for 1 type of surgery - oral surgery (cant put it in the mouth)

question

laryngeal mask

answer

psych (electro shock therapy) - sometimes they'll put this mask in to ensure the pt. doesn't aspirate - for very short term procedures - plugs esophagus to prevent aspiration NOT in the trachea

question

Maintenance Phase: Inhalation agents allow for more control over the blood levels and they leave the body quicker examples:

answer

NO (nitrous oxide)***most common Halothane (Flurothane) Isoflurane (Forane) Suphane

question

Maintenance Phase - Inhalation Agents Nursing Care: monitor what?

answer

VS - ensure they're not depressed too much breathing - they're on a respirator - diapharagm isn't working ****ensure respirator works laryngospasms - muscles around the larynx spazz and they may block off the ET tube or dislodge it - involuntary ****monitor for this hypersensitivity - pt may be allergic to the drugs - issue = constriction of bronchioles - cuts off their breathing, neck swelling, etc. ***monitor for this delirium - inhalation agents can cause delirium - usually pts are sleeping - but they may wake up and become delirious - monitor for this this can also happen when a pt has a withdrawl from alcohol

question

Maintenance Phase - Neuromuscular Blocking Agents

answer

- Pancuronium (Pavulon) - Vecuronium (Norcuron) - Succinylcholine chloride (Anectine) sometimes abbreviated as SUX (common)

question

Succinylcholine chloride (Anectine), sometimes abbreviated as SUX (common)

answer

- very commonly used because its a very clean drug - works very well - only problem with it: associated with malignant hyperthermia ****genetic predisposition

question

Emergence Phase

answer

withdrawal of anesthetic agents drugs are given to reverse effects

question

reversal agents during Emergence Phase

answer

Romazicon (reverses benzodiazipines) Neostigime (reverses paralysis) Narcan (reverses opioid) not given unless overdoses

question

Romazicon reverses what?

answer

benzodiazipines

question

Neostigime reveres what?

answer

patalysis

question

Narcan reveres what?

answer

opioids not given unless overdosed

question

Emergence phase occurs when

answer

during Time Out and the anesthesiologist will withdrawal the anesthetic agents and give some drugs to reverse the effects they may give the Romazicon - but they don't usually do that because benzodiazipines aren't usually used at such high levels where it would hurt the patient

question

Neostigime reverses what?

answer

paralysis

question

Narcan

answer

would never give to the pt unless the pt has overdosed on opioid narcotics - when people OD on opioids, they end up in the ED - narcan is a reversal agent - stays in the system for a long time - but if this is given, pain meds wont work for the remainder of time given during a life threatening situation

question

GOAL = balance between

answer

inhalation agent + muscle relaxant + benzodiazipine + opioid

question

NURSE MONITORS

answer

- if anesthesia is working - pt is still alive - no complications (recognize complications early)

question

Care Team - Peri-operative Nurse

answer

- circulating nurse - scrube role (nurse or tech) - RN First Assistant (based on NPA)

question

Care Team - Peri-operative Nurse Circulating Nurse

answer

most important nurse role - manager for the room - person is not sterile - not around the sterile field - responsible for ensuring that the sterile field is STERILE - gather equipment - set up room - tell you where to stand in the OR

question

Care Team - Peri-operative Nurse Scrub Role (nurse or tech)

answer

- person who is IN THE STERILE FIELD - hands the equipment to the surgeon

question

Care Team - Peri-operative Nurse RN First Assistant

answer

- in some states, an RN can be a 1st Assistant - may assist with surgery

question

RN First Assistant

answer

special training or certification must be documented; if something happens to the surgeon, RN can stabilize; can close wound, punch biopsy but no actual surgery

question

Anesthesia Care Providers

answer

Anesthesiologist - is available for the nurse anesthetist incase they need help Nurse Anesthetist

question

Intra-Op Assessment

answer

- psychosocial assessment - physical assessment - chart review - allergies (latex) - WHO surgical check list "sign in" before anesthesia p. 455

question

Nurse Psychosocial Assessment

answer

- the nurse does this before the pt is under holding area: - very imp. bc patients are very stressed at the time - try to minimize the stress and get a handle of who's outside waiting for them, how they're doing, are they worried?, what's on their mind? ex. if pt suddenly doesn't want surgery - surgery cancelled - nurse = advocate for the pt - always monitor for this

question

Physical Assessment / Chart

answer

- most of that info would be in the chart - dont usually do this in the holding area there's Hx and physical in the chart - must find out the baseline - bc if anything happens, you'd want to compare it to the baseline

question

Allergies

answer

- esp. latex allergy - latex allergies can be lethal - if the pt is allergic to latex, then everyone on the team needs to know that

question

NANDAs

answer

- risk for infection - risk for injury (patient / procedure id) (electrical shocks) (hemodynamic instability) - risk for perioperative positioning injury - deficient / excess fluid volume - ineffective breathing pattern - hypothermia/hyperthermia

question

Risk for Infection

answer

NOC - infection status NICs infection control: intra-op - principles of sterility - sterile/aseptic technique (room prep) - circulating nurse (monitor breaks in the sterile field - maintain asepsis of surgical suite (restricted areas)

question

Risk for Infection scrub nurse

answer

opens the packages and holds it in a certain way not to break sterile technique - sterile - pulls equipment out to set up the table

question

Risk for Infection circulating nurse

answer

- monitors sterile field - your back is never sterile so dont turn your back on the sterile field if it's contaminated, then the whole thing needs to be broken down and re-set regardless of where you are

question

Risk For Injury

answer

NOCs - risk control NICs surgical precautions - patient / procedure identification guidelines "time out" - eye protection / blood & body fluid exposure - grounding / fire hazards - laser safety - vitals

question

Eye protection/blood & body fluid exposure

answer

- usually surgeons and nurses have shields around their face so nothing splashes into your eyes and infect you

question

Grounding/fire hazards

answer

- nurses job to set up the equipment and the nurse does that

question

Laser safety

answer

- look at the book - you never want to look inside of a laser, it will burn out your optic nerve

question

Vitals

answer

- u always want to monitor the pt - VS to make sure nothing is depressed - or if there is no reaction to meds that elevate the VS once they become depressed - VS can go either high or low depending on the situation

question

Risk for Injury surgical assistance

answer

- sponge, sharp instrument count - equipment / supply management - specimen collection - anesthesia administration - administer drugs / fluids

question

Risk for Injury surgical assistance - sponge, sharp instrument count

answer

all need to be counted before and after the procedure

question

Risk for Injury surgical assistance - equipment / supply management

answer

nurses manage the equipment, they get whatever sutures the surgeon needs - sometimes the nurse will need to run out to supply room to get additional equipment and hand it to the scrub nurse using sterile procedure

question

Risk for Injury surgical assistance - specimen collection

answer

circulating nurse will manage the specimens and document, label them

question

Risk for Injury surgical assistance Administer drugs/Fluids

answer

the nurse anesthetist or the nurse will hang additional drugs and fluids

question

Monitor for Anaphylaxis

answer

- due to medications - foreign objects (sutures, sealants, tissue adhesives)

question

foreign objects (sutures, sealants, tissue adhesives) left in the body

answer

***Most common allergic reaction that could happen - particularly for ortho procedures, foreign objects that are supposed to be left in the body ex. orthoplasty (joint replacement) artificial joint ex. sealants ex. adhesives can all cause anaphylaxix monitor for this monitor for breathing, VS, to look for an allergic response, swelling, rashes, any signs of an allergic reaction

question

Risk for Perioperative Positioning injury

answer

NOCs: - circulation status - neuro status - respiratory status - tissue perfusion: peripheral NICs - transport - positioning: intraop

question

who's job is it to position the pt?

answer

the nurse's - very complex bc it affects circulation - you can cause nerve damage if its not done right - it can affect breathing and cause skin damage

question

transport

answer

- whne ppl are medicated, they may not feel pain - pts on peripheral blocks, epidurals, spinals (no pain) - when when transporting the pts, you want to make sure their legs and arms arent caught in the side rails - you can break someones bones or cause tissue damage if not paying attention

question

positions on the OR table SUPINE

answer

patient in position on the OR table for a laparotomy note the strap ABOVE the knees - the arms are at the sides sos they arent' hanging off the table - legs are tied into place so the legs dont roll out and cause undue pressure on the hip joint (may cause a great deal of tissue damage) ***the way the pt is positioned, is very imp to prevent soft tissue damage and promote circulation

question

positions on the OR table Trendelenburg Position

answer

padded shoulder braces in place be sure that the brace doesn't press on the brachial plexuses there's a padding under the lower back to ensure the iliac crest isn't damaged - seat belt - on the shoulders, there are braces to keep the patient from falling off the table

question

positions on the OR table Lithotomy Position

answer

the hips extended over the edge of the table for rectal and gym surgeries - make sure legs are padded and are positioned appropriately so the buttocks isn't hanging off the table and causing pressure on the lower back

question

Patient position for Thoracotomy

answer

- focus on pt alignment - one knee is brought up to decrease pressure on back - left arm is on the side arm board - right arm is hanging over with a trapeze - very imp how the pt is positioned bc you can dislocated the shoulder if not careful

question

NANDA: Decreased/Excess Fluid Volume

answer

NOCs: fluid balance - be careful elderly/CHF VS status NICs: fluid management - IVs - Foley Hemodynamic Regulation - VS - blood Shock Prevention/Management

question

when a pt is undergoing surgery, the most important thing to maintain is what?

answer

cardiovasculature - you're always going on a fluid hunt - a lot of fluid shifts bc of the normal stress response - you must be careful w/ fluid balance esp with elderly bc their adrenal glands may not respond as quickly as a young person's because they've been working hard all their life - you may have fluid shifting at a diff RATE than someone else your age - also people who have CHF can't manage the fluid as well and they could have a fluid overload

question

- so you have to monitor where the fluid is in the different compartments of the body, but how? how do you know what's in the vasculature?

answer

1. vital signs - low vasculature fluid - low BP, high HR 2. urine output - if you don't have enough fluid in your vasculature, the urine output will go down - because the fluid in the urine is pulled out of the vasculature - the body is going to be shifting fluid into the interstitial tissues

question

so during surgery, the most important thing to make sure is if there's enough fluid in the vasculature what type of fluid is hung the most? - isotonic - hypotonic - hypertonic

answer

isotonic fluid Lactated RIngers - It has an electrolyte concentration (same concentration as blood)

question

why do they use Lactated RIngers and not normal saline (isotonic)?

answer

because it has too much saline in it - lactated ringers has less saline but has other electrolytes that maintains the same concentration as blood

question

so you're always monitoring how much fluid is in the vasculature

answer

- and the nurse will administer IV fluids appropriately - and it would be titrated based on the vital signs and the urine output

question

Hemodynamic Regulation for vital signs blood - you may be hanging blood if you have a very bloody procedure you're always monitoring for shockyou need to know what the S/S of shock are

answer

for VS blood - you may be hanging blood if you have a very bloody procedure - always monitor for SHOCK - you must know the s/s of shoc

question

SHOCK

answer

not enough oxygen gets to the tissues for whatever reason - hypovolemic shock - not enough vasculature to feed the tissues - monitor how bloody the procedure is - this will let you know if you will need to hang blood or if additional fluids are needed

question

S/S of shock

answer

- pulse: decreased - HR: increased - BP decreased - tachypnea - cold clammy skin = 1st indication

question

FLUID SHIFTING

answer

- maintain CV - kidney perfusion - pitting edema leads to cell lysis

question

NANDA: Ineffective Breathing Pattern

answer

NOC: - respiratory status: airway patency NIC airway management - monitor airway - respirations - treat n/v monitor ABCs

question

Ineffective Breathing Pattern during intra-op phase, usually intubated so the respirator will manage the breathing - if the patient is NOT intubated, what will the nurse monitor for?

answer

- check respirations - check pulse ox - always monitor for N/V bc if someone vomits during surgery, they will aspirate very easily ****this is why pts are on NPO before the procedure = make sure their stomach is empty - but the stomach is always secreting HCl so they could vomit sub-gastric contents ***always monitor for that and hopefully this is prevented by using anti-metics

question

NANDA: Hypothermia

answer

NOC - thermoregulation NIC temperature regulation: intraop - monitor temp - equipment - blood warmer - blankets

question

what is the most important system of the body that is for temperature regulation?

answer

integumentary system (skin) - keps the heat in and regulates body heat - bc they cut into the skin, pts can get very cold - also due to the stress response, the shifting goes to the vital organs, away from the periphery - this will also stimulate a stress response and make the pt very cold

question

the nurse must monitor temperature

answer

- usually the equip is heated to regulate the temp - if you administer blood, sometimes its through a blood warmer to warm the blood because if you infuse the blood, its usually cold - so its nice to warm it up as it enters the pts body

question

immed. after the procedure, the pt will

answer

- be shaking - get very cold - the pt tried to warm the body by shivering to generate heat - but you dont want them using their ATP for generating heat, so you usually put warm blankets on them - in the OR, there are cabinets with warm blankets and they stack them on the pt

question

NANDA: Hyperthermia

answer

NOC: - thermoregulation NIC: - malignant hyperthermia precautions

question

hyperthermia can happen, is this an emergency situation?

answer

yes - usually people dont get hot postop or intraop - this is a disease/condition called malignant hyperthermia ****life threatening

question

Malignant Hyperthermia

answer

- life threatening, medical emergency - genetic predisposition - causes an increase in Ca+, K+ and metabolic and respiratory acidosis - can occur anytime in the OR or during recovery period - linked to some inhalation anesthetics (halothane) and depolarizing muscle relaxant (succinylcholine)

question

Ca+ and K+ levels in pts who have malignant hyperthermia are increased or decreased?

answer

increased

question

pts who have malignant hyperthermia are have metabolic and respiratory alkalosis or acidosis?

answer

metabolic and respiratory acidosis

question

which inhalation anesthetic is malignant hyperthermia linked to?

answer

halothane

question

which depolarizing muscle relaxant is malignant hyperthermia linked to?

answer

succinylcholine

question

malignant hyperthermia

answer

- it's an electrical electrolyte cascade that can kill a patient - it can cause respiratory and metabolic acidosis

question

malignant hyperthermia - genetic predisposition

answer

- if there's a family hx of this, the anesthesiologist must avoid using those drugs - we still use these drugs bc their very good but we dont use them if the person has a genetic predisposition (halothane and succinylcholine)

question

Malignant Hyperthermia manifests in bradycardia or tachycardia? and what happens to the BP?

answer

tachycardia with unstable BP

question

Malignant Hyperthermia manifests in

answer

hypoxia

question

Malignant Hyperthermia manifests in hypokalemia or hyperkalemia?

answer

HYPER kalemia

question

what are the first signs of malignant hyperthermia?

answer

tachycardia and unstable BP

question

Malignant Hyperthermia: Muscle Rigidity (rigid jaw and chest)

answer

- malignant hyperthermia pts bite down on the ET tube - but if the pt is paralyzed, they wouldn't be able to bite down on the ET tube - so they don't voluntarily bite down, its instead caused by the muscle rigidity - so if you see that, immed. you would tell the surgeon and they would start withdrawing the anesthesia while the surgeon is stopping the surgery - they mustttt stop the process

question

malignant hyperthermia temperature

answer

46 degrees C 108 degrees F

question

the nurse moves very quickly

answer

to keep the pt from dying primary prevention is always best - identify the pt of having this genetic predisposition and avoid the meds

question

malignant hyperthermia Rx

answer

IV fluids, Dantrolene (dantrium - muscle relaxant) - helps slow down the electrical cascade

question

if the patient becomes tachycardia and the BP remains unstable, what should the nurse suspect and do?

answer

suspect malignant hyperthermia tell the anesthesiologist and surgeon know right away' - and the anesthesiologist monitors for muscle rigidity - circulating room nurse monitors as well - as soon as the early signs occur, the surgery is stopped because they will die fast

question

Regional / Local Anesthesia - is the patient awake and what's the status of their LOC?

answer

patient is awake but no LOC

question

which drug (induction agent) is used with Regional/Local anesthesia to calm the patient down?

answer

versed or fentanyl

question

Regional/Local anesthesia does what to the transmission of the sensory nerve impulses?

answer

it numbs the area so it doesnt hurt when they cut into it

question

Regional anesthesia covers how much of the body?

answer

over a large specific area

question

Local anesthesia covers how much of the body?

answer

over a small area

question

Blocks anesthesia

answer

some of nearby nerves affected (peripheral)

question

Regional - Anesthetic over large specific area Ex.

answer

epidural and spinal

question

Regional/Local Anesthesia NANDAS - ineffective individual coping - acute pain - vasoconstriction

answer

NICs - coping enhancement - pain management - no epinephrine with extremities NOCs: - coping - pain level - local circulation

question

pleuropericarditis

answer

excess fluid in the pleural cavity - fluid accumulation in the pericardial sac around her heart - very painful - angina, SOB Tx: tap the lungs

question

tap the lungs - local anesthesia

answer

- ultrasound to see where the fluid is in the lungs - numb area btw the ribs -insert the probe - remove the fluid - cant feel it

question

Vasoconstriction and local anesthesia

answer

- when people have local anesthesia, you must pay attention to what area is being anesthetized ex. lidocaine meds - epinephrine and without epinephrine

question

if you take epinephrine with lidocaine. what will happen to the bleeding?

answer

minimizes bleeding (good thing) - except for peripheral areas, (hands, fingers), then the vasoconstriction can cut off circulation to those areas

question

why would you never use lidocaine with epinephrine?

answer

because you can end up causing decreased circulation to the area and tissue damage

question

no epinephrine for extremities

answer

- you need to recognize that local circulation for those areas bc the local can decrease circulation to those areas or there's epinephrine in the lidocaine

question

Epidural Anesthesia

answer

inject narcotics in the epidural space near spine - usually continuous infusion

question

is epidural anesthesia continuous or intermittent?

answer

continuous infusion - thats the big difference between an epidural and a spinal

question

what is epidural anesthesia used for?

answer

- ortho cases, vaginal, rectal - post op analgesia

question

where does the epidural infect the narcotics? inside or outside of the spinal cord?

answer

outside the spinal cord between the vertebrae doesn't pop into the spinal cord - numbs the area from that point down - from dermatomes from that point down usually used for the following cases (below the waist) - ortho - vaginal - rectal

question

Epidural Procedure

answer

- insert the epidural using needle with a catheter on the OUTSIDE - they remove the needle and keep the catheter in place

question

- nurse's job: assist in positioning the patient for this, the patient is usually on their side or sitting up, and bending over to spread the vertebrae so the anesthesiologist could put the catheter in the right place

answer

- assist in positioning the pt for this - the pt is usually on their side or sitting up and bending over to spread the vertebrae so the anesthesiologist could put the catheter in the right .

question

Epidural Anesthesia Additional NANDAs - Disturbed Sensory Perception - Impaired Physical mobility - Impaired Urinary Elimination - Risk for Infection

answer

Additional NICs: - self care assistance - fall prevention - tube care: urinary (keep Foley in 2 - 3 hour) - tube care: epidural Additional NOCs - neurological status: spinal sensory/motor function - urinary elimination - infection status

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Epidural Anesthesia - affects sensory

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reason: relieves pain

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at high doses, Epidural Anesthesia may affect what? what does the nurse always monitor for?

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mobility - epidurals aren't supposed to affect mobility but at high doses it could - so you're always monitoring for movement

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obviously if you decrease sensory perception below the waist, the pt would have to have a Foley why?

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because they cant control their urine or they wont feel the need to urinate - usually you keep the Foley in for awhile - after the epidural is removed because you want to make sure that sensory and motor are back to normal before you remove the Foley - you dont want an over distended bladder

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the pt could also be at risk for infection when they're under Epidural Anesthesia because

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you have a catheter next to the spine - make sure the catheter is maintained and that there are no breaks in the system - ensure that you don't end up with an infection next to the spine

question

what are you always monitoring for when pts have epidurals and spinals?

answer

neuro stats and CNS checks urine elimination - to ensure Foley is patent and removes urine - imp. bc the nurse uses URINE OUTPUT to determine fluid status nurse must differentiate if this is - a bladder issue (patent?) - or CV fluid management issue no S/S of infection in the site sensory perception - bc the feet are numb, make sure they're aligned, appropriate and not stuck in the side rails - they cant tell you if they're in pain

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Spinal Anesthesia where is the needle placed?

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subarachnoid space, L3-L4

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what type of injection is the Spinal Anesthesia? continuous single or intermittent?

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continuous or single injection

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the Spinal Anesthesia produces no feeling where?

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no feeling / motor below the injection used for below the waist procedures

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the big difference between an epidural and a spinal is that:

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***with a spinal - the anesthesiologist is actually injecting the narcotics INTO THE SPINAL CANAL - into the canal, next to the spinal cord to numb the area - inject and remove NO CATHETER - higher doses - the anesthesiologist will insert it between L3 and L4 - single injection - not continuous

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is EPIDURAL sensory or motor paralysis?

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only sensory NO paralysis

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is the SPINAL anesthesia sensory or motor paralysis?

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both sensory and motor paralysis

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what does a SPINAL do that an epidural doesn't?

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- it causes paralysis when a pt codes, the legs are propped up, this helps the blood pooled in the legs to travel back to the heart from the feet - little valves in the veins - muscle contraction help to do this this would occur if spinal anesthesia doesn't completely eliminate itself from the body and the blood pools to the legs and loses LOC because of that...could lead to resp. arrest

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Spinal Anesthesia Additional NANDAs - decreased CO - respiratory depression - acute pain (spinal headache)

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Additional NICs - shock prevention - monitor vitals / breathing - pain management ( 1 - 2 liters of fluid) Additional NOCs - circulation status - oxygenation - pain level

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downside - the spinal anesthesia can cause

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blood pooling and can affect the cardiac output what the nurse should have done: - get orthostatic BPs post-spinal because you need to make sure the patient can withstand changes in position post-spinal - in this case it caused BP drop and respiratory depression - so you need to make sure that you monitor VS and orthostatic (lying, sitting, standing) to make sure that the patient can tolerate different changes in position

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nurse must monitor oxygenation with a pt with spinal anesthesia

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- ensure breathing is ok - esp with pts who have a spinal - depending on the site of the spinal bc it can cause paralysis, sometimes the med thats injected into the spinal cord, although it iwll numb and paralyze from that point down, it sometimes seeps UP a little bit - may affect the diaphragm - ensure the pt doesnt resp. arrest during the spinal

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spinal anesthesia - pain management spinal headache

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- leakage of CSF fluid - for a spinal, you prin prick a little hole into the spinal canal - and in that canal is the CSF - if you think of the canal as a little balloon, if you prick and deflate it, you stretch it and can see the hole

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what position should the post-spinal anesthesia pt be in to avoid a spinal headache?

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the pt must STAY FLAT (15-30 degrees) - they cannot sit up or bend or have their head be up too high - it will bend the spine and increase the hole so CSF will lead and this causes a horrible headache

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how long should the post-spinal anesthesia pt remain flat for?

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6 hours and push fluids so they're well hydrated so if there's leakage it can replace the CSF with fluid shifting

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major 3 nursing things to monitor post-spinal anesthesia

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1. monitor CO - esp. post spinal when they get up for the 1st time 2. during the spinal, make sure the diaphragm isnt affected - check for oxygenation and breathing 3. positioning is very important - remain flat for 6 hours to prevent spinal headache

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Blocks Anesthesia - Bier Block is for what type of surgeries?

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peripheral surgeries - upper extremities

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Blocks Anesthesia - Bier Block

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Tourniquet Local anesthetic circulation VS monitoring in case anesthetic becomes systemic for short procedures

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what is very important to monitor when a pt has Blocks Anesthesia - Bier Block?

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Vital Signs to ensure the anesthetic doesn't become systemic

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Peripheral nerve blocks where is the anesthetic injected?

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injects the anesthetic over nerve to block the pain

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Bier Block

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peripheral surgeries for upper extremities - you're trying to create a micro circulation around the extremity so you don't need as many drugs - it would be injecting the medication in the arm to minimize circulation in the body - when the tourniquet is released, the anesthesia is dispersed throughout the body so you're wanting to make sure there's not a systemic response once that's released and you also need to worry about pain management

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Peripheral nerve blocks

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the doctor can block the pain for the nerves that innervated his penis so he didn't feel that horrible pain - there are areas that can get blocked peripherally

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Moderate Sedation is used by itself for what type of procedures?

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short term procedures in addition to other local anesthesia Minimally depressed LOC used in situations where someone is going to have a procedure that will make them very nervous and it's usually associated with local anesthesia

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if a pt is going to have a procedure and they're very scared, they will receive the what to cause minimal depression of LOC?

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Fentanyl and Versed - so it would make them loopy so they can endure the local anesthesia Ex. for tapping a pt's lungs

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Moderate Sedation NANDAs - ineffective breathing pattern / cardiac - acute confusion (agitation, combative)

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NICs - respiratory monitoring: constant, vitals q 15-30 min - reality orientation - responds to verbal commands NOCs - respiratory status: airway patency - vitals - cognitive orientation

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moderate sedation

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a decreased level of consciousness in which the patient is not completely asleep sedated, but still aware , and can follow directions

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Moderate Sedation the issue here is that the medications that are given are induction agents... so the most important thing is to make sure of what?

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that you don't cause general anesthesia so you're always prepared in monitoring their breathing and cardiac status because you're depressing them enough that they can go into respiratory arrest so always monitor their airway and check their VS

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NICs for Moderate Sedation

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- monitor VS every 15 - 30 min while they're being medicated also some of these meds can cause a great deal of confusion and delirium - must Tx that - sometimes ppl can get very combative depending on the medication that's used - make sure you maintain their distance from the patient because they may hit you

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Moderate Sedation and for delirium

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you want to always re-orient them, remind them that you're taking care of them because they may think they're in a different place so you need to constantly re-orient them to treat the confusion or delirium

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You are the circulating room nurse. What is your responsibility?

answer

circulatory nurses - help put pts to sleep for surgery - when the surgery starts, they remain in the non-sterile function they venture outside the OR if theres a need for supplies - they also open packages as necessary so doctors can grab the sterile supplies inside without infecting their gloves or gowns - during surgery, theres always a risk of complications with which the circulating nurse must be able to assist

question

The perioperative nurse encourages a family member or a friend to remain with the patient in the pre-operative holding area until the patient is taken into the operating room primarily to A. Ensure the proper identification of the patient before surgery. B. Protect the patient from cross-contamination with other patients. C. Assist the perioperative nurse to perform a complete patient history. D. Help relieve the stress of separation for both the patient and significant others.

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D. Help relieve the stress of separation for both the patient and significant others. Answer: D social supports relieve stress. Also, that sense of connectedness improves spiritual well-being.

question

The patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. At the completion of the surgery, it is most important that the nurse monitor the patient for: A. Nausea and vomiting. B. Agitation and seizures. C. Laryngospasm or bronchospasm D. Adequacy of respiratory muscle movement

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D. Adequacy of respiratory muscle movement Answer D OK even if you did not know all the side effects of all the drugs, think about it. A neuromuscular blocking agent paralyzes the patient. The diaphragm is paralyzed by this medication. It just makes sense that you make sure the patient can breath.

Intraoperative Phase "During Surgery" Includes: Anesthesia and Surgery – Flashcards

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