NURS 4526 Lecture Notes - Lecture 5: Muscle Relaxant, Spinal Anaesthesia, General Anaesthesia

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13 Aug 2016
-Surgery is performed for: diagnosis; cure & repair; palliation; prevention; exploration or cosmetic improvement
-Suffixes: ectomy = removal (ie. Appendectomy), lysis = destruction (electrolysis), orrhapy = repair or reconstruction of;
oscopy = looking into; ostomy = creation of opening into; otomy = cutting or incision of; plasty = repair/reconstruction
-Ambulatory out pt – same day surgery that’s <2 hrs; pt 3-4 hrs in pacu
-Nurse must: 1. Have knowledge of nature of disorder/coexisting disease processes, 2. Must ID individual pt response to stress
of surgery, 3. Must assess results of preop tests, 4. Consider body alterations/potential risks/complications associated w.
surgical procedure
Client Interview
-Purpose of preop interview is to begin teaching, obtain client health info, determine expectations, provide/clarify info about
procedure and assess emo state, begin some post op teaching
Nursing Assessment of the Client Before Surgery
-Overall goal is to ID risk factors and plan care to ensure client safety
-Overall Goals:
oDetermine psychological status to reinforce coping strategies
oDetermine physiological factors of procedure contributing to risk factors
oIdentify cultural & ethnic factors that may affect surgical experience
oDetermine pt has received adequate info from surgeon in order to sign informed consent
oIdentify any psychosocial needs of the client & assess pt ability to cope with stressors and change to lifestyle
oEstablish baseline data
oIdentify medications and herbs taken that may affect surgical outcome
oIdentify, document and communicate results of lab/diagnostic tests
Psychosocial Assessment:
-The psychological and physiological rxns to the surgery elicit the body’s stress response – if the stressors or the response to
the stressors are excessive, the stress response can be magnified and recovery can be affected
-Factors that influence pt susceptibility to stress incl age, past experiences, current health and socioeconomic status
-Emo rxns to impending surgery and hospitalization often intensify in the OA – hospitalization may represent to the pt a
physical decline and loss of health, mobility and independence – may view it as a place to die; nurse can alleviate anxieties
and fears of pt while maintaining and restoring the self-esteem of the OA during surgical experience
-Nurse must use common language and avoid medical jargon when speaking to pt; use translator if needed and mutually ID
stressors to level of anxiety
-Psychosocial assessment of pt undergoing surgery:
oSituational changes – support systems, degree of personal control, DM, etc
oConcerns with unknown – ID expectations of surgery, changes in current H, affect on ADL
oConcerns with body image – ID current roles & view of self, det perceived/potential changes in role and impact on
body image
oPast experiences – review prev experiences in hospital, det response to them, ID current perception of surgical
procedure; Knowledge Deficit – ID amt and type of preop info pt wants to receive, ID what the pt has to know
preop, assess understanding of surgical procedure, ID accuracy of info client has received about surgery from others
-Anxiety: fear of the unknown can impair cognition, DM & coping abilities; it arises form lack of knowledge (ie what to
expect during experience or outcome of surgery); pt can have unrealistic expectations – nurse can help alleviate anxiety by
providing info abt what can be expected
oAnxiety can also arise form conflict with interventions (ie. Blood transfusions & religious and cultural beliefs) –
nurse should ID beliefs & discuss with surgeon and operative staff
oDeath/disability – may prompt postponement of surgery and influence outcome – tell MD
oPain/discomfort – consult with anesthesiologist, reassure drugs will be available, make sure u tell pt to request pain
meds after surgery & discuss that it wont cause addiction
oMutilation/altered body image – assess concerns nonjudgmentally
oAnaesthesia – assess malignant hyperthermia risk, notify anesthesiologist to talk to pt
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oDisruption of life fxning – range form fear of perm disability to temp loss, incl separation from family and financial
concerns, consultations prn!
-Hope: may be strongest positive coping mecha – never deny or minimize it; assess and support
Past Health History
-Past/present health problems, for females – obstetrical/menstrual history, possible inherited conditions (endocrine, diabetes,
cardiac disease), pt or fam rxns to anaesthesia, previous surgery
-Current med use/OTC/herbs bc they can interact with anesthetics
-Drug intolerance, drug allergies, recreational drug/alcohol use
-Nurse should inquire about nondrug allergies incl allergies to foods, chemicals, tape, pollen
-Possible latex allergies; assess for: risk factors, contact dermatitis, urticarial, aerosol rxns
Review of Systems
-Cardiovascular: determine presence of pre or existing disease
oIe. History of cardiac prob incl HT, angina, dysrhythmias, CHF, MI, use of pacemakers, use of cardiac drugs,
problems for effective monitoring
oVitals recorded preop for baseline, bleeding/clotting times, lab reports
oPossible prophylactic antibiotics to risk of bacterial endocarditis if pt has history of HD
-Respiratory: any recent or chronic er resp conditions/infxns – if they have this procedure could be cancelled bc of incr risk
of laryngo/bronchospasm, SpO2 & prob with RR secretions
oClients with COPD/asthma are at risk of hypoxemia & atelectasis post op
oHistory of dyspnea, coughing, hemoptysis is reported to operative team
oSmokers should be encouraged to quit 6 wks before procedure – risk of complications; greater years & number of
packs = risk
oHistory of obesity, spinal, chest or airway deformities & sleep apnea
-Neurological: eval neuro fxn preop – answer Q, follow commands, maintain orderly thought process? – vision/hearing loss
can infl results
oHistory of strokes, TIA, SC injury, CP, MS etc
oCognitive fxn: assess or correct deficits preop – if they cant be corrected det whether there are appropriate resources
and support to assist pt
oPost op delirium (falsely labeled senility/dementia) can occur w/dehydration, hypothermia & adjunctive meds
-Urinary: renal/urinary disease? (UTI, renal insuff) – renal dysfxn contri to fluid & lyte imbalances, risk of infxn,
coagulopathies, wound healing, altered response to drugs & their elim; renal function tests, note problems voiding and
inform operative team
-Hepatic: consider prob with glucose control, clotting abnormalities & response to drugs – consider presence of liver disease if
there is a history of jaundice, hepatitis or alcohol abuse; test liver fxn – ALT, AST, ALP, bilirubin levels
-Integumentary: skin/msk probs, pressure ulcers? – extra padding during procedure, affects postop healing
-Musculoskeletal: mobility – ID joints affected with arthritis, mobility restrictions may affect positioning and ambulation,
bring mobility aids to surgery, report problems affecting neck/lumbar spine –affect management & anesthesia delivery
-Endocrine: diabetes – hyper/hypoglycemia, ketosis, or alterations in CV, wound healing, infections, cap bglu tests morning
of surgery to est baseline, clarify with MD or anaesthesiologist if usual dose of insulin is taken etc; thyroid dysfxn –
hyper/hypo are surgical risk dt altered meta rate, verify with anaesthesiologist abt giving meds
Immune System
-Clients with history of compromised immune system or use of immunosuppressive drugs can have delayed wound healing
and incr risk for infxn
-Fluid/lytes: client asked abt diarrhea, vomiting, difficulty swallowing
oID drugs that alter status (Diuretics), eval serum lyte levels
oNPO status – may require additional fluids/lytes prior to surgery if dehydration occurs
-Nutritional status - nutrition or under – vitamin ACB = wound healing
oObesity: stresses CV & RR system; incr risk of wound dehiscence and infxn, slower recovery from anesthesia,
slower wound healing
oProvide extra padding to underwt pt to prev P ulcers
oID dietary habits that may affect recovery eg. caffeine
Objective Data
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-Physical Exam: review of systems prior to surgery; findings enable anesthesiologist to rate pt for anesthetic admin – indicator
of perioperative risk and overall outcome
oDoc relevant findings and report to periop team
oObtain and eval results of lab tests (urinalysis, chest x ray, blood studies, electrolytes, ABGs, oximetry, INR or PTT,
bglu, creatinine, BUN, ECG, PFT, liver fxn tests, type and crossmatch for blood, pregnancy)
oMonitor bglu for diabetes
Postoperative Teaching
-Client needs to know what to expect and how to participate effectively incr pt satisfaction, post op fear & anxiety, stress,
pain & vomiting, complications, duration of stay
-3 types of info: sensory info – pt wants to know what they will see, hear, smell & feel during op
oProcess info: not specific details but general flow
oProcedural: more specific info
-Limited time available: address needs of highest priority, incl info focused on safety, provide written material
-Teaching must be documented/reported to post-op nurse so that learning can be reinforced and supplemented
oAssess learning – comm nurse has to be informed if pt has ongoing learning needs
-Teach deep breathing, coughing and moving (pt may be hesitant to learn post op)
-Inform if tubes, drains, monitoring devices or special equip will be used postop
-Several days preop – observe and listen to det amt of teaching for each session, anxiety and fear can hinder learning, give
priority to pt concerns
-Basic info before arrival: time & place, fluid & food restrictions, need for enema or other prep, need for shower
Legal Preparedness
-Signed consent form and blood transfusion, advanced directives, power of attorney
-Legally appointed rep of fam may consent if pt is a minor, unconscious, mentally incompetent
-Informed consent: adequare disclosure of diagnosis, pt must demonstrate clear understanding and comprehension of info,
they must voluntarily give consent, operative consent must be signed before any preop med is given
-Surgeon is responsible for obtaining consent – nurse may obtain and witness signature, verify pt has understanding, pt
permission can be withdrawn @ any time
-Medical emergency may override need for consent
-No need for consent if: pt in life/health threatening episode, when tx cant be delayed w/o endangering life or health of pt,
when client is unable to consent bc of consequences beyond their control
Day of Surgery Preparation
-Nursing role: final preop teaching; assessment and report of pertinent findings; verify signed consent (all forms/orders are
complete); labs, history & PE report, baseline vitals, consultation records, nurse’s notes; client shouldn’t be wearing
cosmetics (have to observe skin color), no nail polish; dentures, contacts, prosthesis removed, ID allergy & band on wrist;
void preop – to avoid intra op loss of control or postop retention
-Preop meds:
oBenzodiazepines & barbiturates (sedative/amnestic properties)
oAnticholinergics (to reduce secretions)
oNarcotics (to decrease intraoperative anaesthetic requirements and pain)
oAntiemetics (to decrease post-operative nausea and vomiting)
oAntibiotics, eyedrops, routine prescription drugs
oPO 60-90 min prior, IM-subcut 30-60 min prior, IV after arrival
oProperties of preop meds: analgesia, n/v, sedate/amnesia, anesthetic, facilitate anesthetic, relieve anxiety,
prevent autonomic reflex response, decr resps & GI secretions
Transportation to OR
-Inpatients transported by stretcher to operating room from room
oSide rails raised and secured
oChart and preoperative equipment with client
oFamily may accompany client to holding (depending on hospital policy)
-Outpatients transported by cart, wheelchair, or may walk
oMethod of transport documented by nurse responsible for transferor hospital policy
-Family instructed on waiting area where they can be informed of progress
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