Anesthesia Is an induced state of partial or total loss of sensation, occurring with or without loss of consciousness.

Purposes of Anesthesia To To To To To produce muscle relaxation produce analgesia produce artificial sleep or to cause loss of consciousness block transmission of nerve impulses suppress reflexes

Selection of anesthesia is influenced by the following: Type and duration of the procedure Area of the body having surgery Safety issues to reduce injury, such as airway management Whether the procedure is an emergency Options for management of pain after surgery How long it has been since the client ate, had any liquids, or any drugs Client position needed for the surgical procedure

Classification: General anesthesia Local or regional anesthesia

General anesthesia Is a reversible loss of consciousness induced by inhibiting neuronal impulses in several areas of the central nervous system General anesthetics are agents that block the pain stimulus at the cortex

Produces a state of the ff: Analgesia Amnesia Unconsciousness characterized by loss of reflexes and muscle tone

Stages of General anesthesia: Stage 1 (analgesia and sedation, relaxation) Description 1. Begins with induction and ends with loss of consciousness 2. Client feels drowsy and dizzy, has a reduced sensation to pain and is amnesic 3. Hearing is exaggerated Nursing Intervention 1. Close operating room doors, dim the lights, and control traffic in the operating room 2. Position client securely with safety belts

Stage 2 (Excitement, delirium) Description Characterized by struggling, shouting, laughing, singing or crying--- maybe prevented if anesthetic is administered smoothly and quickly Client may have irregular breathing, increased muscle tone, and involuntary movement of the extremities during this stage Laryngospasm or vomiting may occur Pupils dilate but contract if exposed to light Nursing Intervention 1. Avoid auditory and physical stimuli 2. Protect the extremities 3. Assist the anesthesiologist or CRNA with suctioning as needed 4. Stay with client. Stage 3 ( Operative anesthesia, surgical anesthesia) 1. Begins with generalized muscle relaxation and ends with loss of reflexes and depression of vital function 2. Pupils are small but contract when exposed to light. Respirations are regular, the pulse rate and volume are normal, and the skin is pink or slightly flushed 3. The jaw is relaxed, and there is quite, regular breathing. 4. The client cannot hear 5. Sensations are lost Stage 4 (Danger) Description 1. Begins with depression of vital function and ends with respiratory failure, cardiac arrrest, and possible death 2. Respiratory muscles are paralyzed; apnea occurs 3. Pupils are fixed and dilated. Nursing Intervention 1. Prepare for and assist in treatment of cardiac and /or pulmonary arrest 2. Document occurrence in the clients chart. Rationale 1. Teamwork and preparedness help decrease injuries and complications, and promote the possibility of a desired outcome for the client Administration of General Anesthesia Inhalationa. Gaseous Agent nitrous oxide is the most common used agent and is usually given with oxygen. It is colorless, odorless gas that provides analgesia b. Volatile agents liquid agents vaporized for inhalation. O2 is the carrier, flowing over or bubbling through the liquid in the vaporizer system on the anesthesia machine. Intravenous injection- administered through a vein. The patient feels a simple, pleasant and rapid induction. Unconsciousness generally ocurs about 30 seconds to 1 minute after the initial IV adminstration. 1. Barbiturates it acts rapidly, causing unconsciouness within 30 seconds. Ex: Thiopental Na ( Penthotal Na)

2. Ketamine (Ketalar) ketamine is a dissociative anesthetic agent. Rapid onset of a trancelike, analgesic state occur. Often used for diagnostic and short surgical procedures. 3. Propofol (Diporivan) is a short acting anesthetic agent. Hypnosis occurs in less than 1 minute from the time of injection. The drug is eliminated rapidly and the client becomes responsive within 8 minutes after the infusion ends. Adjuncts to General anesthetic Agents Sedatives common drugs in the class include midazolam (Dormicum) and diazepam (Valium). All have hypnotic, sedative, muscle relaxant, and amnesic effects Opioid analgesics (narcotics) common opioid analgesic enhance anesthesia include morphine sulfate, meperidine, fentanyl and sufentanil Neuromuscular Blocking Agents are used to relax the jaw and vocal cords immediately after induction so that the endotracheal tube can be placed. This is used to provide continued muscle relaxation. Ex: Succinylcholine Local anesthesia Injection of a solution containing anesthetic into the tissues at the planned incision site. Briefly disrupts sensory nerve impulse transmission form a specific body area or region. Advantages: Simple, economical, and nonexplosive Equipment needed is minimal Post operative recovery is brief Undesirable effects of GA are avoided Ideal for short and superficial surgical procedures Types of Local anesthesia 1. Topical anesthesia topical agents are applied directly to the area of skin or mucous membrane surfaced to be anesthetized 2. Local infiltration is the injection of an anesthetic agent directly into the tissue around an incision, wound, or lesion. Regional Anesthesia A form of local anesthesia in which an anesthetic agent in injected around the nerves so that the area supplied by the nerves is anesthetized. The patient receiving RA is awake and aware of his surroundings unless medications are given to produce mild sedation or to relieve anxiety. Administration of Regional Anesthesia Spinal Anesthesia- produces a nerve block in the subarachnoid space by introducing a local anesthetic at the lumbar level, usually between L4 and L5. Autonomic nerve fibers are the first affected and the last to recover Spinal anesthesia blocks the following in order: 1. Touch 2. Pain 3. Pressure 4. motor Common drugs used in SA Procaine (Novocaine) Lidocaine (Xylocaine)

 Bupivacaine (Mercaine) Advantages Eliminates the need for expensive equipments and drugs Relatively safe method of anesthesia Provides excellent method of anesthesia Does not cloud the patients consciousness or alertness Useful for patients with respiratory or cardiac problems Complications Hypotension Headache Post op paralysis Nausea and vomiting Urine retention Epidural Anesthesia A commonly used conduction block by injecting a local anesthetic into the epidural space that surrounds the dura matter of the spinal cord Blocks sensory, motor, and autonomic functions Have much higher doses All the complications in the SA can be observed except headache Local conduction blocks Brachial plexus block- produces anesthesia of the arn Para vertebral anesthesia- produces anesthesia of the nerves supplying the chest, abdominal wall and extremities Transsacral (caudal) block produces anesthesia of the perineum and occasionally the lower abdomen Common medications used in local/regional anesthesia

Major complications of Anesthesia Severe respiratory and circulatory problems Disturbs or suppress all physiologic function (GI motility, renal function may fail entirely) Metabolic activities slows and becomes disturbed Dangerous neurologic changes (elderly may suffer CVA-Anoxia due to airway obstruction and may lead to convulsion and cerebral tissue ischemia) Corneal abrasions--- blinking and tearing may be suppressed Lip and tongue injuries Vocal cord damage Peripheral nerve injury

Abscess formation, tissue necrosis, and /or gangrene

NURSING PROCESS FOR THE INTRAOPERTIVE PERIOD Assessment Classify the clients physical status for anesthesia: Mild disturbance (eg, mild cardiac disease, mild diabetes mellitus) Severe systemic disturbance (eg, poorly controlled diabetes mellitus, pulmonary complications) Life-threatening systemic disease (eg, severe renal or cardiac disease) Moribund, with little chance of survival (eg, rupture aortic aneurysm) Assess the clients record for appropriate documentation including Current signed consent form Completed history and physical assessment record Recent laboratory and diagnostic reports Evaluation of the clients overall physiologic, emotional and psychologic status Specifically ask the client about any known allergies. Verify client identification and that the correct surgery is scheduled. Assess for special surgical considerations (eg, locations where an electric grounding plate can be safely placed on the clients, avoiding areas where metal or a prosthesis is present) and precautions (eg, shielding with a lead apron if radiation is involved, if the client is pregnant). Assess the clients risk for accidental hypothermia or malignant hypothermia during anesthesia administration and surgery. Be sure that antidotal supplies are readily available in an emergency. Possible Nursing Diagnoses Risk Risk Risk Risk Risk for for for for for fluid volume deficit or excess hypothermia or hyperthermia infection altered tissue perfusion: cardiac, respiratory, and peripheral injury

Planning and Outcome Identification The major goals for the client during the intra-operative period may include: maintenance of fluid balance maintenance of normothermia prevention of infection adequate tissue perfusion absence of injury.

Implementation

Promote measures that maintain adequate fluid and electrolyte balance. Monitor intake and output accurately Assess the client for dehydration to include skin turgor and mucous membranes. Assess the client for circulatory overload to include breath sounds, peripheral edema and jugular vein distention Monitor pertinent electrolyte values. Perform other actions as appropriate. Act in the role of client advocate, providing privacy and protection from harm Follow established procedures and protocols. Document all OR care. Help coordinate health team activities. Promote ethical behaviors (eg, respect, confidentiality). Monitor blood, fluid and other drainage output. Maintain a quiet, relaxing atmosphere. Remember, the client can hear. Apply grounding pad. Outcome evaluation The client maintains adequate fluid balance as evidenced by elastic skin turgor, moist buccal mucosa, and no peripheral edema or jugular vein distention, and the electrolyte status remains within normal limits. The client maintains satisfactory body temperature between 96F and 100F on completion of surgery. The client shows no signs or symptoms of systemic or wound infection The client show safely in the PACU and exhibits adequate cardiac, respiratory and peripheral circulation. The client remains free of any operative injury from electrical, chemical or physical hazards related to surgery. The client remains free form injury linked to positioning during surgery, as evidenced by no complaints of numbness, paralysis, or abrasions.

Concept on Surgery Post-operative Care Post operative period Extends from the time the patient leaves the OR until the follow up visit with the surgeon Nursing care focuses on reestablishing the patients physiologic equilibrium, alleviating pain, preventing complications, and teaching the patient self care.

PostAnesthesia Care Unit (PACU) Also called the recovery room or postanesthesia recovery room Kept clean, quiet, free of unnecessary equipment, with indirect lighting, and well ventilated to help patients decrease anxiety and promote comfort Should be equipped with necessary facilities

Phases of Postanesthesia Care Phase I PACU- used during the immediate recovery phase, intensive nursing care is provided. Phase II PACU- the patient is prepared for self care or care in the hospital or an extended care setting. Phase III PACU- patient is prepared for discharge

Admitting the patient to the PACU Transferring of the patient from the OR to the PACU is the responsibility of the anesthesiologist. During transport the anesthesiologist remains at the head part of the patient and a surgical team member remains at the opposite side. Transporting the patient involves the special consideration of the incision site, potential vascular changes and exposure.

Initial Nursing Assessment Before receiving the patient, there should be proper functioning of monitoring and suctioning devices, oxygen therapy equipment, and all other equipment. The following initial assessment is made by the nurse in the PACU. 1. Verify the patients identity, the operative procedures, and the surgeon who performed the procedures. 2. Evaluate the following signs & verify their level of stability with the anesthesiologist. Respiratory Status Circulatory Status Pulses Temperature Hemodynamics Values 3. Determine swallowing, gag reflexes and level of consciousness, including patients response to stimuli. 4. Evaluate any lines, tubes or drains, estimated blood loss, condition of the wounds (open, closed, packed), medications used, infusions, including transfusion and output. 5. Evaluate the patients level of comfort, safety by indications sucha sa pain and protective reflexes.

6. Perform safety checks to verify that side rails are in place and restraints properly applied, as needed for infusions, transfusions and so forth. 7. Evaluate actively status, movements of extremities. 8. Review health care providers order. Possible Nursing Diagnoses Risk for ineffective airway clearance r/t depressed respiratory function, pain, and bed rest Acute pain r/t surgical incision Decreased cardiac output r/t shock or hemorrhage Risk for activity intolerance r/t generalized weakness secondary to surgery Impaired skin integrity r/t surgical incisions and drains Ineffective thermoregulation r/t surgical environment and anesthetic agents Risk for imbalanced nutrition, less than body requirements r/t decreased intake and increased need for nutrients secondary to surgery Risk for constipation r/t effects of medications, surgery, dietary change, and immobility Risk for urinary retention r/t anesthetic agents Risk for injury r/t surgical procedure/positioning or anesthetic agents Anxiety r/t surgical procedure Risk for ineffective management of therapeutic regimen r/t wound care, dietary restrictions, activity recommendations, medicines, follow up care, or s/sx of complications

Possible Outcome Statements The major goals include: Restoration of optimal respiratory function Relief of pain Optimal cardiovascular function Increased activity tolerance Unimpaired wound healing Maintenance of body temperature Maintenance of nutritional balance Resumption of usual bowel and bladder elimination Acquisition of sufficient knowledge to manage self-care after discharge Absence of complications Initial Nursing Interventions Maintaining a Patent Airway 1. Allow metal, rubber, or plastic airway to remain in place until the patients begin to waken and is trying to eject the airway. The airway keeps the passage open & prevents the tongue falling backward and obstructing the air passages. Leaving the airway in after the pharyngeal reflex has returned may caused the patient to gag and vomit. 2. Aspirate excessive secretion heard in the nasopharynx and oropharynx. 3. Place patient in the lateral position with neck extended (if not contraindicated) and the upper arm supported with a pillow. a. This will promote chest expansion

b. Turn the patient every hour or two to facilitate breathing and ventilation 4. Encourage patient to take deep breaths to aerate lungs fully and prevent hypostatic pneumonia, use incentive spirometer to aid in this function. 5. Assess lung fields frequently by auscultation 6. Evaluate periodically the patients orientation response to name or command Note: Alteration in cerebral function may suggest impaired oxygen delivery to tissues. 7. Administer, humidified oxygen if required. a. Heat and moisture are normally lost during exhalation b. Dehydrated patients may require oxygen and humidity because of higher incidence of irritated respiratory passages in these patients. c. Secretions can be kept moist to facilitate removal. 8. Use mechanical ventilation to maintain adequate pulmonary ventilation if required. Preventing Respiratory Complications Recognize signs and symptoms of respiratory complicaitons Assist patient in the use of incentive spirometry, deep breathing, and coughing exercises Auscultate breath sounds Encourage patient to turn every 2 hours Administer oxygen as prescribed Encourage early ambulation

Common respiratory complications

Atelectasis (alveolar collapse; inadequate lung expansion) - may be a risk for patients who are not ambulating or is not performing DBE, coughing exercises or incentive spirometry - signs and symptoms include decreased breath sounds, crackles, and cough Pneumonia- characterized by chills and fever, tachycardia, and tachypnea. Cough may or may not be present, may or may not be prodcutive Hypostatic pulmonary congestion- caused by a weakened CV system that permits stagnation of secretions at lung bases. Occurs more frequently in elderly who are not mobilized effectively. Symptoms are sometimes vague, with perhaps a slight elevation of temperature, pulse, and RR. PE reveals dullness and crackles at the base of the lungs. Subacute hypoxemia- constant low level oxygen saturation although breathing appears normal Episodic hypoxemia- develops suddenly, and patient may be at risk for cerebral dysfunction, myocardial ischemia, and cardiac arrest Maintaining Cardiovascular Stability 1.Take V/S (BP, P and Respiration) per protocol, as clinical condition indicators, until the patients is well stabilized. Then check every 4 hours there after or as ordered. a. Know the patients preoperative blood pressure to make significant comparison. b. Report immediately a falling systolic pressure to an increasing heart rate. c. Report variation in BP, cardiac arrythmias and respiration over 30. d. Evaluate pulse pressure to determine status of perfusion. (a narrowing pulse pressure indicates impending shock). 2. Monitor intake and output closely

3. Recognize the variety of factors that may alter circulating blood volume a. Reaction in anesthesia and medication b. Blood loss and organ manipulation during surgery c. Moving the patient from one position on the operating table to another on the stretcher. Primary CV complications seen in the PACU 1. 2. 3. 4. 5. Hypotension and shock Shock Hypertension Dysrhythmias Deep vein thrombosis