Transcript Ch 4 PreOp and IntraOp Patient

Medical-Surgical Nursing:
Concepts & Practice
3rd edition
Chapter 4
Care of Preoperative and Intraoperative
Surgical Patients
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Theory Objectives
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Discuss the advantages of current
technological advances in surgery.
Explain the preparation of patients physically,
emotionally, and psychosocially for surgical
procedures.
Identify the types of patients most at risk for
surgical complications and state why each
patient is at risk.
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Theory Objectives (Cont.)
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Plan and implement patient and family
teaching to prevent postoperative
complications.
Compare the roles of the scrub nurse and the
circulating nurse.
Analyze the differences in various types of
anesthesia and list the advantages and
disadvantages of each to the surgeon and the
patient.
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3
Clinical Practice Objectives
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Perform a thorough nursing assessment for a
preoperative patient.
Teach the patient postoperative exercises
during the preoperative period.
Prepare a patient for surgery using a
preoperative checklist.
Document preoperative care and assessment
data.
Observe during a patient’s surgery.
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4
Types of Surgery
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Diagnostic
Curative
Restorative
Palliative
Cosmetic
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Terminology Used for Surgical
Procedures
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-ectomy –cutting out or off
-lysis – removal or destruction
-oma – tumor …excision of a fibroma
- ostomy – to furnish an outlet …colostomy
- otomy – cut into – thoracotomy –cut into the
chest cavity
- plasty – revision or repair of tissue
- pexy – fixation, anchor into place
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Diagnostic
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Description
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Performed to determine the origin and cause of a
disorder or the cell type for cancer
Examples
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Breast biopsy
Exploratory laparotomy Exploratory laparotomy is a method of abdominal
exploration, a diagnostic tool that allows physicians to examine the abdominal organs. The procedure
may be recommended for a patient who has abdominal pain of unknown origin or who has sustained
an injury to the abdomen.
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Arthroscopy surgical procedure that allows your doctor to look at the inside of a joint in
your body through a thin viewing instrument called an arthroscope.
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Curative
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Description
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Performed to resolve a health problem by
repairing or removing the cause
Examples
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Laparoscopic cholecystectomy (gallbladder)
Mastectomy
Hysterectomy
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Restorative
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Description
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Performed to improve a patient’s functional ability
Examples
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Total knee replacement
Finger reimplantation
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Palliative
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Description
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Performed to relieve symptoms of a disease
process but does not cure
Examples
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Colostomy
Nerve root resection
Tumor debulking
Ileostomy (ileum)
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10
Cosmetic
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Description
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Performed primarily to alter or enhance personal
appearance
Examples
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Liposuction
Revision of scars
Rhinoplasty
Blepharoplasty (eyelid)
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11
Urgency of Surgery
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Elective
Urgent
Emergent
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12
Elective
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Description
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Planned for correction of a non-acute problem
Examples
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Cataract removal
Hernia repair
Hemorrhoidectomy
Total joint replacement
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Urgent
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Description
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Requires prompt intervention; may be life
threatening if treatment is delayed more than 24 to
48 hours
Examples
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Intestinal obstruction
Bladder obstruction
Kidney or ureteral stones
Bone fracture
Eye injury
Acute cholecystitis
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Emergent
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Description
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Requires immediate intervention because of lifethreatening consequences
Examples
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Gunshot or stab wound
Severe bleeding
Abdominal aortic aneurysm
Compound fracture
Appendectomy
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Degree of Risk of Surgery
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Minor
Major
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Minor
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Description
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Procedure without
significant risk; often done
with local anesthesia
Examples
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Incision and drainage
(I&D)
Implantation of a venous
access device (VAD)
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Major
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Description
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Procedure of greater risk; usually longer and more
extensive than a minor procedure
Examples
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Mitral valve replacement
Pancreas transplant
Lymph node dissection
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Extent of Surgery
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Simple
Radical
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Simple
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Description
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Only the most overtly affected areas are involved
in the surgery
Example
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Simple or partial mastectomy
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Radical
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Description
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Extensive surgery beyond the area obviously
involved; is directed at finding a root cause
Examples
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Radical prostatectomy
Radical hysterectomy
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Trends in Surgery
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Technological advances in surgery
Autologous (related to self) blood for
transfusion –banking your own blood for surgery
Bloodless surgery
Cultural considerations
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Autologous Blood for Transfusion
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Patients undergoing elective surgery have
their own blood withdrawn several weeks
prior.
For patients concerned with contracting Hep
C or HIV through donated transfused blood.
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Bloodless Surgery
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Epogen, Procrit may be given prior to surgery
to stimulated red blood cell production
Hemostatic agents may be given before or
during surgery to promote clotting
Surgeon may induce hypotension or
hypothermia to decrease oxygen demand
Option for Jehovah Witness patients who will
not accept blood transfusions as against their
religious beliefs.
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Audience Response Question 1
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In discussing options for fluid resuscitation during
major surgery, the physician indicates availability of
bloodless surgery. The nurse would include which
intervention(s)? (Select all that apply.)
1.
2.
3.
4.
5.
Administration of erythropoietin
Provision of postoperative hyperbaric oxygen therapy
Induction of hypothermia
Banking blood before surgery
Autologous transfusion
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Preoperative Nursing Management
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Perioperative nursing
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Refers to care of the patient before, during, and
after surgery
Assessment (data collection)
Laboratory and diagnostic tests
Surgical risk factors
Learning needs
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Older Adult Care Points
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Surgery and physiologic changes of aging
Surgery and coexisting medical conditions
Emotional state
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Older Adult Care Points
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>75 yo surgical complication rates 3x higher
Physiologic reserves have declined (cardiac,
respiratory, renal) – impact metabolism and
excretion of drugs and anesthesia.
Chronic diseases causes vulnerability to fluid
and electrolyte imbalances during and after
surgery.
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Cultural Considerations
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Financial burden
Beliefs regarding surgery – example blood
transfusions
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General Nursing Goals
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Patient will be:
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Prepared for surgery physically and emotionally
Able to demonstrate deep breathing, coughing,
and leg exercises
Able to verbalize understanding of the procedure
and the expectations for the postoperative period
Able to maintain fluid and electrolyte balance
throughout the perioperative period
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See Table 4- 2 page 65
Surgical Risk Factors
Implementation
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Preoperative preparation
Preoperative patient teaching
Older adult considerations
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Consent for Surgery
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Written permission signed by the patient,
guardian, or whoever holds power of attorney
must be obtained.
Written consent protects the surgeon against
claims of unauthorized surgery and provides
the patient an opportunity to exercise the right
of informed consent.
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Consent for Surgery (Cont.)
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The surgeon explains the procedure, risks,
and benefits; the nurse only witnesses the
patient’s signature.
The patient must be mentally competent and
give consent freely and without coercion.
The consent form is attached to the patient’s
chart and is sent to the operating room (OR)
with the patient.
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Consent for Surgery (Cont.)
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The nurse must always check that a consent
form has been signed before giving the
preoperative medication.
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Clinical Cues
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Patients have the right to change their minds
and revoke consent up until the time of
surgery.
If a patient tells you the surgery is not wanted,
delay preoperative preparations and explore
the issue with the patient.
If it appears the consent for surgery really is
being revoked, notify the charge nurse and
the surgeon.
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Food and Fluids
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Restrict for 8 hours before surgery and
nothing per mouth (NPO) status.
A light meal such as toast and clear fluids
may be allowed up to 6 hours before surgery.
Clear liquids such as black coffee, tea, apple
juice, or carbonated beverages may be
consumed up to 3 hours before surgery in
elective cases.
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Food and Fluids (Cont.)
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Often the surgeon or anesthesiologist will
allow an oral blood pressure medication,
heart medication, or an anticonvulsant to be
taken with a sip of water the morning of
surgery.
Always check the physician’s order before
giving anything by mouth in the immediate
preoperative period.
The purpose of oral restriction is to prevent
nausea, vomiting, and aspiration.
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Food and Fluids (Cont.)
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Confirm with the patient that the NPO order
has been heeded.
Usual insulin may or may not be given.
If a patient has not remained NPO for the
prescribed period, surgery may be cancelled.
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Elimination
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If the patient is having abdominal or colon
surgery, enemas may be ordered to clear the
bowel.
Sometimes oral GoLYTELY solution is used.
The patient may be on a special soft or liquid
diet for the 3 days before surgery to decrease
the contents of the bowel.
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Elimination (Cont.)
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When completing the preoperative checklist,
ask the patient to empty the bladder (unless a
catheter is in place).
If the bladder is not empty, relaxation induced
by medications and anesthesia causes the
urge to urinate.
The bladder should be emptied before any
sedating medication is given.
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Tubes and Equipment
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If a nasogastric tube will be inserted during
surgery for postoperative use, explain its
purpose, its care, and what it will feel like to
the patient.
Give an estimate of how long the tube will
remain in the stomach.
The tube is usually removed when bowel
sounds return and nausea has passed.
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Tubes and Equipment (Cont.)
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If surgery has occurred on the
stomach or intestinal tract, the
tube may remain longer.
Explain the function of other
tubes such as drains, an
intravenous (IV) line, oxygen
delivery and monitoring
devices, a chest tube, and a
urinary catheter, as well as
their care and probable
duration of use.
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Rest and Sedation
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It is desirable for the patient to be as well
rested as possible before surgery so the body
is not compromised in meeting the stresses of
anesthesia and surgical procedure.
A sedative may be ordered for the patient the
night before surgery, but the inpatient often
must ask for it.
Check on the patient frequently during the
night.
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Rest and Sedation (Cont.)
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If the patient awakens and is
restless, sit and listen and try to
dispel fears, offer a soothing
backrub, or give backup
sedation as ordered.
The patient scheduled for sameday surgery should take the
sedative at home and retire early
the night before because it may
be necessary to arise early to
enter the hospital.
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Pain Control
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Many surgeons order a patient-controlled
analgesia (PCA) pump for their patients
postoperatively.
If a PCA pump is ordered, patients should
receive instruction before surgery about the
pump and how to operate it.
If patients will be receiving injections for pain
control, explain that this type of medication is
ordered on an as-needed basis every 3 to 4
hours and that patients must ask for it.
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Pain Control (Cont.)
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Oral pain medication is usually ordered for
every 4 to 6 hours as needed.
Explain that asking for the pain medication
before the pain becomes severe makes it
easier to control the pain level.
Teach the patient about the pain scale that is
used at the facility.
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Skin Preparation
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The night or morning before surgery, the
patient may be asked to shower with a
special antibacterial cleanser to remove as
many microorganisms from the skin as
possible.
On the morning of the surgery, hair may be
removed from the operative site; this is done
either in the surgical holding area or in the
OR.
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Skin Preparation (Cont.)
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As a Core Measure for reducing surgical site
infection, use hair clippers only for hair
removal before surgery.
Explain to the patient the hair removal area to
be prepared, the hair removal process, and
the timing for hair removal.
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Skin Preparation (Cont.)
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Nail polish is removed so that the pulse
oximeter can function correctly when
attached to the finger.
Makeup is removed; note the presence of
permanent makeup on the preoperative
checklist.
Ask about contact lenses and have them
removed as well.
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Preoperative Teaching
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Teaching the patient correct breathing,
coughing, turning, and leg exercises is a high
priority during the preoperative period.
It is helpful to have a relative or close friend
present for these teaching sessions so this
person can later give coaching and
encouragement to the patient.
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Preoperative Teaching (Cont.)
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Instruct the patient about what to expect
before, during, and after surgery.
Help the same-day surgery patient devise a
schedule for doing the necessary exercises.
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Preoperative Teaching (Cont.)
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Venous return is often hampered during the
surgical procedure because of the position
assumed on the operating table and pooling
of blood in the lower extremities.
Stasis of blood places the patient at risk for
thrombophlebitis.
Specific leg exercises help to prevent this
complication.
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Preoperative Teaching (Cont.)
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Explain the importance of doing the
exercises, show the patient how to do each
one, and ask for a return demonstration.
One way to remind patients to do the
exercises is to have them exercise whenever
a commercial comes on if they watch TV.
The exercises should be done after surgery
at least 5 to 10 times every hour while awake
until the patient is up and moving about.
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Older Adult Care Points
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Older patients should be taught needed
information in short segments to prevent
confusion and increase the patient’s
comprehension.
Written reminders of key instructions should
be given to the patient.
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Postoperative Foot and Leg Exercises
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Flex and extend the right foot, moving the
toes upward and downward, four or five
times.
Repeat with the left foot.
Trace circles to the right with the right foot
five times; repeat with circles to the left.
Trace circles to the right with the left foot five
times; repeat with circles to the left.
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Postoperative Foot and Leg Exercises
(Cont.)
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Bend the right leg at the knee, sliding the foot
back toward the buttocks as far as possible;
raise the bent leg off the bed, extend the leg
and dorsiflex the foot; and extend the foot
and lower the leg to the bed.
Repeat with the left leg.
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Postoperative Foot and Leg Exercises
(Cont.)
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Tighten the buttocks muscles for a count of
10 and release to exercise the quadriceps
muscles.
Repeat each exercise four more times.
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Deep Breathing and Coughing
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For deep breathing and coughing, it is
preferable for the patient to sit up, with the
back away from the mattress or chair.
This allows for full lung expansion and
clearing of secretions.
The surgical chest or abdominal incision
should be splinted with a pillow.
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Deep Breathing and Coughing (Cont.)
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The surgeon may order use of an incentive
spirometer.
Instruct the patient in its use and supervise
until the patient has mastered the technique.
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Deep Breathing
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Sit up and away from the mattress.
Take a deep breath in through the nose, hold
for a few seconds, and slowly exhale.
Repeat four more times.
Perform every 2 hours during the day and
when awakened at night for vital signs.
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Forced Exhalation Coughing
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Sit up and away from the mattress.
Splint the abdominal or chest incision.
Take a deep breath through the nose and
cough as you exhale with the mouth open but
covered with a tissue.
If you cannot move secretions with your
cough, use a forced exhalation cough.
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Forced Exhalation Coughing (Cont.)
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Take a deep breath through the nose and
forcibly exhale, producing a “huff” cough.
Repeat the process.
Repeat again four more times, using three
short “huffs” as you exhale to bring the
secretions to the mouth, where they can be
expectorated.
Perform every 2 hours during the day and
when awakened at night for vital signs.
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Using an Incentive Spirometer
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Sit up and away from the mattress.
Insert the mouthpiece, covering it completely
with the lips.
Take a slow, deep breath and hold it for at
least 3 seconds.
Exhale slowly, keeping the lips puckered.
Breathe normally for a few breaths.
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Using an Incentive Spirometer (Cont.)
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Try to increase the inspired volume by at
least 100 mL with each breath on the
spirometer.
When maximal volume is achieved, attempt
to inspire this volume 10 times, resting a few
breaths in between each attempt.
Clean the mouthpiece of the spirometer when
finished.
During the first 3 postoperative days, try to do
this every hour.
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Turning
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Show the patient how to turn in bed by flexing
the legs to relax the abdominal muscles,
placing a pillow between the legs, grabbing
onto the side of the bed, and slowly turning to
the side.
This maneuver is also used for getting up out
of bed.
A trapeze bar for orthopedic patients is very
helpful for turning and repositioning.
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Family Instructions
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Advise the family to come to the hospital 1 to
11⁄2 hours before surgery.
The family should be told about the usual
routines; where to wait; the approximate time
before the patient may be expected to return;
and what to anticipate in the way of tubes,
equipment, and patient appearance after
surgery.
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Family Instructions (Cont.)
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This knowledge keeps the family from
thinking the patient has “taken a turn for the
worse” when they see the extra equipment for
suction, oxygen, or IV therapy in use after
surgery.
A warning about the occasional delays in
starting surgery can keep the family from
becoming excessively anxious if the patient is
not back at the expected time.
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Immediate Preoperative Care
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The patient is usually dressed in a clean
hospital gown, without underwear, for the OR.
Hair is covered with a surgical paper cap.
Long hair should be fixed so that it can tangle
only minimally and all hairpins and barrettes
must be removed.
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Immediate Preoperative Care (Cont.)
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Ask about body piercings and the presence of
piercing jewelry, including the tongue and
genital areas.
Explain why all jewelry must be removed for
safety because of electrocautery used during
surgery and the danger of an electrical burn
from conduction of electricity through metal.
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Immediate Preoperative Care (Cont.)
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Jewelry, along with money and credit cards,
is given to a family member or relative to
keep or is secured in a valuables envelope
and placed in a safe, according to facility
policy.
If a wedding band is to be worn to surgery,
tape the ring to the finger without restricting
circulation.
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Immediate Preoperative Care (Cont.)
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Dentures are removed, placed in a labeled
cup, and kept in a designated place,
according to hospital policy.
Sometimes the anesthesiologist will order the
dentures left in place to facilitate the
administration of anesthesia by mask.
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Immediate Preoperative Care (Cont.)
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If a hearing aid is left in place, a very visible
note should be placed on the front of the
chart cover, and placement of the hearing aid
should be noted on the preoperative checklist
sheet.
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Immediate Preoperative Care (Cont.)
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Verify that the identification bracelet matches
the chart to avoid any error or mix-up of
patients in the OR.
Verify that the procedure site indicated on the
surgical consent form is the same as what the
patient states.
The procedure site will be verified and
marked on the patient before transport to
surgery or in the preoperative holding area.
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Immediate Preoperative Care (Cont.)
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Attend to all items on the preoperative
checklist that can be handled ahead of time.
This prevents hurrying, which can increase
mistakes, and prevents delaying
administration of any preoperative medication
while the list is completed.
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Preoperative Medications
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Most preoperative medications are given by the
anesthesiologist.
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A medication to inhibit gastric acid secretion may be
administered intravenously.
Check that the surgical consent is signed and start
any ordered medications on time.
You may need to send an IV piggyback antibiotic to
the OR with the patient.
Often no medication is given before the patient is in
the surgical area.
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Preoperative Medications (Cont.)
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Preoperative medications may be given to
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Reduce anxiety and promote a restful state.
Decrease secretion of mucus and other body
fluids.
Counteract nausea and reduce emesis.
Enhance the effects of the anesthetic.
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Preoperative Medications (Cont.)
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If the patient has received a sedative
preoperatively, remember to put up the side
rails of the bed per facility protocol and lower
the bed.
Remind the patient not to get up without
assistance.
These are important patient safety measures
after administering sedatives.
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Cultural Variances in Drug Metabolism
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Asians, particularly Chinese individuals,
metabolize psychotropic drugs differently
than other ethnic groups.
Valium causes greater sedation with normal
doses.
Atropine is also metabolized differently and
can greatly accelerate the heart rate.
Asian patients should be monitored closely
when receiving these drugs.
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Transfer to the Operating Room
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Assist in transferring the patient to the
stretcher when the transport person comes to
take the patient to surgery.
Compare the patient’s identification bracelet
name and numbers with the transport request
sheet for accuracy.
Check the chart to make certain that
everything ordered has been done and
complete final documentation.
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Older Adult Care Points


Because of decreasing liver and kidney function
that occurs with age, older patients, especially
those older than 75 years of age, need reduced
dosages of preoperative narcotics and
sedatives.
Observe for signs of toxicity.
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86
Think Critically

How would you handle a situation in which a
patient scheduled for an abdominal
procedure has put back on underwear or
jewelry after you finished doing the
preoperative checklist?
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Preparation of the Patient Unit

While patients are in surgery, prepare the
room for their return.



Make the bed with fresh linen; include a draw
sheet between the shoulder and the knee area
that can be used as a lift sheet to reposition the
patient.
For abdominal or perineal surgery, place an
underpad at the hip area to catch excess
drainage.
Fan-fold the top covers to the far side of the bed or
to the bottom of the bed.
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88
Preparation of the Patient Unit (Cont.)



Raise the bed to the height of the stretcher that will
return the patient and arrange furniture so that the
stretcher can be pulled up alongside the bed.
Place the IV pole at the head of the bed.
Gather an emesis basin, tissues, frequent vital signs
sheet or postoperative record, intake and output sheet,
small towel and washcloth, and pen and place them
on the bedside table or console.
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89
Preparation of the Patient Unit (Cont.)



Connect oxygen and suction equipment if their
need is anticipated.
A thermometer, sphygmomanometer, pulse
oximeter, and stethoscope should be close at
hand upon the patient’s return to the unit.
If a PCA pump, sequential pneumatic
compression devices, or a passive range-ofmotion machine will be needed, see that they are
obtained and ready.
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90
Audience Response Question 2

Which nursing intervention(s) would be
critical in preoperative preparation of the
patient? (Select all that apply.)
1.
2.
3.
4.
5.
No oral intake for at least 6 hours.
Allow clear liquids up to 2 hours before major
procedures.
Ensure timely administration of insulin injections
at all times.
Withhold all cardiac medications,
antihypertensives, and anticonvulsants.
Confirm patient compliance with the NPO status.
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91
Evaluation

Determine if the nursing goals have been
met.

Is the patient properly prepared for surgery, kept
NPO, reasonably calm, and knowledgeable about
the procedure and what is expected?
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92
Intraoperative Care

Before surgery begins


A “time out” occurs during which a final verification
of the correct patient, procedure, site, and
implants (if applicable) is performed.
Any questions or concerns must be resolved.
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93
Surgical Team


Consists of the surgeon, physician’s
assistant, surgical assistants, anesthesia care
provider, circulating nurse, and scrub person
or scrub technician
The surgeon is the head of the surgical team
and may be a physician, an oral surgeon, or a
podiatrist.
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94
Surgical Suite

The unrestricted zone is essentially the
control desk area.


Street clothes may be permitted here.
Semi-restricted zones include the hallways
and outer regions of the ORs.


The circulating nurse and anesthesia care
providers work in these areas.
Clean scrub clothes and caps are required.
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95
Surgical Suite (Cont.)

The restricted zone is the area surrounding
the operating table and instrument trays and
table.


Personnel wear scrub cloths, sterile gowns, caps,
shoe covers, masks, and sterile gloves within this
area.
Asepsis is the responsibility of all surgical
personnel.
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96
Major Functions of the Scrub Person





Gathers all equipment for the procedure
Prepares all sterile supplies and instruments
using sterile technique
Gowns and gloves surgeons upon entry into
OR
Assists with sterile draping of the patient
Maintains sterility within the sterile field during
surgery
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97
Major Functions of the Scrub Person
(Cont.)



Hands instruments and supplies to the
operating team during surgery, anticipating
what is needed
Maintains a neat instrument table
Labels and handles surgical specimens
correctly
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98
Major Functions of the Scrub Person
(Cont.)



Maintains an accurate count of sponges,
sharps, and instruments on the sterile field;
verifies counts with the circulating nurse
before and after surgery
Monitors for breaks in sterile technique and
points them out
Cleans up after the surgery is over
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99
Major Functions of the Circulating
Nurse




Coordinates care, oversees the environment,
and cares for the patient in the OR
Greets patient and performs patient
assessment
Verifies that consent is signed and accurate
and that surgical site is correctly marked
Checks medical record and preoperative
forms for completeness
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100
Major Functions of the Circulating
Nurse (Cont.)




Sets up the OR; adjusts lights, stools, and
discard buckets; and ensures supplies and
diagnostic support are available
Gathers and checks all equipment that is
anticipated to be used, ensuring its safe
function
Opens sterile supplies for scrub nurse
Provides needed padding and warming or
cooling devices for the operating table
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101
Major Functions of the Circulating
Nurse (Cont.)




Assists with ties of surgical team’s gowns
Assists with the transfer of the patient to the
operating table and positions the patient
Places electrocautery ground pad under
patient if electrocautery is to be used
Assists the anesthesia induction provider with
anesthesia
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102
Major Functions of the Circulating
Nurse (Cont.)





May prep the patient’s skin before sterile
draping occurs
May insert a Foley catheter
Handles labeling and disposition of
specimens
Coordinates activities with radiology and
pathology departments
Monitors urine and blood loss during surgery
and reports findings to the surgeon
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103
Major Functions of the Circulating
Nurse (Cont.)




Supplies, monitors, and documents the
infusion of ordered fluids
Observes for breaks in sterile technique and
announces them to the team
Monitors traffic and noise within the OR
Communicates information on the surgery’s
progress to family during long procedures
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104
Major Functions of the Circulating
Nurse (Cont.)



Documents care, events, interventions, drugs,
fluids, and findings
Assists with final count of sponges and
sharps with the scrub person
Helps transfer patient to gurney and
accompanies patient to recovery area,
providing report of the surgery and patient
condition to the recovery nurse
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105
Anesthesia


Anesthesia is the loss of sensory perception
Goals of anesthesia administration are to:



Prevent pain.
Achieve adequate muscle relaxation.
Calm fear, ease anxiety, and induce forgetfulness
of an unpleasant experience.
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106
Anesthesia (Cont.)


Patients are classified according to their age,
physical condition, and risk status and are
assigned a risk potential.
The choice of anesthesia depends on the
type of surgical procedure to be performed
and the risk potential.
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107
Anesthesia (Cont.)


The anesthetic to be used is chosen by the
anesthesia care provider, although it is
discussed with the patient.
The anesthesia care provider may be an
anesthesiologist, another physician, or a
certified registered nurse anesthetist (CRNA)
who is supervised by an anesthesiologist.
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108
General Anesthesia

Stages of general anesthesia



Induction—unconsciousness is induced
Maintenance—period during which the surgical
procedure is performed
Emergence—surgery is completed and the patient
is prepared to return to consciousness;
neuromuscular blocking agents are reversed
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109
Older Adult Care Points



Accurate height and weight of the elderly
patient are very important for calculation of
anesthetic agents and medication dosages.
Kidney function is declining in older persons,
and drugs are not eliminated from the body
as quickly.
Reduced dosages are often needed.
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110
Regional Anesthesia




Regional anesthesia is accomplished by
administering a nerve block.
It is often more economical than general
anesthesia.
Regional anesthesia may be accomplished
by injecting the spinal, epidural, caudal, or
peripheral nerve area.
The block anesthetizes the local area or the
area distal to the block.
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111
Regional Anesthesia (Cont.)


Spinal or epidural blocks are frequently used
for high-risk patients undergoing pelvic or
lower-extremity surgery.
Epidural blocks are widely used in obstetric
procedures.
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112
Procedural Sedation Anesthesia
(Moderate Sedation)


A local anesthetic agent or regional
anesthesia to numb the area plus IV sedation
are used to provide systemic analgesia and
sedation during a surgical procedure.
The combination can be used for any
procedure that can be done with local or
regional anesthesia and is being used more
frequently.
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113
Procedural Sedation Anesthesia
(Moderate Sedation) (Cont.)


The patient is monitored closely for blood
pressure changes, oxygen saturation levels,
and heart activity.
Recently, carbon dioxide levels have begun
to be monitored by capnography.


Capnography is measurement of inhaled and
exhaled carbon dioxide.
It provides a graphic representation of exhaled
CO2.
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114
Local Anesthesia


Local anesthesia is used for minor
procedures such as superficial tissue
biopsies, surface cyst excision, insertion of
pacemaker, and insertion of venous access
devices.
The patient who has had local anesthesia is
transferred directly to the nursing unit and
does not need care in the postanesthesia
care unit (PACU).
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115
Potential Intraoperative Complications





Infection
Fluid volume excess or deficit
Hypothermia
Malignant hyperthermia
Injury related to positioning
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116