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7/29/2019 Surgery Slides Fall 13
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(Relates to Chapter 18,
“Nursing Management:
Preoperative Care,”
in the textbook)
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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• Art and science of treating
diseases, injuries, and deformities
by operation and instrumentation
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• Performed for
Diagnosis
CurePalliation
Prevention
ExplorationCosmetic improvement
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• Elective surgery vs. emergency
surgery
•
InpatientSame-day admission
• Ambulatory (outpatient)
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• Have knowledge of the nature of
the disorder requiring surgery.
•
Identify the individual patient’sresponse to the stress of surgery.
• Assess the results of appropriate
preoperative diagnostic tests.• Provide a baseline by identifying
potential risks and complications.
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• Check documented information prior
to interview.Avoids repetition
• Occurs in advance or on day of surgery
• Purpose
Obtain health information.
Determine expectations.Provide and clarify information on
procedure.
Assess emotional state and readiness.Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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• Overall goals
Identify risk factors.
Plan care to ensure patient safety.• Determine psychologic status to
reinforce coping strategies.
• Determine physiologic factorsthat may contribute to increasedsurgical risk.
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• Establish baseline data.
• Identify medications and herbs
taken that may affect surgicaloutcome.
• Identify, document, and
communicate results of laboratory/diagnostic tests.
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• Identify cultural and ethnic factors
that may affect surgical
experience.• Determine receipt of adequate
information from surgeon to sign
informed consent.• Determine informed consent and
that informed consent form is
signed and witnessed.Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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• Psychosocial assessment
Excessive stress response can be
magnified and affect recovery.• Influencing factors
Age
Past experienceCurrent health
Socioeconomic status
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• Use common language.
• Use translators if needed.
Decreases level of anxiety• Communicate all concerns to
surgical team.
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• Anxiety can impair cognition,
decision making, and coping
abilities.• Anxiety can arise from
Lack of knowledge
Unrealistic expectations• Information lessens anxiety.
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• Anxiety may arise from conflict
with interventions (i.e., blood
transfusions) andreligious/cultural beliefs.
Identify beliefs and discuss with
surgeon and operative staff.
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• Fears
Death or disability
• May prompt postponement
• Influence outcome
Pain
• Consult with HCP
• Confirm drugs will be available.
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• FearsMutilation/alteration in body image
• Assess concerns nonjudgmentally.
Anesthesia• HCP for consult
Disruption of life functioning
• Range from fear of permanent disability totemporary loss
• Include family and financial concerns
•
Consultations PRNCopyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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• Hope
May be strongest positive copingmechanism
• Never deny or minimize.
Assess and support.
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• Health historyDiagnosed medical conditions (previous
and current)
Previous surgeries and problemsMenstrual/obstetric history
Familial diseases
• Conditions
Reactions/problems to anesthesia(patient or family)
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• Current medications
Prescription and OTC
HerbsDietary supplements
Recreational
•
Drugs• Alcohol
• Tobacco
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• Allergies (drug and nondrug)
• Screen for latex allergy:
Risk factorsContact urticaria or dermatitis
Aerosol reactions
History of reactions suggesting latexallergy
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• Cardiovascular system
Report
• Any cardiac problems so they can be
monitored during the intraoperative
period
• Use of cardiac drugs
• Presence of pacemaker/ICD
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• Cardiovascular system
Vitals recorded preoperatively forbaseline
Bleeding/clotting times
Laboratory reports
Possible prophylactic antibiotics
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• Respiratory system
Inquire about recent airway infections.
• Procedure could be cancelled because of
increased risk of laryngo/bronchospasm or
decreased SaO2.
History of dyspnea, coughing, or
hemoptysis reported to operative teamCOPD or asthma
• High risk for atelectasis and hypoxemia
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• Respiratory system
Smokers should be encouraged to quit6 weeks before procedure.
• Decreases risk of complications
• Greater years and number of packs =greater risk
• Nervous system
Evaluation of neurologic functioning• Vision or hearing loss can influence results.
Cognitive function
•
Determine if any deficits are presentCopyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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• Genitourinary systemHistory of urinary or renal diseases
Renal dysfunction contributes to• Fluid and electrolyte• Increased risk of infection
• Impaired wound healing
•
Altered response to drugs and theirelimination
Renal function tests
Note problems voiding, and inform
operative team.Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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• Hepatic system
Liver detoxifies many anesthesics andadjunctive drugs.
Hepatic dysfunction may increase risk of
postoperative complications.
• Integumentary system
History of skin and musculoskeletal
problems
History of pressure ulcers
• Extra padding during procedure
• Affects postoperative healingCopyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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• Musculoskeletal system
Identify joints affected with arthritis.
Mobility restrictions may affectpositioning and ambulation.
Bring mobility aids to surgery.
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• Musculoskeletal system
Report problems affecting neck orlumbar spine to HCP.
• Can affect airway management and
anesthesia delivery
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• Endocrine systemPatients with diabetes mellitus
especially at risk for:• Hypo/hyperglycemia
•
Ketosis• Cardiovascular alterations
• Delayed wound healing
• Infection
Serum or capillary glucose tests morningof surgery (baseline)
Clarify with physician or ACP regarding
insulin dose.Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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• Endocrine system
Patients with thyroid dysfunction
• Hyper/hypothyroidism are surgical risks dueto altered metabolic rate.
• Verify with ACP about giving thyroidmedications.
Patients with Addison’s disease
•
Abruptly stopping replacementcorticosteroids could cause addisonian crisis.
• Stress of surgery may require increased dose
of corticosteroids.
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• Immune system
Patients with history of compromised immune system or useof immunosuppressive drugs canhave
• Delayed wound healing
• Increased risk for infection
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• Fluid and electrolyte status
Vomiting, diarrhea, or difficultyswallowing can cause imbalances.
Identify drugs that alter F and E status.
• Diuretics
Evaluate serum electrolyte levels.
NPO status
• May require additional fluids and electrolytes
before surgery if dehydration occurs
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• Nutritional status
Obesity• Stresses cardiac and pulmonary systems
• Increased risk of wound dehiscence and infection
• Slower recovery from anesthesia
• Slower wound healing
Provide extra padding to underweight patients to
prevent pressure ulcers.
Identify dietary habits that may affect recovery(e.g., caffeine).
May be protein and vitamin deficient
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• Findings enable HCP to rate patient foranesthesia administration.
Indicator of perioperative risk and overall
outcome• Document relevant findings, and report to
perioperative team.
• Obtain and evaluate results of laboratory
tests.
• Monitor blood glucose for patients with
diabetes.
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• Preoperative teaching
Patient has right to know what to expectand how to participate.
• Increases patient satisfaction
• Reduces fear, anxiety, stress, pain, and
vomiting
Limited time available• Address needs of highest priority.
• Include information focused on safety.
•
Provide written material.Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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•Preoperative teaching
Three types
•Sensory
•Process
•Procedural
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• Preoperative teaching
Must be documented and reportedto postoperative nurses
• Avoid duplication of information.
• Assess learning. Teach deep breathing, coughing, and early
ambulation as appropriate.
Inform if tubes, drains, monitoringdevices, or special equipment will be usedpostop.
Provide surgery-specific information.
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• Preoperative teaching
Basic information before arrival
• Time and place
• Fluid and food restrictions
• Need for enema
• Need for shower
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• Legal preparation
All required forms are signed and
in chart:• Informed consent
• Blood transfusions
• Advance directives• Power of attorney
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• Consent for surgery
Informed consent must include
• Adequate disclosure
• Understanding and comprehension• Voluntarily given consent
• Surgeon responsible for obtaining consent
Nurse may obtain and witness signature. Verify patient has understanding.
Permission may be withdrawn at any time.
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• Consent for surgery
Medical emergency may overrideneed for consent.
• Legally appointed representativeof family may consent if patient is
MinorUnconscious
Mentally incompetent
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• Day-of-surgery preparation
Final preoperative teaching
Assessment and report of pertinentfindings
Verify signed consent.
Labs
History and physical examination
Baseline vitals
Consultation records
Nurse’s notes Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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• Day-of-surgery preparation
Patient should not wear any cosmetics.• Observation of skin color is important.
• Remove nail polish for pulse oximeter.
Valuables are returned to family memberor locked up.
Dentures, contacts, prostheses are
removed. Identification and allergy bands on wrist
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• Void before surgery
Prevents involuntary eliminationunder anesthesia or during earlypostoperative recovery
Before medication administration
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• 45-year-old woman presents to holdingarea for presurgical workup for rightbreast lumpectomy.
• The nurse notes constant fidgeting.
• She is unable to articulate details aboutwhat the surgeon will do or her disease
process.• She reacts angrily when asked if she would
consent to transfusion, if needed.
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1. What do you think is happening
with her?
1. What can you do to help her and
prepare her for the procedure?
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(Relates to Chapter 19,“Nursing Management: Intraoperative Care,”
in the textbook)
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• Nursing care requires
understanding of
Anesthesia
Pharmacology
Surgery
Surgical interventions• Allows you to monitor patient’s
response
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• Historically, took place in OR
• Current trend to ↓ in-hospital
surgery and ↑ ambulatoryprocedures
Healthier patients
Shorter procedures
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• Specialties with highest numbers
of surgical patients
Ophthalmology
Gynecology
Plastic surgery
OtorhinolaryngologyOrthopedic surgery
General surgery (e.g., hernia repair)
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• You must keep current on
technologies.
•
Maintain asepsis in the surgicalenvironment.
• Continue to be a strong advocate
for the patient.
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• Surgical suite
Controlled environment
Designed to minimize spread of infection
Allows smooth flow of patients,personnel, andinstruments/equipment
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• Unrestricted areas
Personnel in street clothes interactwith those in scrubs.
Holding area
Locker room
Information areas
• Nursing station
• Control desk
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• Semirestricted areas
Peripheral support areas andcorridors with only authorizedpeople
Must wear surgical attire and coverall head and facial hair
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• Restricted areas
Operating rooms
Scrub sink areas
Clean core
Surgical attire, head covers, andmasks required
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• Holding area
Waiting area inside or adjacent tosurgical area
Final identification and assessment
Friends/family allowedSurgical Care Improvement Project
(SCIP) measures to implement here
•Patient warming
• Prophylactic antibiotic administration
• Application of sequential compression
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• Operating room
Geographically, environmentally,bacteriologically controlled
Restricted inflow and outflow of personnel
Preferred location is next to PACU and surgical
ICU.
Filters
Controlled airflow
Positive air pressure
Ultraviolet lighting
No dust-collecting surfaces
Materials resistant to corrodingCopyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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• Adjustable, easy-to-clean, and easy-to-move furniture is used.
• Equipment is checked for electrical
safety.
• Lighting provides low to high
intensity for precise view of surgicalsite.
• Communication system is used.
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• Perioperative nurse Prepares room with team Patient advocate throughout surgical
experience
•
Circulating nurse Not scrubbed, gowned, or gloved
Remains in unsterile field
Documents
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• Scrub nurse
Follows designated scrub procedureGowned and gloved in sterile attire
Remains in sterile field
• LPN or surgical technician
Performs scrubbed or circulating function
Passes instruments and implements othertechnical functions during procedure
Supervised by RN
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• Surgeon
Physician who performs theprocedure
Responsible for
• Preoperative medical history
• Physical assessment
• Patient safety• Postop management
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• Surgeon’s assistant can be
physician or RN who functions inassisting role.
Holds retractors
Assists with homeostasis andsuturing
May perform portions of procedureunder direct supervision
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• Registered nurse first assistant
Must have formal education
Handles tissue
Uses instruments
Provides exposure to surgical site
Assists with homeostasisPerforms suturing
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• Anesthesia care provider
Administers anesthesiaAnesthesiologist or nurse anesthetist
Maintenance of physiologic
homeostasis throughout intraoperativeperiod
Prescribes preoperative and adjunctive
medicinesMonitors cardiac and respiratory status
and vital signs throughout procedure
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• Before surgery Psychosocial assessment Cultural assessment
History and physical assessment
•
Baseline data• Herbs and dietary supplements increase risk
of complications for patients.
Education
Chart review
• History and physical examination
• Urinalysis, ECG, Chest x-ray
• CBC, Serum electrolytes
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• Admitting patient
GreetingExtension of human contact and warmth
Proper identification
Complementary and alternative therapies• Decrease anxiety
• Promote relaxation
• Reduce pain• Accelerate healing process
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• Admitting patient
ReassessmentLast-minute questions
Review of chart
Final questioning about valuables,prostheses, contacts, last intake of food/fluid
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• Room preparation
Surgical attire worn by all personsentering OR suite
Electrical and mechanical equipment
checked for proper functionAseptic technique practiced when
placing instruments
•Counts
• Functions of team members delineated
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• Transferring patient
Patient transported into OR afterpreparation
Sufficient number of staff to lift, guide,
and prevent patient falls, as well asinjury to staff
Straps across patient
Caution with monitor leads, IVs, andcatheters
Wheels locked
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• Scrubbing, gowning, and gloving
Cleanse hands and arms by scrubbingwith detergent and brush.
• Eliminates dirt and oil
•
Decreases microbes• Inhibit rapid regrowth of microorganisms
Standard procedure for personnel
Waterless products are sometimes used.Sterile gown and gloves are put on after
scrub
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• Basic aseptic technique
Center of sterile field is site of surgical incision.
Only sterilized items in sterile field
Protective equipment
• Face shields, caps, gloves, aprons, and
eyewear
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• Assisting anesthesia care provider
Understand mechanism of anestheticadministration and pharmacologiceffects of the agents.
Know location of emergencyequipment and drugs in the OR.
Circulating nurse may place monitoring
devices on patient.Remain at patient’s side to ensure
safety.
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• Safety considerations
Smoke particles
Grounding pad
Universal protocol
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• Positioning of patient
Accessibility of operative siteAdministration and monitoring of
anesthetic agents
Maintenance of airwayCorrect skeletal alignment
Prevent pressure on nerves, skin, bony
prominences, or eyes.Provide for adequate thoracic
excursion.
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• Positioning of patient
Prevent occlusion of arteries and veins.Provide modesty in exposure.
Recognize and respect needs such as
pain or deformities.Prevent injury
• Patient will not feel pain impulses because
of anesthesia.• Secure extremities.
• Provide adequate padding and support
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• Preparing surgical site
Scrubbing or cleaning around the surgicalsite with antimicrobial agents
• Circular motion from clean to dirty area
Hair may be removed with clippers.• After surgery HCP and perioperative team member take
patient to PACU and give report. Perioperative nursing data set (PNDS) reflects
standards of nursing care in any perioperative
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• General anesthesia
Technique of choice for surgerieswith significant duration or that
require relaxation/uncomfortableposition/control of respiration
Loss of sensation with loss of
consciousnessMay be induced by IV or inhalation
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• General anesthesia
IV agents
• Beginning of virtually all general
anesthesia
• Induce pleasant sleep
• TIVA (total intravenous anesthesia)
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• General anesthesia
Inhalation agents
• Volatile liquids or gases
• Easy administration and rapid excretion
• Irritating to respiratory tract
• Once initiated, use endotracheal tube or
LMA (laryngeal mask airway) .
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• General anesthesia
Rarely use only one agent
• Adjuncts
Dissociative anesthesia
• Ketamine (Ketalar)
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• Adjuncts to general anesthesia
Opioids• Sedation and analgesia
• Induction and maintenance
intraoperatively• Pain management postoperatively
• Respiratory depression
Benzodiazepines
• Premedication for amnesia
• Induction of anesthesia
• Monitored anesthesia care
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• Adjuncts to general anesthesia
Neuromuscular blocking agents• Facilitate endotracheal intubation
• Relaxation/paralysis of skeletal muscles
•
Interrupt transmission of nerve impulsesat neuromuscular junction
• Classified as depolarizing or
nondepolarizing muscle relaxants
• Duration of effects may be longer than theprocedure.
• Reversal agents may not be effective in
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Neuromuscular blocking agents
• Observe closely for airway patency andadequacy of respiratory muscle movement.
• Lack of movement or poor return of reflexes
and strength may indicate need for ventilator.
• Adjuncts to general anesthesia
Antiemetics
• Prevent nausea and vomiting associated with
anesthesia
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• Local anesthesiaLoss of sensation without loss of
consciousness
Types
• Topical
• Ophthalmic
• Nebulized• Injectable
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• Regional anesthesiaLoss of sensation in body region
without loss of consciousness when
specific nerve or group of nerves isblocked by administration of localanesthetic.
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• Local and regional anesthesiaLittle systemic absorption
• Rapid recovery
• Little residual “hangover”
Possible discomfort, hypotension,and seizures
Technical difficulties
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• Regional anesthesiaMay assist in administration
• Detailed assessment
Allergies
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• Methods of administrationTopical
• Apply 30 to 60 minutes before
procedure.
Local infiltration
• Inject agent into tissues through which
incision will pass.
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• Methods of administrationRegional nerve block
• Inject agent into or around specific nerve
or group of nerves.
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• Methods of administrationSpinal anesthesia
• Injection of agent into CSF of
subarachnoid space• Usually below L2
• Autonomic, sensory, and motor
blockade
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• Methods of administrationEpidural block
• Injection of agent into epidural space
• Does not enter CSF
• Binds to nerve roots as they enter and
exit the spinal cord
•
Sensory pathways blocked, but motorfibers intact
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• Spinal and epidural anesthesiaObserve closely for signs of
autonomic nervous system (ANS)
blockade• Bradycardia
• Hypotension
•Nausea/vomiting
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• Anesthetic drugs should be carefullytitrated.
• Assess for poor communication.
• Risk from tape, electrodes, andwarming/cooling blankets
• Osteoporosis
• Perioperative hypothermia
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• Anaphylactic reactionsManifestation may be masked by
anesthesia.
Vigilance and rapid intervention areessential.
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Malignant hyperthermia
Rare metabolic diseaseHyperthermia with rigidity of skeletal
muscles (high fever, acidosis, high HR))
Often occurs with exposure tosuccinylcholine, especially in conjunctionwith inhalation agents
Usually occurs under general anesthesiabut may also occur in recovery
Other triggers
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• Malignant hyperthermia
Inherited hypermetabolism of skeletalmuscle resulting in altered control of intracellular calcium
TachycardiaTachypnea
Hypercarbia
Ventricular dysrhythmiasRise in body temperature NOT an early sign
Can result in cardiac arrest and death
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• Treatment
• Dantrolene (Dantrium) slows
metabolism, reduces muscle
contraction, and mediates thecatabolic processes associated
with MH.