1. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 13: The Postanesthesia Patient

2. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Differences Between Sedation Levels Moderate Sedation More responsive to verbal or tactile stimulation Maintains airway on own Able to breathe on own Monitored Anesthesia Care Responsive only to deep stimulation May need an artificial airway placed May need assistance with breathing

3. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Anesthetic Options for Surgery

4. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Medication Choices for Anesthetic Options See Figure 13-1.

5. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following is expected in a patient under moderate sedation? A. Impaired coordination B. Protective reflexes intact C. Response to purposeful or painful stimuli D. Loss of consciousness

6. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. Protective reflexes intact Rationale: A client under moderate sedation responds purposefully to verbal commands and has protective reflexes intact. The client can manage his or her own airway. Impaired coordination is seen with a client under mild sedation. A client under deep sedation responds only to purposeful or painful stimuli. A client under general anesthesia has a loss of consciousness.

7. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Anesthesia Provider-to-Nurse Report: Information to Convey

8. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Oxygenation/Ventilation Care Assessment Assess for clinical signs of hypoxia or hypoventilation Assess weaning parameters before extubation from mechanical ventilation Interventions “Stir-up” regimen Head of bed elevated, unless contraindicated Position head in neutral position Protect airway from aspiration

9. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Circulation/Perfusion Care Assessment Compare baseline with postop values in the following areas: ECG rhythm, rate BP, heart rate Peripheral vascular- sensory checks Estimated blood loss Interventions Monitor VS and ECG/protocol Monitor peripheral vascular-sensory checks Assess I&O Assess estimated blood loss and Hgb/Hct (assess wounds)

10. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Fluid/Electrolyte Balance Hypervolemia Elevated blood pressure Pulmonary crackles Neck vein distention Decreased urine specific gravity (if measured) Potential for electrolyte imbalance Hypovolemia Low blood pressure, tachycardia Increased urine specific gravity (if measured) Decreased skin turgor, dry mucous membranes Potential for electrolyte imbalance

11. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Mobility/Safety for the Postanesthesia Patient Assess level of consciousness Reorient to surroundings and events Maintain safety measures with bed and equipment Assess motor/sensory function to determine whether the neuromuscular blockade is wearing off Assess level of local anesthesia, if used

12. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Skin Integrity Care for the Postanesthesia Patient Assess for skin breakdown Protect skin from pressure, moisture, and shearing forces Reposition as soon as possible, considering any limitations in positioning

13. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Nutrition for the Postanesthesia Patient Assess for nausea and treat with antiemetics Assess for bowel sounds Provide fluids once airway is patent and no risk of aspiration Provide enteral feeding once bowel sounds return

14. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Comfort/Pain Control for the Postanesthesia Patient Assess pain and treat with pharmacological and non- pharmacological interventions Monitor epidural analgesia –Observe site of insertion and dressing for patency –Observe pain level, respiratory rate, BP, level of consciousness, and sensation

15. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Psychosocial Care for the Postanesthesia Patient Include the patient’s support system as soon as possible (as the patient has predetermined to be appropriate) Explain the care being provided and the reasons on an ongoing basis to the patient/support system Assess for patient/support person understanding and clarify any areas of misunderstanding Get referrals to social service, clergy, etc. as needed

16. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Teaching/Discharge Planning for the Postanesthesia Patient Instruct patient’s support system on reason for orientation and how to provide it Instruct on proper use of incentive spirometer and splinting when coughing Instruct on mobility preparation exercises performed in bed Instruct on need to call the nurse for assistance before ambulation, especially the first time Instruct on pain control strategies

17. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Management of Laryngospasm Brief spasm (involuntary contraction of muscle) of vocal cords interrupting speech and breathing for 30 to 60 seconds Causes: General anesthesia, inhalation injury, hypocalcemia, severe GERD Treatment: establish airway, give 100% O2 via bag- valve mask with tight seal, inhalation of racemic epinephrine, paralysis and ventilator if needed

18. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Management of Airway Obstruction Signs/Symptoms –Wheezing and stridor –Use of accessory muscles and paradoxical breathing –Change in level of consciousness Treatment –Head tilt/chin lift; jaw thrust –Establish airway - intubation

19. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following is the first action the critical care nurse should take when a postanesthesia client has a laryngospasm? A. Prepare client for intubation. B. Administer succinylcholine as ordered. C. Administer racemic epinephrine via inhalation as ordered. D. Apply 100% FI02 via a bag-valve mask with a tight seal.

20. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer D. Apply 100% FI02 via a bag-valve mask with a tight seal. Rationale: First establish the airway by the head-tilt/chin- lift maneuver. Next give 100% FI02 via a bag-valve mask with a tight seal. That will usually resolve the laryngospasm. If it doesn’t, the nurse could give the racemic epinephrine via inhalation. If that doesn’t work, then the nurse should prepare for intubation and the patient would receive the succinylcholine to relax the airway so the bag-valve mask with 100% oxygen can be used effectively, and if needed the patient is intubated.

21. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions to Take When a Client Has Residual Neuromuscular Blockade Assess for inability to raise head from bed for 5 seconds, air hunger, weak chest rise or fall, weak use of abdominal muscles, anxiety, tachycardia (Rogovin, 2008). Monitor temperature: hypothermia prolongs neuromuscular blockade. Provide airway/breathing support until reversal agents take effect.

22. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following is the reversal treatment for a nondepolarizing muscle relaxant? A. Edrophonium and atropine B. Naloxone (Narcan) C. Flumazenil (Romazicon) D. Dantrolene sodium (Dantrium)

23. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A. Edrophonium and atropine Rationale: To reverse the effects of a nondepoloraizing muscle relaxant, an anticholinesterase, such as edrophonium, and an anticholinergic, such as atropine, are given. Other possible combinations include neostigmine and glycopyrrolate, or pyridostigmine and glycopyrrolate. Narcan is the reversal agent for opioid overdose. Romazicon is the reversal agent for benzodiazepine overdose. Dantrium is used to reverse malignant hyperthermia.

24. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Conditions and Medications That Increase the Effects of Neuromuscular Blocking Agents

25. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Postanesthesia Hypotension Defined as a 25% to 30% decrease in systolic BP from baseline Assess for orthostatic hypotension, supine and with head of bed at 60 degrees (unless contraindicated) Determine underlying causes and provide treatment accordingly –Reverse anesthetic agents –Improve venous return –Avoid vasovagal reactions

26. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Risk Factors That Precipitate Dysrhythmias

27. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Temperature Regulation Problems Hypothermia Body temp <35 degrees C Due to heat loss and blockage of motor and sensory nerve fibers during anesthesia Warm the patient using passive heat at 1-2 degrees C/hr Hyperthermia Body temp >39 degrees C Due to anticholinergic drugs, thermal drapes, inhalation anesthetics Pyrogenic response due to septicemia Allergic reactions could cause hyperthermia

28. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Management of Malignant Hyperthermia Due to a hypermetabolic state triggered by anesthesia in a sensitive person Occurs during surgery until 12 hours after surgery. Report increase of 0.5 degrees C, muscle rigidity, diaphoresis, and instability of BP Treat with dantrolene sodium (Dantrium) and 100% O2, avoid triggering events, and correct any acid-base abnormalities Cool externally and provide cold fluids

29. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Factors Influencing Pain

30. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Safe Administration of Epidural Analgesia Use only preservative-free medications. Use infusion sets without injection ports. Infusion pump, bag, and tubing should be labeled “epidural.” Monitor VS, respiratory status, oxygen saturation, level of sedation, motor assessment, and sensory level. Inspect epidural catheter insertion site dressing and report any drainage. Keep naloxone (Narcan) and ephedrine on hand.

31. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Side Effects From Epidural Analgesia See Box 13-12.