Barr, Cheryl, BSN, RN, CPAN

Safi-Litz, Ruth, RN, BSN, CPAN

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksPatient Care Services / NursingDevelopment of Clinical Practice Guidelines: Careof the Patient Following Anesthesia (Poster)Cheryl Barr BSN, RN, CPANLehigh Valley Health Network, Cheryl.Barr@lvhn.orgRuth Safi-Litz RN, BSN, CPANLehigh Valley Health NetworkFollow this and additional works at: http://scholarlyworks.lvhn.org/patient-care-services-nursingPart of the Perioperative, Operating Room and Surgical Nursing CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtBarr, C., & Safi-Litz, R. (2013, April). Development of clinical practice guidelines: Care of patient following anesthesia. Poster presented at:The American Society of PeriAnesthesia Nurses (ASPAN) National Conference, Chicago, IL.Lehigh Valley Health Network, Allentown, PennsylvaniaDevelopment of Clinical Practice Guidelines:Care of the Patient Following AnesthesiaPerioperative ServicesPROBLEM STATEMENT:The written standards of care for patients in the Post Anesthesia Care Unit (PACU) in a Magnet® hospital were in need of amendment.  Inconsistencies in practice among PACU RNs had also been noted.PURPOSE:© 2013 Lehigh Valley Health NetworkClinical Practice Guidelines•		To	develop	a	more	comprehensive	standard	of	care	for	post	anesthetic	patients.METHODOLOGY:•		An	interdisciplinary	team	was	formed	consisting	of	the	unit	based	educator,	anesthesia	providers,	and	clinical	experts.•		Current	institutional	written	practice	standards	were	reviewed.	A	literature	search	was	completed	with	assistance	from	the	library	services	staff.		•		Current	nursing	literature,	ASPAN	Standards,	and	practice	guidelines	from	the	American	Society	of	Anesthesiologists	were	incorporated	and	cited.		•		In	accordance	to	the	institution’s	approval	process,	a	review	by	key	stakeholders	and	a	senior	risk	manager	was	completed.•		The	compiled	clinical	practice	guidelines	utilize	a	systems	approach	and	include	assessment,	common	complications,	and	practice	recommendations.IMPLEMENTATION:•		Review	of	the	clinical	practice	guidelines	by	current	staff.•		Utilize	as	an	educational	tool	for	new	PACU	RNs.•		Use	as	an	electronically	accessed	reference	at	the	bedside.	g. Assess readiness for weaning from mechanical ventilation and extubate perprotocol/physician order.h. Provide reassurance to patient/family to decrease anxiety.(Schick, 2010)B. Breathing1. Once airway patency is assured, assess ventilation and breathing includingrespiratory rate, rhythm, depth of respirations, respiratory effort, pulse oximetry andbreath sounds on admission.a. Monitor respiratory rate and effort every 5 minutes for first 15 minutes,then every 15 minutes during Phase 1 or more frequently as patient’scondition requires (ASPAN, 2011).2. Monitor continuous pulse oximetry during Phase 1. This is necessary for earlydetection of hypoxemia in the post anesthetic patient (ASA, 2002).3. Assess for signs of hypoxemia which include dyspnea, cyanosis, altered mental status,agitation, obtundation, tachycardia, hypertension, and arrhythmias (Dunn, 2007).4. Administering supplemental oxygen during emergence from anesthesia is especiallyimportant for the general or spinal anesthesia patient (Drain, 2009). Administer oxygenand titrate according to patient need to prevent hypoxemia (Sa02 > 93%) using one ofthe following modalities:a. Nasal cannula: provides 24-40% O2 with flowrate up to 6 L/min.b. Simple face mask: provides 40-60% O2 with 5-10 L /min.c. Face tent: provides 30-55% humidified O2 with flowrate 4-10 L/min.d. Non-rebreather mask: provides 40-100% O2 with flowrate 6-15 L/min.(American Association for Respiratory Care [AARC], 2002)5. Assess for hypoventilation (ineffective respiratory effort) which may result inhypercapnia and acute respiratory acidosis (Dunn, 2007) and treat cause:a. Ongoing sedation- monitor closely and attempt to arouse patient, do notleave bedside.b. Narcotized - consider naloxone administration if severe.c. Pain/inadequate analgesiad. Reparalysis or incomplete reversal of neuromuscular blockade:i. Patients may experience generalized muscle weakness, shallowrespirations and if awake may appear anxious and restless.ii. Consider myasthenia gravis, pseudocholinesterase deficiency, orhypothermia as possible causes (Dunn 2007).iii. Notify the anesthesiologist as patient may need additional reversal.e. Upper airway obstruction (see IV.A.3.)7. Encourage deep-breathing and coughing exercises frequently as part of the stir-upregimen (Drain, 2009).OUTCOMES:•		By	standardizing	practice,	the	comprehensive	clinical	practice	guidelines,	“Care	of	the	Patient	Following	Anesthesia”,	serve	to	promote	quality	and	safety	by	providing	evidence-based	recommendations	for	general	patient	care	and	treatment	interventions	after	general	anesthesia,	monitored	anesthesia	care,	and	regional	anesthesia.•		Future	education	is	being	developed	network-wide	utilizing	these	guidelines	to	promote	necessary	knowledge	for	nursing	staff	beyond	the	PACU	who	care	for	post	anesthetic	patients.IV. GUIDELINE A. Airway1. Airway patency should be assessed immediately in the patient emerging fromanesthesia. One to one monitoring should be performed until stable/secure airway isensured. One to one monitoring should also be employed in any unconscious patientless than 8 years old (ASPAN, 2010).2. Position the patient with the head of bed elevated or in lateral decubitus position,unless contraindicated, to maximize airway patency (Dunn, 2007).3. Monitor for signs of upper airway obstruction in the sedated patient which mayinclude increased respiratory effort, snoring, use of accessory muscles, asynchronouschest movement, and/or signs of hypoxemia (restlessness, agitation, lethargy, etc.).Treat by:a. Stimulate the patient.b. Reposition and/or head tilt- chin lift; elevate head of bed.c. Insert nasopharyngeal or oropharyngeal airway.d. Suction if needed.e. Ventilate by bag/valve mask and notify the anesthesiologist.f. Prepare for intubation.g. Consider use of continuous positive airway pressure in patients with knownobstructive sleep apnea under direction of physician and respiratorytherapist.4. Laryngospasm, caused by spasm of the vocal cords, is an airway emergency whichmay occur after extubation. Partial airway obstruction due to laryngospasm is oftensignified by stridor. Treat by:a. Elevate head of bed and immediately notify the anesthesiologist.b. Apply 100% humidified oxygen (Shick, 2010). Treatment may als includeinhaled racemic epinephrine and/or intravenous corticosteroids.c. Total obstruction due to laryngospasm can be indicated by absence ofbreath sounds, agitation and hypoxemia. Provide immediate treatmentusing positive-pressure ventilation by bag valve mask, and prepare forreintubation (Schick, 2010).5. In intubated patients with endotracheal tube (ETT) in place:a. Maintain ordered ventilator settings. Obtain assistance from RespiratoryTherapy as needed and to verify correct settings.b. Attach patient to ventilator and assure adequate tidal volume is obtained.c. Check ETT size and placement. Ensure ETT is secured with tape or ETTholder.d. Apply soft limb holders to patient as needed to prevent accidentalextubation during emergence from anesthesia; remove when cooperative,awake and alert.e. Suction orally or via ETT if rhonchi auscultated or if secretions are visuallypresent.f. Administer reversal agents per anesthesiologist prior toweaning/extubation.Lehigh Valley Health NetworkPost Anesthesia Care UnitCLINICAL PRCTICE GUIDELINECare of the Patient Following Anesthesia  I.  INTRODUCTION/PURPOSE: The purpose of this guideline is to provide evidence-based recommendations to facilitate general careand treatment interventions specific to the patient after administration of general anesthesia,monitored anesthesia care, and regional anesthesia. It recognizes that the postanesthesia period is anextension of the anesthesia process that requires close monitoring of oxygenation, ventilation,circulation, level of consciousness and temperature (American Society of Anesthesiologists [ASA], 2009).These guidelines may be applied to patients of all ages, and should be modified to meet the individualneeds of each patient. Theses guidelines do not address specific postsurgical needs of the patient, andare not meant to supersede physician orders. In addition, the nurse should notify the anesthesiologistand/or surgeon for unusual circumstances or in any emergency situation.II. DEFINITIONS General Anesthesia: A drug-induced loss of consciousness during which the patient is not arousable,even to painful stimulation. The ability to independently maintain ventilatory function is often impaired.Patients often require assistance in maintaining a patent airway and positive pressure ventilation maybe required because of depressed spontaneous ventilation or drug induced depression ofneuromuscular function. Cardiovascular function may be impaired.Monitored Anesthesia Care (MAC): A drug-induced depression of consciousness during which thepatient responds purposefully to verbal commands either alone or by little tactile stimulation. Nointerventions are required to maintain a patent airway, and spontaneous ventilation is adequate.Cardiovascular function is usually maintained and recovery is typically more rapid than generalanesthesia. Monitored anesthesia care implies a deeper level of sedation than that provided bymoderate sedation, and is always administered by a member of the Anesthesia Department.Regional Anesthesia: Involves the introduction of local anesthetics to block the nerve supply to a part ofthe body. Regional anesthesia includes peripheral nerve blocks, epidural and spinal anesthesia. Spinalanesthesia is achieved by injecting local anesthetics into the subarachnoid space and provides significantneuromuscular blockade. Epidural anesthesia is achieved by introducing local anesthetics into theepidural space. Continuous blockade may be maintained by infusions through the catheter left in place.Phase I: The level of care in which close monitoring is required including airway and ventilatorysupport, progression towards hemodynamic stability, pain and fluid management, and other acuteaspects of patient care (American Society of PeriAnesthesia Nurses [ASPAN], 2010). This level of care isrequired to recover patients after receiving general or major regional anesthesia, or after intraoperativecomplications in any patient (Drain, 2009).

Development of Clinical Practice Guidelines: Care of the Patient Following Anesthesia (Poster)

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Development of Clinical Practice Guidelines: Care of the Patient Following Anesthesia (Poster)

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