MS CH 12 Nursing Care of Patients Having Surgery.pdf

4068_Ch12_202-236 19/11/14 11:13 AM Page 202 12 Nursing Care of Patients Having Surgery KEY TERMS adjunct (ADD-junkt) anesthesia (AN-es-THEE-zee-uh) anesthesiologist (an-es-THEE-zee-uhl-la-just) aseptic (ah-SEP-tik) atelectasis (AT-e-LEK-tah-sis) débridement (da-breed-MAHNT) dehiscence (dee-HISS-...

4068_Ch12_202-236 19/11/14 11:13 AM Page 202 12 Nursing Care of Patients Having Surgery KEY TERMS adjunct (ADD-junkt) anesthesia (AN-es-THEE-zee-uh) anesthesiologist (an-es-THEE-zee-uhl-la-just) aseptic (ah-SEP-tik) atelectasis (AT-e-LEK-tah-sis) débridement (da-breed-MAHNT) dehiscence (dee-HISS-ents) evisceration (E-VIS-sir-a-shun) hematoma (HEE-muh-TOH-mah) hypothermia (HY-poh-THUR-mee-ah) induction (in-DUCK-shun) intraoperative (IN-trah-AW-pruh-tiv) perioperative (PER-ee-AW-pruh-tiv) postoperative (post-AW-pruh-tiv) preoperative (pre-AW-pruh-tiv) purulent (PURE-u-lent) serosanguineous (SEER-oh-SANG-gwin-ee-us) surgeon (SURGE-un) 202 LINDA S. WILLIAMS LEARNING OUTCOMES 1. Describe factors that influence surgical outcomes. 2. Identify the LPN/LVN role in each perioperative phase. 3. Explain the LPN/LVN role in obtaining informed patient consent. 4. Develop a teaching plan to enhance learning for the older preoperative patient. 5. Identify nursing interventions used for common postoperative patient needs. 6. Describe how to evaluate effectiveness of nursing interventions. 7. List signs and symptoms of common postoperative complications. 8. List the criteria for ambulatory discharge. 9. Describe the role of the home health nurse in caring for postoperative patients. 4068_Ch12_202-236 19/11/14 11:13 AM Page 203 Chapter 12 Surgery is the use of instruments during an operation to treat injuries, diseases, and deformities. Sur gical procedures are named according to (1) the in volved body organ, part, or location and (2) the suffix that describes what is done during the procedure (Table 12.1). Physicians who perform surgery include surgeons or other physicians trained to do certain surgical procedures. Sur gery is scheduled based on the urgency required for a successful outcome for the patient (Table 12.2). The reasons for sur gery to be performed are listed in Table 12.2. Nursing Care of Patients Having Surgery 203 TYPES OF SURGERY Laser, scope, and robotic technologies reduce the in vasiveness of surgical procedures. Minimally invasive surgery is less damaging to tissues than traditional open incision sur gery. This allows a faster and less painful recovery. Laser surgery uses a laser instead of a scalpel to cut tissue. It is often used for eye surgery. An endoscope is used for minimally invasive surgery, also called k eyhole surgery. Minimally TABLE 12.1 SURGICAL PROCEDURE SUFFIXES Suffix -ectomy Meaning Removal by cutting Word-Building Examples crani (skull) + ectomy = craniectomy appen (appendix) + ectomy = appendectomy -orrhaphy Suture of or repair colo (colon) + orrhaphy = colorrhaphy herni (hernia) + orrhaphy = herniorrhaphy -oscopy Looking into colon (intestine) + oscopy = colonoscopy gastr (stomach) + oscopy = gastroscopy -ostomy Formation of a permanent artificial opening ureter + ostomy = ureterostomy colo (colon) + ostomy = colostomy -otomy Incision or cutting into oust (bone) + otomy = osteotomy thoro (thorax) + otomy = thoracotomy -plasty Formation or repair oto (ear) + plasty = otoplasty mamm (breast) + plasty = mammoplasty TABLE 12.2 SURGERY URGENCY LEVEL AND PURPOSE Type Definition Examples Immediate surgery needed to save life or limb without delay Ruptured aortic aneurysm or appendix, traumatic limb amputation, loss of extremity pulse from emboli Urgent Surgery needed within 24–30 hours Fracture repair, infected gallbladder Elective Planned/scheduled, with no time requirements Joint replacement, hernia repair, skin lesion removal Optional Surgery requested by the patient Cosmetic surgery Requested by patient for improvement Blepharoplasty, breast augmentation Diagnostic To obtain tissue samples, make an incision, or use a scope to make a diagnosis Biopsy Exploratory Confirmation or measurement of extent of condition Exploratory laparotomy Urgency Level Emergency Purposes of Surgery Aesthetic Continued 4068_Ch12_202-236 19/11/14 11:13 AM Page 204 204 UNIT TWO Understanding Health and Illness TABLE 12.2 SURGERY URGENCY LEVEL AND PURPOSE—cont’d Type Preventive Definition Removal of tissue before it causes a problem Examples Mole or polyp removal to prevent cancer Curative Removal of diseased or abnormal tissue Inflamed appendix, tumor, benign cyst, hernia Reconstructive Correction of defects of body parts Scar repair, total knee replacement, face lift, mammoplasty Palliative Alleviation of symptoms when disease cannot be cured Rhizotomy (cuts nerve root to relieve pain), partial tumor removal to relieve pain or pressure; gastrostomy tube to provide tube feedings for swallowing problem; colostomy for incurable bowel obstruction invasive surgery includes laparoscopic sur gery (abdominal and pelvic cavity) and thoracoscopic surgery (chest and thoracic cavity). The endoscope is a fle xible tube with a light, camera, and suction attached. It is inserted through a small incision and projects an image on a screen for the surgeon to watch. Additional incisions are made for other instruments depending on the type of surgery. Robotic surgery, which uses robots, includes minimally invasive surgery. The da Vinci is one type of surgical robot with three or four arms. One is a camera, tw o are robotic arms that act as the surgeon’s hands, and the fourth arm moves obstructions out of the w ay (Fig. 12.1). As the surgeon moves his or her hands, the robotic arms (which are inside the patient’s body) mimic the movements by cutting, suctioning, or suturing. Visit www.intuitivesurgical.com for more information and videos. PHASES OF SURGERY There are three phases in the surgical process: preoperative, intraoperative, and postoperative. These phases together are referred to as perioperative, which is the time before, during, and after surgery. Each of the perioperati ve surgical phases has a defined time frame in which specif ic events related to surgery occur (Table 12.3). FIGURE 12.1 Operating room featuring the da Vinci Si Surgical System with surgeon at the da Vinci robotic surgery console and nurse at the vision cart. Courtesy of Intuitive Surgical, Inc., Sunnyvale, CA. 4068_Ch12_202-236 19/11/14 11:13 AM Page 205 Chapter 12 TABLE 12.3 PERIOPERATIVE SURGICAL PHASES Perioperative All three phases surrounding and during surgery Preoperative Begins with decision for surgery and ends with transfer to the operating room Intraoperative Begins with transfer to operating room and ends with admission to perianesthesia care unit (PACU) Postoperative Begins with admission to PACU and continues until recovery is complete Nursing Care of Patients Having Surgery 205 these reactions to assist the patient in coping with them. If any of the patient’s fears are extreme, such as a fear of dying or not waking up after surgery, the surgeon should be informed. Surgical patients may experience various fears related to anesthesia (reversible loss of sensation): possible brain damage, feeling sensation during sur gery, feeling loss of control, or a fear of not waking up. The patient should discuss these concerns with the anesthesia professional. Listening to music or using guided imagery before surgery may reduce a patient’s anxiety (see “Evidence-Based Practice”). It is normal for patients to be concerned about pain. During surgery, the anesthesia provider gives medications to control pain. Nurses give prescribed analgesics for pain relief after surgery. Complementary techniques can also be used to help reduce pain, such as guided imagery or focused breathing. Changes in body image may be a great fear for some patients. The thought of disfigurement, mutilation, bleeding, or having a scar causes great anxiety for some patients.Allow them to discuss these fears. PREOPERATIVE PHASE Your primary role as a licensed practical nurse/licensed vocational nurse (LPN/LVN) in the preoperative phase is to: • Assist in data collection for developing the patient’s plan of care. • Reinforce explanations and instructions given to the patient and family by the surgeon and registered nurse (RN). • Provide emotional and psychological support for patients and their families. You can help reduce family members’ anxiety by providing explanations so that they are less anxious and able to assist the patient during recovery. Other health team members assist in preparing the patient for surgery. The surgeon obtains a medical history, performs a physical e xamination, and orders diagnostic testing. RNs perform a baseline preoperati ve assessment, provide explanations and instructions, of fer patients and families emotional and psychological support to ease anxiety, develop a plan of care, and then verify the patient’s name, surgical site (along with the patient), aller gies, and related information when the patient arri ves in the surgical area. EVIDENCE-BASED PRACTICE Clinical Question Does listening to music reduce preoperative anxiety for surgical patients? Evidence Twenty-six studies comparing music listening with standard care preoperatively (Bradt, Dileo, & Shim, 2013). Music listening was found to have a beneficial effect on preoperative anxiety. Music even reduced anxiety more effectively than a sedative in one study. Implications for Nursing Practice Patients can be informed to bring in favorite music to listen to before surgery to reduce anxiety. REFERENCE Bradt, J., Dileo, C., & Shim, M. (2013). Music interventions for preoperative anxiety. Cochrane Database of Systematic Reviews, 6, CD006908. DOI: 10.1002/14651858 .CD006908.pub2. Factors Influencing Surgical Outcomes Age When preparing a patient for sur gery and assisting in the development of a nursing care plan, the goal is to identify and implement actions that reduce surgical risk factors. Preoperative care focuses on helping the patient achie ve the best possible surgical outcome by being in the healthiest possible condition for surgery. Surgery can be a positive experience that promotes quality of life for many older patients. F or healthy older patients, age alone does not mean that the y are at greater sur gical risk. Complications can occur, however, related to previous health status, immobilization occurring from surgery, normal aging changes reducing the ef fectiveness of deep breathing and coughing, and the ef fects of administered medications (see “Gerontological Issues”). Older patients may need a longer time to reco ver from anesthetic agents because of changes in drug metabolism and elimination related to aging. Emotional Responses The word surgery causes a common anxious emotional reaction in patients and their f amilies. You need to be a ware of 4068_Ch12_202-236 19/11/14 11:13 AM Page 206 206 UNIT TWO Understanding Health and Illness Gerontological Issues Surgical Considerations for the Older Adult Older adults usually have limited physiological reserve, resulting in decreased ability to compensate for changes that occur during sur gery. The risk for hemorrhage, anemia, fluid/electrolyte imbalance, and infection are increased in older adults. Increased risk for complications is secondary to age-related loss of blood v essel elasticity and decreased cardiac, respiratory , and renal reserves. Nursing interventions should be aimed at these age-related changes before, during, and after the surgical procedure to help reduce complications. Preoperatively • Reassure the patient and family. • Pad bony prominences to protect against pressure ulcers and muscle and bone discomfort. • Teach what to expect before, during, and after surgery; diet changes; description and length of surgical procedure; activities in the recovery room; pain management; coughing and deep breathing exercises; procedures; and treatments (e.g., dressings, catheters). • Ensure preoperative screening: blood work, radiographic studies, nutritional assessments, pulmonary function tests, electrocardiogram (ECG). Intraoperatively • Assess patient for hypothermia • Assess patient for hypoxia (older adult may exhibit restlessness). • Assess patient for hemorrhage. • Assess patient’s output (urine, drainage, bleeding, emesis). Postoperatively Pain Control—Provide adequate pain relief so required postoperative activities, such as deep breathing, coughing, position changes, and e xercise, can be performed more effectively. Respiratory Function—Reduce respiratory complications by encouraging deep breathing and coughing: • Perform after pain medication has begun to take effect to encourage deep breaths due to less pain. Assess the patient carefully when giving narcotics because they can cause respiratory depression. • Use a pillow and instruct the patient to hold it firmly over abdominal or chest incisions to support the incision. Taking a deep breath increases chest expansion, as well as abdominal pressure, which may pull or stretch an incision. • Older adults perform deep-breathing and coughing exercises better if the nurse performs the exercises with them. For example, say the following: “Let’s take a deep breath in through the nose, hold it and count to three, then slowly blow it out completely through the mouth. When you blow the air out, shape your lips like they are going to whistle. Great, let’s do it again.” Mobility—Encourage mobility through the following nursing actions and observations: • Use pillows to support the patient’s body alignment; assist the patient to ambulate as soon as possible after surgery; and regularly help the patient with passive or active range-of-motion exercises, along with flexion and extension exercises, for legs and feet. • Monitor for unilateral swelling of the leg and calf or groin pain, which may indicate deep venous thrombosis (DVT), a risk related to venous pooling in the lower extremities. This risk is increased with postoperative inactivity. • Assist the patient to change position at least every 2 hours. If patients lay in one position too long, pressure ulcers can develop. When tissues are compressed between bones and the bed surface, blood supply is reduced to the tissue and cells begin to die. This results in painful open wounds. Bowel Function—Assess bowel sounds. It is common for patients to feel bloated after surgery. Increasing activity, such as w alking—not just sitting in a chair— stimulates peristaltic action of the bo wel. This helps expel flatus and reduce discomfort. Urinary Function—Be aware of the follo wing aspects of urinary function: • Individuals often have difficulty emptying their bladder after surgery. Patients who are sleeping but restless should be evaluated for bladder distention. It is often difficult to void on a bedpan or in a urinal in a supine position. • Older men with an enlarged prostate may have even greater difficulty voiding if they have received medications that have urinary retention side effects. • Assisting patients to sit or stand to use urinals, use a bedside commode, or ambulate to the bathroom promotes bladder emptying and helps avoid the use of urinary catheters. • Measure urine output that is voided or from a catheter. Note the color and odor of the urine. Older adults are prone to dehydration, and this provides an indication of their hydration status for intervention. Delirium—Perform the following nursing actions to minimize delirium: • Monitor level of consciousness routinely. Provide a calm environment and orient patients to their environment. Restraints should not be used because they can worsen delirium. • Recognize that the presence of a urinary catheter can contribute to delirium, so methods to avoid the need for a catheter should be tried. 4068_Ch12_202-236 19/11/14 11:13 AM Page 207 Chapter 12 Nursing Care of Patients Having Surgery 207 Nutrition Smoking and Alcohol Patients should be well nourished to adequately heal and recover from surgery (“Nutrition Notes”). Higher levels of protein (tissue repair and healing), vitamin C (collagen formation), and zinc (tissue growth, skin integrity, and cell-mediated immunity) are required. Patients who are obese or underweight may not heal as well and may ha ve complications. Patients who are obese have more respiratory problems and wound healing difficulties, such as delayed healing and wound dehiscence (opening of the incision). Patients who are emaciated may have more infections and delayed wound healing because they lack the nutrients needed for tissue healing. Tobacco and alcohol use increases the surgical patient’s risks. Smoking thickens and increases the amount of lung secretions and reduces the action of cilia that remo ve the secretions. Patients should be encouraged to a void smoking for at least 24 hours before sur gery or 3 to 4 weeks before surgery if they have a chronic lung disorder. Not smoking increases the action of the lungs’ defense mechanisms and makes more hemoglobin a vailable to carry oxygen during surgery. It also improves wound healing. Long-term alcohol use may cause nutritional deficiencies and liver damage, which can create bleeding problems, fluid volume imbalances, and drug metabolism alterations. In addition, alcohol interacts with medications and should be avoided before surgery. Nutrition Notes Chronic Disease Screening and Nourishing the Preoperative Patient Identifying and treating malnutrition before surgery may improve the patient’s outcome. Unintended weight loss or a low serum albumin level should prompt further nutritional assessment. Before elective surgery, the patient may have time to correct some nutritional def iciencies. If patients are overweight they are often instructed to lose weight to reduce the risk of surgery. For anemia, an iron preparation can be administered. At least 2 to 3 weeks are required for objective evidence of the effectiveness of nutritional therapy. Before surgery on the gastrointestinal (GI) tract, a lo w-residue diet may be gi ven for 2 to 3 days to minimize bowel contents. Preoperative fasting time orders vary but the American Society of Anesthesiologists’ (2011) guidelines recommend a minimum of the follo wing time frames before anesthesia: • Clear liquids: 2 hours • Light meal (toast/clear liquid): 6 hours • A meal containing meat or fat: 8 hours. Clinical judgment is required re gardless of the guidelines, which do not apply to: • Patients with gastromotility or metabolic disorders • Those with potential airway problems • Women in labor Chronic disorders may increase the patient’ s surgical risk unless they are well controlled. A medical clearance for surgery may be needed from the patient’ s health care practitioner (HCP). Preadmission Surgical Patient Assessment Nonemergent surgical patients have either an interview with the anesthesiologist or a preadmission telephone or face-toface interview with RNs in the preadmission testing department under the direction of the anesthesia professional. The interview process includes a health history, identification of risk factors, patient and family teaching, discharge planning, and necessary referrals to social w ork, support groups, and educational programs. Patients are asked if there have been any personal or f amily problems with anesthesia or malignant hyperthermia. Malignant hyperthermia is a rare hereditary muscle disease that can predispose the patient to a serious life-threatening reaction to certain anesthetic agents (discussed later). Preoperative diagnostic testing is based on the patient’ s age, medical history, assessment findings, and institutional protocols (see Table 12.4). A urine or serum pre gnancy test as appropriate for female patients may be done to pre vent fetal exposure to anesthetics. Health information and diagnostic testing results are re viewed by anesthesia providers. Abnormal test results are reported to the surgeon. Interventions are ordered for abnormalities. TABLE 12.4 PREOPERATIVE DIAGNOSTIC TESTS Diagnostic Test Chest x-ray Purpose Detect pulmonary and cardiac abnormalities Oxygen saturation Obtain baseline level and detect abnormality Serum Tests Arterial blood gases Obtain baseline levels and detect pH and oxygenation abnormalities Continued 4068_Ch12_202-236 19/11/14 11:13 AM Page 208 208 UNIT TWO Understanding Health and Illness TABLE 12.4 PREOPERATIVE DIAGNOSTIC TESTS—cont’d Bleeding time Detect prolonged bleeding problem Blood urea nitrogen Detect kidney problem Creatinine Detect kidney problem Complete blood cell count Detect anemia, infection, clotting problem Electrolytes Detect potassium, sodium, chloride imbalances Fasting blood glucose Detect abnormalities, monitor diabetes control Pregnancy Detect early, unknown pregnancy Partial thromboplastin time Detect clotting problem International normalized ratio (INR) Detect clotting problem, monitor warfarin therapy Type and cross-match Identify blood type to match blood for possible transfusion Urine Tests Pregnancy Detect early, unknown pregnancy Urinalysis Detect infection, abnormalities Federal law says patients must be asked before surgery if they have a signed advance directive (e.g., health care durable power of attorney or living will) for their medical record (see Chapter 17). If there is no adv ance directive, written information on advance directives is offered. Preoperative Teaching Preoperative Routines Preoperative teaching provides information about common surgical preparation procedures and routines: • Date and time of admission and surgery • Admission procedures, including arriving about 2 hours before surgery to allow preparation time • Length of stay, items to bring and wear • Recovery after surgery • Family information, such as where to wait during surgery and who communicates patient’s status to them • Discharge criteria, including the need for a responsible adult to take the patient home after outpatient surgery. Preoperative Instructions To reduce the risks of pulmonary aspiration during surgery, the anesthesia professional orders fluid and food restrictions. The minimal fasting time frame guidelines of theAmerican Society of Anesthesiologists are listed in the “Nutrition Notes.” Patients may brush their teeth or rinse their mouth without swallowing. Cancellation of sur gery can result if the patient has not followed instructions to stop eating or drinking as specified. Medications the patient is to take the morning of surgery, with an ounce of water, are explained. Special preparations, such as an enema, are also described. F or abdominal or intestinal surgery, enemas are ordered to empty the bowel to reduce fecal contamination preoperatively and straining or distention postoperatively. Instructions for postoperative care are given before surgery so the patient is alert when being taught and has time to learn. Patients should be told that active participation in postoperative care aids in their reco very. Teach patients how to report their pain level using a pain rating scale so that prompt pain relief can be provided (see Chapter 10). Pain rating scales include a 0 (none) to 10 (w orst possible) rating scale, a color based rating scale, or a scale using pictures of faces showing varying degrees of frowning or smiling that indicate a certain pain level. Pain relief methods are described, such as analgesic injections, an epidural catheter, or patient-controlled analgesia (PCA). Anticipated dressings, tubes, casts, or special equipment are also described. If needed, crutches are f itted to the patient, and their proper use is explained and demonstrated. Postoperative exercises are taught to decrease complications. They include deep breathing and coughing, use of incentive spirometry, leg exercises, turning, and how to get out of bed. After an exercise is taught, the patient should perform a return demonstration so understanding and ability to perform the exercise correctly can be evaluated. Deep breathing helps prevent the development of atelectasis (collapse of the lung caused by hypoventilation or mucous obstruction preventing some alveoli from opening and being fully v entilated) by e xpanding and v entilating the lungs. The patient is taught to sit up, e xhale fully, take in a • WORD • BUILDING • atelectasis: ateles—imperfect + ektasis—expansion 4068_Ch12_202-236 19/11/14 11:13 AM Page 209 Chapter 12 deep breath through the nose, hold the breath and count to three, and then exhale completely through the mouth. The patient is told to repeat this hourly while awake, in sets of five, for 24 to 48 hours postoperatively. Incentive spirometry can also be ordered postoperati vely to prevent atelectasis by increasing lung volume, alveoli expansion, and venous return (Fig. 12.2). All patients can benefit from incentive spirometry, especially the older adult and those at increased risk for lung complications. The spirometer stays at the patient’s bedside for hourly use while awake (not on the window sill or in a drawer where it cannot be reached by the patient!). Offer the spirometer to the patient each hour to ensure that it is used. Teach patients to do the following: • Sit upright, at 45° minimum, if possible. • Take two normal breaths. Place mouthpiece of spirometer in mouth. Nursing Care of Patients Having Surgery 209 • Inhale until target, designated by spirometer light or rising ball, is reached, and hold breath for 3 to 5 seconds. • Exhale completely. • Perform 10 sets of breaths each hour. Coughing moves secretions to prevent pneumonia. Teach patients how to cough effectively if not contraindicated by the patient’s condition (such as hernia repair or head injury; Table 12.5). Give pain medication before asking the patient to cough and offer reassurance that coughing should not harm the incision. Splinting the incision with a pillow may be comforting. Several sets of coughing are performed e very 1 to 2 hours while the patient is awake. Leg exercises and foot circles done e very hour while awake, if not contraindicated, impro ve circulation and help prevent complications related to stasis of blood, such as emboli formation. Teach patients to do the following: • Lie down, raise leg, and bend leg at the knee. • Flex foot, extend leg, and lower it to the bed. • Do sets of five for each leg. • For foot circles, raise a leg slightly off the bed with toes pointed. • Draw a circle in the air with the great toe. • Rotating to the right four times, then to the left four times. • Repeat this five times and then repeat with the other foot. Patients are taught that turning from side to side in bed is aided by bending the leg that is to be on top and placing a pillow between the legs to support the top leg. Unless contraindicated, have patients use the bed’s side rail to pull themselves over to the side. To promote comfort, patients are encouraged to deep breathe while turning instead of holding their breath. To make it easier for patients to get out of bed and to reduce strain on the incision, instruct patient to do this: FIGURE 12.2 An incentive spirometer aids lung expansion. • Turn on side without pillows between knees. • Place hands flat against the bed. • Push up while swinging legs out of bed into a sitting position. TABLE 12.5 TEACHING PATIENTS COUGHING TECHNIQUES Procedure Have patient sit up and lean forward. Rationale Promotes lung expansion and ability to generate forceful cough. Show patient how to splint incision with hands, pillow, or blanket. Reduces incision pressure so it does not feel as if incision is opening. Have patient inhale and exhale deeply three times through mouth. Helps expand lungs. Have patient take in deep breath and cough out the breath forcefully with three short coughs using diaphragmatic muscles. Take in quick deep breath through mouth, cough deeply, and deep breathe. Generates forceful cough and expands lungs to help move secretions. 4068_Ch12_202-236 19/11/14 11:13 AM Page 210 210 UNIT TWO Understanding Health and Illness • Sit for a few minutes after changing position to avoid dizziness and falling. • Deep breathe while sitting to expand lungs. or uneasiness resulting from the uncertainties and risks associated with surgery, whereas fear, a feeling of dread from a source known to the patient, is an extreme reaction to surgery. Nursing Process for Preoperative Patients Data Collection HEALTH HISTORY. Upon admission for surgery, patient data are collected (Table 12.6). Ensure that patients use their contact lenses, glasses, or hearing aids for accurate communication. Note the patient’s emotional reaction to surgery. If the patient is anxious, explore the cause of the anxiety and allo w the patient to express concerns. Anxiety is a feeling of apprehension Medications. All prescription and o ver-the-counter medications that the patient takes are reviewed, along with any herbal remedies or recreational drugs. Anticoagulants such as w arfarin (Coumadin), or nonsteroidal anti-inflammatory drugs (NSAIDS) including aspirin may need to be stopped se veral days before surgery to avoid bleeding problems during sur gery. Because herbal medicines can interfere with medications used during surgery or increase bleeding times, patients may be instructed to stop them 1 to 2 weeks before surgery. TABLE 12.6 NURSING ASSESSMENT OF THE PREOPERATIVE PATIENT Subjective Data: Health History Questions Demographic information Name, age, marital status, occupation, roles? Condition for which surgery is scheduled Why are you having surgery? Medical history Any allergies, acute or chronic conditions, current medications, pain, or prior hospitalizations? Surgical history Any reactions or problems with anesthesia? Previous surgeries? Tobacco use How much do you smoke? Pack-year history (number of packs per day × number of years)? Alcohol use How often do you drink alcohol? How much? Coping techniques How do you usually cope with stressful situations? Support systems? Family history Hereditary conditions, diabetes, cardiovascular or anesthesia problems? Female patients Date of last menses and obstetrical information? Physical Assessment Vital signs, oxygen saturation Height and weight Emotional status Calm, anxious, tearful Neurologic Ability to follow instructions Skin Color, warmth, bruises, lesions, turgor, dryness, mucous membranes Respiratory Infection (cough; breath sounds); chronic obstructive pulmonary disease; respiratory rate, pattern, and effort; barrel chest Cardiovascular Angina, myocardial infarction, heart failure, hypertension, valvular heart disease, mitral valve prolapse, heart rate and rhythm, peripheral pulses, edema, jugular vein distention Gastrointestinal Bowel sounds, date of last bowel movement, abdominal distention, firmness, ostomy Musculoskeletal Deformities, weakness, decreased range of motion, crepitation, gait, artificial limbs, prostheses 4068_Ch12_202-236 19/11/14 11:13 AM Page 211 Chapter 12 Patients with diabetes who tak e insulin are usually instructed by anesthesia either to hold their insulin or to tak e half of their normal dose of insulin the day of surgery. On the day of sur gery, blood glucose monitoring is done e very 4 hours or as ordered to ensure that blood glucose levels are maintained within a desired range. Patients on chronic oral steroid therap y cannot abruptly stop steroids e ven though the y may be NPO (nothing by mouth) before or after sur gery. Serious complications, such as circulatory collapse, can de velop if steroids are stopped abruptly. The physician should order a patient’s steroid therapy to be given by a parenteral route if the patient is NPO, so that it is not interrupted. Make sure that the steroid therapy is ordered and continued for the patient. Patients should be asked about the use of alcohol or drugs such as cocaine, marijuana, or opioids because the y can interact with anesthesia or other medications. To obtain honest, accurate information, patients should be told of this potential interaction. Information and questions should be stated in a nonjudgmental manner. For example, you should ask, “How much alcohol do you drink daily or weekly?” instead of “Do you drink alcohol?” The first statement assumes that people drink alcohol. This allows the patient who does not drink to indicate none and the patient who does to state an amount rather than having to say yes and then give an amount upon further questioning. More accurate responses are gi ven because this approach is viewed more positively by the patient who consumes alcohol. Another example would be to ask the patient, “What roles do drugs or alcohol play in your life?” Physical Assessment A physical assessment of body systems is performed. This information can highlight risk factors for surgery, determine the type of anesthesia to be used, and assist in planning in terventions to reduce risk factors. A cough, cold, or fever is reported to the surgeon because surgery may be delayed until the patient reco vers from an acute infection. Dentures, bridges, capped teeth, and loose teeth are documented because they can become dislodged during intubation (insertion of endotracheal breathing tube) for general anesthesia, causing complications. Nursing Diagnoses, Planning, and Interventions Anxiety or Fear related to potential change in body image, hospitalization, pain, loss of control, and uncertainties surrounding surgery EXPECTED OUTCOME: Patient will state reduced anxiety or fear before surgery. • Inform patients about procedures and surgical routines, which helps reduce anxiety. • Allow patients to express their concerns to allow inaccurate information to be corrected. • If patients express extreme anxiety or fear, inform the surgeon because complications or even death could result. When fear is excessive, the surgeon may reschedule the surgery until the patient is better able to cope. Nursing Care of Patients Having Surgery 211 Deficient Knowledge related to lack of previous experience with surgical routines and procedures EXPECTED OUTCOME: Patient will demonstrate understanding of surgical information and routines before surgery. • Patient anxiety levels should be considered when providing explanations because learning can be affected by high anxiety levels. • Identify knowledge deficiencies with the patient so that he or she is motivated to learn. • Reinforce information provided before admission and new information to patients to promote informed choice and increase self-care abilities. Teaching is caring in action and empowers patients to be a participant in their care. • Include the patient’s family or caregivers in teaching sessions so they can assist the patient through the surgical experience. • Use a variety of teaching methods (discussion, written materials and instructions, models, and videos) to allow for different learning styles and to reinforce learning. • Individualize explanations so the patient is not overwhelmed. • Use teaching methods that can be adapted to aging changes that may affect learning. “Gerontological Issues” describes methods to provide a positive learning experience for the older patient. • Document teaching and patient understanding. Documentation is essential as proof of what was explained and patient understanding. Gerontological Issues Considerations for Older Patient Teaching Sessions Environmental Considerations • Comfortable: anxiety free, quiet, appropriate temperature • Correctly lit: small, intense lighting with nonglare, soft white light (not fluorescent) • Private: no distractions, no background noise, turn off pagers Presentation Considerations • Assess readiness to learn. • Assess comfort and safety needs. • Use past experience and relate to new learning. • Base learning on assessment data and current knowledge base. • Use simple, understandable words and avoid medical jargon. • Use legible audiovisual materials: large print, black print on white nonglare paper. • If using colors, remember that older adults see red, orange, and yellow best; blue, violet, and green are more difficult to see. 4068_Ch12_202-236 19/11/14 11:13 AM Page 212 212 UNIT TWO Understanding Health and Illness • Perform ongoing assessment of energy level of patient. • Answer questions as they occur. Presenter Considerations • Have a positive attitude and belief in self-care promotion for older adults. • Earn trust by being viewed as a credible, positive role model. • Maintain a professional appearance. • Use knowledge of aging changes in presentation. • Speak slowly in a low tone. • Sit near patient for best visibility. • Ensure that prostheses are in place, such as glasses, hearing aids. • Allow patient increased response time, and use memory aids such as pictures or diagrams. • Use touch appropriately to convey caring. • Teach most important information first. • Present one idea at a time. • Provide instruction using multiple senses (vision and hearing). • Provide repetition. • Ask for feedback to ensure comprehension. • Provide feedback and positive reinforcement. Evaluation The goal of decreased anxiety is achieved if the patient states and demonstrates that anxiety is relieved. If the patient is able to learn during teaching sessions, anxiety is not a barrier to learning. The goal for correcting def icient knowledge is reached if the patient states understanding of the information presented and accurately performs return demonstrations of presented information. without treatment. If the patient has questions before signing the consent, the surgeon must be contacted to provide further explanation to the patient. It is not within the nurse’s scope of practice to provide this information. 2. The consent must be signed before analgesics or sedatives are given because patients must demonstrate to the witness that they are informed and understand the surgery. 3. Consent must be given voluntarily. No persuasion or threats can be used to influence the patient. The patient can withdraw consent at any time, even after the consent form has been signed. To ensure that patients are truly informed before signing a consent form, in some institutions, patients must tak e and pass a knowledge quiz, which can be given verbally. If they do not pass the quiz, then further e xplanation is needed by the surgeon. Also, in the surgical holding area, patients verbally reconsent. They are asked, “Do you still remember what you were told about your surgery?” It is often your role to obtain and witness the patient’ s or authorized person’ s signature on the consent form (Fig. 12.3). As the patient’s advocate, you must ensure that the person signing the consent form understands its meaning and has no further questions to be directed to the HCP before it is signed and that it is being signed voluntarily. If the patient is unable to read, the entire consent must be read to the patient before it is signed. Patients are unable to give consent if they are unconscious, are mentally incompetent, are minors, or have received analgesics or drugs that alter central nervous system function within time frames specified by agency policy. Consent may be obtained in an y of these cases from parents, next of kin, or legal guardians as specified by law. Preoperative Consent Before performing surgery, it is the surgeon’s responsibility to obtain voluntary, written, informed consent from the patient. The consent gives legal permission for the surgery and has two purposes: It protects the patient from unauthorized procedures, and it protects the sur geon, anesthesia professional, hospital, and hospital employees from claims of performance of unauthorized procedures. A signed consent is needed for all invasive procedures, surgery, anesthesia, blood administration, and radiation or cobalt therapy. It is typically valid for 30 days after signing. Informed consent involves three elements: 1. The surgeon must explain in terms the patient understands about the diagnosis, the proposed treatment and who will perform it, the likely outcome, possible risks and complications of treatment, alternative treatments, and the prognosis FIGURE 12.3 Nurse is witnessing signature of patient on surgical consent. 4068_Ch12_202-236 19/11/14 11:13 AM Page 213 Chapter 12 NURSING CARE TIP Witnessing a Consent Your signature as a witness on a consent form indicates that you observed the informed patient or patient’s authorized representative voluntarily sign the consent form. It does not mean that you informed the patient about the surgical procedure; that is the responsibility of the HCP. In a medical emergency, the patient may not be able to give consent. In this case, the next of kin or legal guardian may give telephone consent, or a court order can be obtained. If time does not permit this, the surgeon documents the need for treatment in the chart as necessary to save the patient’s life or avoid serious harm, according to state law and institutional policy. Preparation for Surgery Preoperative Preparation Checklist A preoperative checklist is usually completed and signed by the nurse (per agency policy) before the patient is transported from the sur gical unit to sur gery (Fig. 12.4). The checklist provides guidance for preoperative preparation of the patient: • An identification band is placed on the patient. A hospital gown is given to the patient to wear. Underwear is removed, depending on the type of surgery. • Vital signs are taken and recorded as baseline information and to assess patient status. • Makeup, nail polish, and artificial nails (if applicable) are removed to allow assessment of natural color and pulse oximetry for oxygenation status during surgery. • Removal of hairpins, wigs, and jewelry prevents loss or injury. Rings, such as wedding rings, are taped in place if the patient does not want to take them off, except if the ring is on the operative side (arm or chest surgery), because edema may occur. • Dentures, contact lenses, and prostheses are removed to prevent injury. Some patients are concerned about body image and do not want family members to see them without dentures or makeup. Remove dentures after the family goes to the waiting room and insert them before the family sees the patient postoperatively. • Glasses and hearing aids go with patients to surgery if they are unable to communicate without them. Label them with the patient’s name and document where they go. • All orders, diagnostic test results, consents, and history and physical (required on the chart) are reviewed for completion and documented on the checklist. • Patient valuables are recorded and given to a family member or locked up per institutional policy by the nurse. Nursing Care of Patients Having Surgery 213 • Antiembolism devices are applied if ordered. • Patients are asked to void before sedating preoperative medications are given, unless a urinary catheter is present, to prevent injury to the bladder during surgery. Preoperative Medications Preoperative medications are given at the time ordered or on call to surgery (i.e., surgery calls to instruct that it is time to give the drugs; Table 12.7). If sedati ves or analgesics are given, the bed rails are raised for safety and the patient is instructed not to get up alone. BE SAFE! National Surgical Care Improvement Project (SCIP) Goal: Improve the safety of surgical care by reducing postoperative complications. The Centers for Medicare and Medicaid Services, the Joint Commission, and other national organizations partnered for this quality project (www.jointcommission.org). Education for the public is provided in “Tips for Safer Surgery,” which summarizes project categories for reducing surgical complications. The information encourages patients to ask their HCP and nurses questions about their surgery. Being aware of this project will help you accurately answer your patients’ questions in providing safe surgical care. Prevention: Areas covered by the SCIP include surgical site infections (SSIs), normothermia, venous thrombo event (VTE), and adverse cardiac events. Methods for preventing SSIs include the following: • Giving prophylactic antibiotics within 1 hour before incision time and stopping them within 24 hours. • Using electronic clippers for site hair removal, controlling perioperative serum glucose during major cardiac procedures, and removing urinary catheters by postoperative day 2. • Maintaining core body temperature within normal range (normothermia) reduces risk (infection, impaired wound healing, MI, blood transfusion) in the perioperative period. • VTE can be prevented by administering appropriate perioperative anticoagulants to those at risk. • Avoiding adverse cardiac events includes giving beta blockers during the perioperative period to eligible major noncardiac surgical patients and to surgical patients who have coronary artery disease, and informing the HCP of all medications and herbs taken. 4068_Ch12_202-236 19/11/14 11:13 AM Page 214 214 UNIT TWO Understanding Health and Illness Pre-op Surgical Checklist Client Name I.D. BAND ON NPO AS ORDERED PRE-OP TEACHING COMPLETED INFORMED CONSENT SIGNED HISTORY AND PHYSICAL ON CHART ALLERGIES LAB RESULTS CBC: HGB HCT WBC PLATELETS POTASSIUM URINALYSIS PREGNANCY TEST PT SERUM PTT URINE BLEEDING TIME TYPE AND SCREEN - CROSSMATCH UNITS ECG ON CHART CHEST X-RAY REPORT ON CHART SHOWERED/BATHED HOSPITAL GOWN ON PREPS COMPLETED AS ORDERED ANTIEMBOLISM STOCKINGS JEWELRY TAPED/REMOVED: DISPOSITION VALUABLES: DISPOSITION DENTURES, PROSTHESIS REMOVED HAIR PINS, WIGS, MAKE UP, NAIL POLISH, ONE ACRYLIC NAIL REMOVED CONTACT LENSES REMOVED VOIDED VITAL SIGNS: T P R BP PRE-OP MEDICATIONS GIVEN SIDE RAILS UP IV STARTED EYE GLASSES AND HEARING AID(S) TO OR OLD CHART TO OR X-RAYS TO OR FAMILY LOCATION NEXT OF KIN CLIENT READY FOR SURGERY TIME (NURSE SIGNATURE) COMMENTS: FIGURE 12.4 Sample preoperative checklist form. Transfer to Surgery Department Post-Transfer to Surgery Department When the surgery department is ready, the patient is transported to the surgical holding area on a gurney (Fig. 12.5). The patient’s chart, inhaler medications for those with asthma, and glasses or hearing aids to aid communication are tak en with the patient. Family members can accompany the patient. During the surgery, the family waits in the surgical waiting area, which is a communication center where the family can be called via cell phone or given a beeper to be kept informed of the patient’s status. After the patient goes to the surgery department, you can prepare the patient’s room and necessary equipment so it is ready upon the patient’s return (Table 12.8). Patient Arrival in Surgery Department The holding area nurse greets the patient; verifies the patient’s name, age, aller gies, surgeon performing the sur gery, informed consent, surgical procedure (right site, especially right 4068_Ch12_202-236 19/11/14 11:13 AM Page 215 Chapter 12 Nursing Care of Patients Having Surgery 215 TABLE 12.7 PREOPERATIVE MEDICATIONS Class/Action Examples Nursing Implications Analgesic/Antipyretic Relieves mild to moderate pain and reduces fever. acetaminophen (OFIRMEV) Given intravenously as 15-minute infusion. Antipyretic effect may mask fever. diazepam (Valium) lorazepam (Ativan) midazolam (Versed) Contraindicated for acute narrowangle glaucoma. Monitor respirations. ondansetron (Zofran) metoclopramide (Reglan) promethazine hydrochloride (Phenergan) Redness, pain, or burning at the site of injection. Increased drowsiness with opioids. Variety of antibiotics used Give within 30–60 minutes of incision for best effect. fentanyl (Sublimaze, Duragesic) morphine sulfate meperidine (Demerol) Monitor vital signs, level of sedation, and respiratory status. Antianxiety and Sedative Hypnotics Sedation; anxiety reduction Antiemetics Control nausea and vomiting Antibiotics Prevention of postoperative infection Opioids Bind to opioid receptors in the central nervous system to alter perception of pain and enhance postoperative pain relief or left when applicable), and medical history; answers questions; and alleviates anxiety. The patient is introduced to the anesthesiologist and certif ied registered nurse anesthetist (CRNA), who also verify patient information and explain the type of anesthesia that is to be used.All surgical patients have IV fluids started. The patient may also recei ve prophylactic antibiotics. Avoid meperidine use in older adult. Before entering the operating room (OR), the patient should be told what to expect: • “If the room feels cool, you can request extra blankets.” • “There is a lot of equipment in the room, including a table and large, bright overhead lights.” • “Several health care team members will introduce themselves to you.” • “Your surgeon will greet you.” • “A safety checklist will be performed.” Preoperative Warming To maintain normal body temperature (normothermia) and reduce intraoperative hypothermia, which is associated with complications, prewarming peripheral tissues or surface skin before anesthesia is helpful. Use of forced-air warming devices for 30 minutes may reduce hypothermia. Patients should be normothermic before transfer to surgery. INTRAOPERATIVE PHASE FIGURE 12.5 Surgical holding area. When the patient is transferred to the operating table, the next phase of the perioperative period, the intraoperative phase, begins. Surgery may take place in a hospital OR or 4068_Ch12_202-236 19/11/14 11:13 AM Page 216 216 UNIT TWO Understanding Health and Illness TABLE 12.8 POSTOPERATIVE PATIENT HOSPITAL ROOM PREPARATION After patient transfer to surgery, prepare the patient’s room for the patient’s postoperative care needs on return from the perianesthesia care unit. Preparation Rationale Bed Bed linens should be clean and are changed if used by patient before surgery. Reduces contamination of surgical wound. Place disposable, absorbent, waterproof pads on bottom sheet if drainage is expected. Protects linen from wetness and soiling so a patient in pain does not have to be disturbed for linen change. Apply lift sheet on bed of patient needing assistance with repositioning. Makes lifting and turning easier for patient and nurse. Have extra blankets available. Patient may be cold. Fanfold top cover to end of bed or to side of bed away from patient transfer side. Readies bed to receive patient on transfer and allows covers to be easily pulled up over patient. Obtain extra pillows as needed for positioning, elevating extremities, splinting during coughing. Pillows help maintain position when patient is turned, or splint an incision during coughing, or elevate operative extremities for comfort and swelling reduction. Equipment Have vital sign equipment available. Promotes ability to promptly obtain vital signs. Have intravenous (IV) pole/controller pump available. Surgical patients have IV infusions postoperatively. Have oxygen set up as needed. After tracheostomy, patients wear humidified oxygen mask. Prepare suction setup for tracheostomy, nasogastric tube, or drains as ordered. Suction may be ordered related to surgical procedures: Sterile suction: tracheostomy Nasogastric tube: thoracic, abdominal, gastrointestinal surgery T-tube: cholecystectomy. Have emesis basin at bedside. Nausea or vomiting may occur, especially after movement during transfer. Have tissues and washcloths in room. Promotes comfort: washing face or a cool cloth on forehead. Have urinal or bedpan available in room. Patients may be unable to get out of bed for first voiding. Obtain special equipment as indicated by the surgical procedure. Institutional policy and surgeon orders may require specialized equipment. Examples: Jaw surgery: suction, wire cutters, tracheostomy tray Tracheostomy: suction, extra tracheostomy set, tracheostomy care supplies Documentation Forms Place any agency postoperative documentation forms in room. Promotes timely and accurate documentation of patient data. 4068_Ch12_202-236 19/11/14 11:13 AM Page 217 Chapter 12 Nursing Care of Patients Having Surgery 217 BE SAFE! Follow the Joint Commission’s Universal Protocol for Preventing Wrong-Person, Wrong-Site, WrongProcedure Surgery. Preprocedure Verification Conduct a preprocedure verification process to ensure that all relevant documents, information, and equipment are available. Implement a process to mark the surgical site and involve the patient in the marking process. Time Out Take a time out immediately before beginning the procedure to conduct a final assessment that the correct patient, site, and procedure have been identified. No procedure (conducted in any setting) should start unless all personnel involved in the patient’s care have honored the “time out” (Joint Commission’s 2014 National Patient Safety Goals. © The Joint Commission, 2013. Reprinted with permission.). freestanding ambulatory or outpatient sur gical center (Figs. 12.6 and 12.7). Additionally, surgery is performed in physician’s offices, cardiac catheterization laboratories, radiology centers, emergency rooms, and specialized units that perform endoscopy procedures. The OR team members (Box 12-1) must perform a sterile surgical hand scrub to reduce the amount of microorganisms on their hands and arms. Je welry (e.g., watches, rings, bracelets) is also remo ved. Fingernails are k ept short and clean. Artificial nails and nail polish may harbor microorganisms and therefore are recommended not to be FIGURE 12.6 Operating room. Anesthesia equipment is on the left. FIGURE 12.7 Operating room in use. Anesthesia equipment is on the right. worn. If nail polish is w orn, it should not be chipped and should be remo ved and reapplied e very 4 days. Sterile gloves are then w orn by the sur gical team to k eep the surgical field sterile. The OR is designed to enhance aseptic (elimination of microorganisms) technique. Clean and contaminated areas are Box 12-1 Surgical Health Care Team Members and Roles Members of the surgical health care team and their roles are as follows: • Surgeon (medical doctor, doctor of osteopathy, oral surgeon, or podiatrist) • Surgical (first) assistant: assists the surgeon and is another physician, a specially trained RN, or a physician’s assistant • Anesthesiologist: physician who specializes in administering anesthesia and supervises certified registered nurse anesthetists (CRNAs) in the operating room • CRNA: an RN trained and certified in administering anesthesia, usually at the master’s degree level • RN: circulates in the OR; roles include being patient’s advocate, planning care, protecting patient safety, monitoring patient positioning, checking vital signs and patient assessment, reducing patient’s anxiety, monitoring sterility during surgery, preparing skin before incision, managing equipment such as by making sponge counts, documenting the procedure, and aiding health team communications • Surgical (second assistant) technician: assists surgeon (may be an RN, LPN/LVN, or surgical technologist) 4068_Ch12_202-236 19/11/14 11:13 AM Page 218 218 UNIT TWO Understanding Health and Illness separated. Special v entilation systems control dust and prevent air from flowing into the OR from hallways. The temperature and humidity in the room are controlled to discourage bacterial growth. Ambient room temperature to reduce patient hypothermia is recommended to be 68° to 77°F (20°–25°C). Everyone entering the OR wears surgical scrubs, shoe covers, caps, masks, and goggles to protect the patient from infection and themselves from bloodborne pathogens. Traffic in and out of the OR is limited. Strong disinfectants are used to clean the OR after each surgical case, and instruments are sterilized. Before the patient arrives in surgery, a nursing plan of care with intraoperative nursing diagnoses and expected outcomes is developed from preadmission assessment data (Box 12-2). Attention is given to the safety needs of the patient.A surgical case cart containing sterile instruments required for the patient’s case is prepared ahead of time. The patient is assisted onto the operating table, and a safety strap is carefully applied. A time-out is taken. Then monitoring equipment is applied and readings recorded. The anesthesia provider begins administering anesthesia. When the anesthesia provider gives permission, the patient is carefully positioned to prevent pressure points that could cause tissue or nerve damage. Any needed tubes that are not already in place, such as a nasogastric (NG) tube or urinary catheter, are inserted by the RN. Patient allergies, including skin prep solutions, are rechecked. If the patient requires body hair remo val, hair should be removed with electric clippers. Shaving is avoided because of the potential for microabrasions and colonization Box 12-2 Intraoperative Nursing Diagnoses and Expected Outcome • Risk for Injury related to perioperative positioning, chemicals, electrical equipment, and effect of being anesthetized Is free from injury. • Risk for Impaired Skin Integrity related to chemicals, positioning, and immobility Skin integrity is maintained. • Risk for Deficient Fluid Volume related to NPO status and blood loss Maintains blood pressure, pulse, and urine output within normal limits. • Risk for Infection related to incision and invasive procedures Is free of symptoms of infection. • Pain related to positioning, incision, and surgical procedure Reports pain is relieved to satisfactory level. by microorganisms. Then a skin prepping solution such as povidone-iodine is used to cleanse the skin. A large area surrounding the operative site is scrubbed to allow for extension of the incision. The scrub is completed in a circular motion from inside to outer edge. If an allergic reaction to the solution occurs, it can cause skin redness and blistering wherever the solution was used. After the skin is scrubbed, a sterile drape is applied with the incisional area left exposed. BE SAFE! Improve the safety of using medications. Label all medications, medication containers (e.g., syringes, medicine cups, basins), or other solutions on and off the sterile field in perioperative and other procedural settings (Joint Commission’s 2014 National Patient Safety Goals. © The Joint Commission, 2013. Reprinted with permission.). Anesthesia Anesthesia is used during surgery to prevent pain and allow the procedure to be done safely. The type of anesthesia and the anesthetic agents are ordered by the anesthesia pro vider with input from the patient and surgeon. There are two types of anesthesia: general and local (regional). General anesthesia causes the patient to lose sensation, consciousness, and reflexes. It acts directly on the central nervous system (Box 12-3). Local anesthesia blocks nerve impulses along the nerve where it is injected, resulting in the loss of sensation to a region of the body without the loss of consciousness. General Anesthesia General anesthesia is commonly gi ven by IV or inhalation. It is chosen when patients are anxious or do not w ant local anesthesia, when the surgical procedure will take a long time and there is a need for muscle relaxation, or when the patient is unable to cooperate, as in head injury, muscle disorders, or impaired cognitive function. INTRAVENOUS AGENTS. To begin most general anesthesia, the patient is induced (which means “to cause anesthesia”) with a short-acting IV agent that pro vides a rapid, smooth induction (the period from when the a