Pre/Intra/Postoperative Care Flashcards
What is the total surgical episode called
Perioperative period
What is an ACP
Anesthiaa care partner
What is an ASA rating
P1-P5 P1 normal healthy person P5 declared brain dead organ harvest given by HCP
What three things should you counsel your patient to do post op general surgery?
deep breathing, cough, early ambulation
cefazolin
anitbiotic to prevent postoperative infection
atropine glycopyrrolate
decrease oral/respritory secretions
scopolamine
prevent nausea/vomiting and provide sedation
insulin (humulin r)
stablize BG
metoclopramide
increase gastric emptying
ondansetron
prevent nausea and vomiting
diazepam, lorazepam, midazolam
(valium, ativan) decrease anxiety, induce sedation, amnesic effects
labetalol
manage hypertension
famotidine, ranitidine
decrease hydrochloric acid secretion, increase ph, decrease gastric volume
fentanyl, morphine
relieve pain during preoperative procedures
What is an SRE?
Serious Reportable Event
What are the three parts of Surgical Care Improvement Project
A prophylactic antibiotic statrted w/ in 30-60min before surgical incision
apply warming blanket
apply intermiitent pneumatic compression devices to minimize VTE
When are National Patient Safety Goals used?
preprocedure verification process
Why use the Universal Protocol?
To prevent wrong site, procedure, and patient.
When can RNs administer anesthesia?
Moderate to deep sedation in an emergency outside of the OR (Ex: ER) under physician supervision.
What is MAC?
monitored Anesthesia care: includes varying levels of sedation, done inside an OR, must be an ACP
What are the patient effects of general anesthesia?
loss of sensation w/ loss of consciousness
combo of hypnosis, analgesia, and amnesia
usually involves use of inhalation agents
skeletal muscle relaxation
elimination of coughing, gagging, vomiting, and sympathetic nervous system responsiveness
requires an advanced airway
What are the patient effects of local anesthesia?
loss of sensation w/ out loss of consciousness
induced topically or via infiltration, intracutaneously, or subcutaneously
topical applications may be aerosolized or nebulized
What are the patient effects of moderate sedation/analgesia
sedative, anxiolytic (reduces anxiety), and/or analgesic drugs used
does not include inhalation agents
patient is responsive and breathes w/ out assistance
not expected to induce sedation that would compromise airway
usually used for minor therapeutic procedures like a fracture realignment in the ER
What are the patient effects of monitored anesthesia care
sedative, anxiolytic (reduces anxiety), and/or analgesic drugs used
might need airway management
GIVES GREATEST FLEXIBILITY TO MATCH SEDATION LEVEL TO PT NEEDS AND PROCEDURAL REQ
often used in conjunction w/ regional/local anesthesia
often used for minor therapeutic/Dx procedures (eye surgery, colonoscopy)
What are the patient effects of regional anesthesia
Loss of sensation to region of body w/ out loss of consciousness
Blocks a specific nerve/group of nerves by admin local anesthetic
Includes spinal, caudal, and epidural anesthesia and IV peripheral nerve blocks (interscalene, axillary, infra-/supra-clavicular, popliteal, femoral, sciatic)
What kind of drugs are used during the preinduction phase?
benzos, opioids, antibiotics, aspiration prophylaxis (H2 receptor blockers, gastric motility agents, anticholinergics)
What kind of reversal agents might they use in case of an emergency?
Anticholinesterases (neostigmine), opiod antagonists (naloxone), benzodiazepine antagonist (flumazenil), neuromuscular block reversal of rocuronium (zemuron) and vecuronium (norcuron) and sugammadex (bridion)
Supplemental opiods
Antiemticis
The IV agent methohexital (brevital) is a barbituate used for ________
general anesthesia. It has advantage of rapid induction, usually under 5min. It may cause myocardial depression, hypotension, excitation, or involuntary movement. It has a short duration of action and usually has minimal effects on pt post-op. Causes nausea in pts that are sensitive to barbiturates and/or have high histamine.
The IV agent etomidate (amidate) is a non-barbituate hypnotic used for ________
general anesthesia.
Benefit is that it has little effect on cardio function (unlike methohexital) and is used on hemodynamically unstable pts. It has minor respiratory depression and does not cause histamine release.
it can cause myoclonia (quick, uncontrollable jerking) nausea, vomiting, hiccups, and inhibits adrenocortical processes (aka, stops release of polycyclic steroid hormones that have a variety of roles that are crucial for the body’s response to stress (for example, the fight-or-flight response), and they also regulate other functions in the body. Threats to homeostasis, such as injury, chemical imbalances, infection, or psychological stress, can initiate a stress response. Examples of adrenocortical hormones that are involved in the stress response are aldosterone and cortisol. These hormones also function in regulating the conservation of water by the kidneys and glucose metabolism, respectively.)
The IV agent propofol (diprivan) is a non-barbituate hypnotic used for ________
general anesthesia
Ideal for short, outpatient procedures b/c of rapid onset action/metabolic clearance. May be used for induction/maintenance of anesthesia.
Can cause bradycardia, dysrhythmias, hypotension, apnea, transient phlebitis (the inflammation of the internal lining, tunica intima, of a vein. It is associated with pain, swelling and erythema around the intravenous cannula insertion site or along the course of the vein without systemic involvement.4 In severe cases, it may lead to thrombosis of the vein which manifests as a small lump.) nausea, vomiting, hiccups, and hypertriglyceridemia
The inhalation agent nitrous oxide is a gas used for ________
General anesthesia.
Is liquid at room temperature, but evaporating easily for administration by inhalation (volatile agent) which speeds induction with reduced total dosage and side effects.
it is a weak anesthetic that is rarely used alone although it has good analgesic potency.
It has little to no toxicity at therapeutic concentrations.
Should be avoided in pts w/ bone marrow depression. Pt must be given O2 to prevent hypoxemia. Avoid in pts w/ history of nausea/vomiting.
The inhalation agent nitrous oxide is a volatile liquid used for ________
general anesthesia
All cause skeletal muscle relaxation and Resp depression, myocard depression, hypotension
Desflurance: fastest onset/emergence and is widely ised in amb settings d/t its least postoperative cognitive dysfunction. is a potential airway irritant. Resp depression, myocard depression, hypotension
Isoflurane: no increase in ventricular irritability and does not cause renal/liver toxicity. Is resistant to metabolic breakdown. Not good for coronary art disease pts
Sevoflurane: predictable effect of cardio/resp systems and is rapid acting. Preferred for inhalation induction d/t nonirritating to resp tract. Can cause emergence delirium/seizure
The dissociative anesthetic ketamine is a drug used for ________
general anesthesia
Given IM/IV and is a potent analgesic/amnesic
May cause hallucinations/nightmares.
increases intracranial/intraocular pressure.
Increases HR and BP
May need benzos post op to manage agitation. Need calm, quiet atmosphere.
Describe some antiemetics that you may use in adjunct to general anesthesia
Aprepitant (emend), granisetrinmetoclopamide (reglan), ondansetron (zofran), palonosetron, prochlorperazine, promethazine, rolapitant (varubi)
Counteracts nausea/vomiting r/t histamine release, vagal stimulation, vestibular disturbance, procedure (abdominal laparoscopy). Can be used prophylactically.
Can cause headache, dizziness, dysrhthmias, dysphoria, dystonia (neuromuscular spasms, abnormal postures), CNS sedation, dry mouth
Describe some benzodiazepines that you may use in adjunct to general anesthesia
Diazepam (valium)
Lorazepam (ativan)
midazolam (versed)
Reduces anxiety, induces/maintain anesthesia, treats emergence delirium, supplements sedation in local/regional anesthesia and MAC
Has a synergistic effect w/ opioids which may cause significant respiratory depression, hypotension, and tachycardia. May cause prolonged sedation/confusion.
Reduce respiratory depression with flumazenil (rumazicon)
Describe some DEPOLARIZING neuromuscular blocking agents that you may use in adjunct to general anesthesia
Succinylcholine (anectine)
promotes endotracheal intubation and access to surgical sites d/t skeletal relaxation (paralysis)
Causes apnea r/t paralysis of resp muscles. Action of depolarized agents may take longer than the surgery to fade.
Describe some NON-DEPOLARIZING neuromuscular blocking agents that you may use in adjunct to general anesthesia
Atracurium, cisatracurium, pancuronium, rocuronium
effects can be reversed toward end of surgery w/ anticholinesterase agents (neostigmine) unlike depolarized agent.
The reversal agent still may not completely reverse the effects.
Correction of hypothermia may increase muscle weakness.
May cause confusion and nausea.
Describe some opioids that you may use in adjunct to general anesthesia
Used to induce and maintain anesthesia by reducing stimuli from sensory nerve endings. it provides analgesia during surgery and recovery in the PACU.
it causes respiratory depression, vomiting, bradycardia, peripheral vasodilation (when combined w. anesthetics), and it high risk for pruritus w/ both regional and IV admin.
Usually coincides w/ standing order for antiemetics and antipruritics.
Have naloxone on hand by keep in mind use also reverses analgesic effects.
Describe the balanced technique
using adjunctive drugs to complement an induction for general anesthesia
Describe the steps of putting a patient under routine general anesthesia
You begin with an IV induction agent (hynotic, anxiolytic, dissociative agent). These agents induce sleep rapidly. However, a single dose only lasts a few minutes. This is long enough to place an advanced airway. Once this is done the ACP give the inhalation and IV agents.
What are two types of advanced airways that may be used during general anesthesia?
LMA (Laryngeal mask airway, option for difficult airways by do not provide access to trachea/airway protection w/ same certainty as ET) or ET (endotracheal tube).
What are two types of inhalation agents
volatile liquids or gas
Define drug adjuncts
Drugs other than the inhalation anesthetic in general anesthesia
Define dissociative anesthesia
dissociative anesthesia interrupts associative brain pathways while blocking sensory pathways.
Pt may appear catatonic, is amnesic, and has profound analgesia that lasts into the postoperative period.
Ex: Ketamine is given to trauma pts to increase heart rate and maintain cardiac output. It also is given to asthmatic pts to promote bronchodilation. It causes hallucinations/nightmares by that can be counteracted w/ midazolam (versed)
What is the physiology of local anesthesia?
Ex: lidocaine
Interrupts generation of nerve impulses by changing the flow of sodium into nerve cells. Results in autonomic nervous system blockade that presents as skeletal muscle flaccidity/paralysis.
Can be topical, ophthalmic, nebulized, injected
Does not involve sedation/loss of consciousness
What is the physiology of regional anesthesia?
otherwise known as a “block”
Always injected
Involves a central nerve (spinal) or group of nerves (plexus) that innervate a site remote to the point of injection.
May involve MAC. Can be done before, during, after operation. Pump can be implanted during surgery for continuous pain relief up to 72 hours after the procedure.
Pros/cons of using local/regional anesthesia over general anesthesia
PROS
Rapid recovery
Discharge w/ post-op anesthesia w/ out any accompanying cognitive dysfunction
Safely used in patients w/ comorbidities
CONS
technical problems, difficulty matching duration of action w/ duration of procedure, risk for inadvertent vascular injections that could led to LOCAL ANESTHETIC SYSTEMIC TOXICITY (LAST) which presents as confusion, metallic taste, oral numbness, and dizziness.
Why mix epinephrine with a local anesthetic cream?
To cause localized vasoconstriction that decreases absorption and extends the action of the agent
What would be the symptoms of a patient with local anesthetic in their general circulation?
tachycardia, hypertension, general feeling of panic
Spinal and epidural anesthesia is a type of ______ anesthesia
regional
Where is spinal anesthesia anatomically placed?
injection into the cerebrospinal fluid in the subarachnoid space, usually below L2.
Used for extremities, joint replacements, lower GI procedures, prostate/gynecological procedures.
Where is epidural anesthesia anatomically placed?
injection into the epidural space via a throacic or lumbar approach. The anesthetic does not enter the cereospinal fluid, but binds to nerve roots as they enter and exit the spinal cord. Sensory pathways are blocked but motor fibers are still intact in lower doses. higher doses both sesnory and motor are blocked.
What are symptoms of a autonomic nervous system blockade
seen in spinal/epidural anesthesia
hypotension, bradycardia, nausea, vomiting
Describe malignant hyperthermia
MH is an adverse affect that some people have to certain anestheitc agents, especially volatile inhalation agents. Stress. trauma, and heat can also trigger.
Usually occurs during general anesthesia. Can also occur post-op.
Its a dominant genetic trait. Happens because skeletal muscle cells hypermetabolize which eventually destroys them
Treated w/ dantrolene which slows the metabolism and reduces muscle contraction
What are the most common causes of airway compromise?
obstruction (pt’s tongue, laryngeal edema/spam, thick secretions), hypoxemia (atelectasis, pulmonary edema/embolism, aspiration, bronchospams), hypoventilation (depress CNS, mechanical restriction, pain, poor resp muscle tone)
How should you prevent respritory problems in the PACU
supine position w/ elevated head, O2 therapy can help eliminate gasses, encourage deep breathing to decrease atelectasis, effective coughing, change position every 1-2 hours,
What is the goal of a preoperative nursing assessment?
Identify risk factors and plan care to ensure safety
throughout the surgical experience.
What are the three types of consent taken preoperatively?
– Surgical consent
– Anesthesia
– Blood products
What is the purpose of a surgical time-out?
- To prevent wrong site, wrong
procedure, and wrong surgery - Components:
– Pre-procedure verification process
– Mark the procedure site
– Perform a time-out
How do you conduct a pre-procedure verification process?
Verify correct site,
procedure, and patient
Verify critical items are present (documentation, lab results, blood, special equipment)
What are 6 key things the HCP must disclose prior to a procedure?
There must beadequate disclosureof the (1) diagnosis; (2) nature and purpose of the proposed treatment; (3) risks and consequences of the proposed treatment; (4) probability of a successful outcome; (5) availability, benefits, and risks of alternative treatments; and (6) prognosis if treatment is not instituted.
What is the number one risk to look out for in a patietn under general anesthesia?
malignant hyperthermia, Treated with Dantrolene (Dantrium)
Succinylcholine (Anectine), especially when given with volatile inhalation agents, is the primary trigger of MH
