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Monitoring Patients for Local Cases: Nursing Responsibilities
AORN JOURNAL
NOVEMBER 1986, VOL. 44, NO 5
Monitoring Patients for Local Cases v
NURSINGRESPONSIBILITIES Brenda C. Mauldin, RN It is 7:45 AM on a weekday, and all 8 AMpatients are in the OR suite ready for surgeiy. All OR rooms have full schedules from 7 AM to 3:30 PM-the only sh$ with an assigned stajJ In the bustle of morning preparations, the charge nurse notices that an anesthesiologist has not reported for work. When he is called, he says he is very ill and unable to work. It appears that a full room of surgery will have to be reassigned into other rooms, and the staff will have to work overtime. When the jrst surgeon arrives and fin& his patient in another room and the starting time delayed the nursing and anesthesia stafls suggest using local anesthesia with intravenous (IV) sedation. All three of his patients are scheduled for procedures amenable to local anesthesia, so
he agrees with the suggestion and discusses the change ofpans with hispatients. Hispatientsagree to have local anesthesia One nurse is assigned to monitor the patients under local anesthesia, and the remainder of rhe day proceeds according to the original schedule. All of thepatients were kept comfortable with local anesthesia and intermittentsedation ordered by the surgeon and administered by the nurse. What could have been a disastrousday worked out wellfor all The added bonus is that the patients who received local anesthesia did not have to recover from general anesthesia.
Hktoiy
S
Brenda C. Mauldin, Rh? BS, is the director of surgical services, Doctors Hospital, Tucker, Ga She earned her associate degree in nursing from DeKalb Community College, Clarkston, Ga, and her bachelor of science degree in health and human resources from Georgia State University,Atlanta
urgery without the benefit of anesthesia is not a new concept. Surgical Operation, a painting by David Teniers, the Younger (1610-1690), gives us a glimpse of how things were done in the past (Fig 1). Throughout the evolution of outpatient surgery, ambulatory surgery practitioners have recommended that candidates for outpatient surgery be generally healthy (ie, American Society of Anesthesiologists (ASA) Class I or I1 patients).’ But with the advent of diagnosis related groups (DRGs), there has been a tendency towards an increase in the number of ASA Class 111 patients having surgery on an outpatient basis. (See “American Society of Anesthesiologists’ Classification of Patients.”) Local anesthesia has always been an option for many procedures, and it has been common practice to have anesthesia standby for longer, 841
AORN JOURNAL
NOVEMBER 1986, VOL. 44. NO 5
Fig I . Surgical Operation by David Teniers, the Younger (1 610- 1690). Neither anesthesia nor hygiene had been discovered. more involved local procedures, such as rhytidectomy. These patients are usually given some additional sedation; it is unreasonable to expect a patient to lie still on an OR bed for several hours without it. In April 1986, the Medicare division of the Prudential Insurance Company sent out a notice that routine payment for general or local/standby anesthesia on pacemaker insertion would no longer be allowed in the state of Georgia.2 This has far-reaching implications for OR nursing in both inpatient and outpatient settings. Pacemakers are not usually implanted on an outpatient basis; however, pacemaker battery changes are done on an outpatient basis under local anesthesia.
or standards of care. Policies and procedures for local anesthesia must be written and must include protocols specifying the types of medications nurses can administer during local procedures and safe medication doses that can be given in a short period of time. (See “Example of Protocol for Diazepam and Meperidine.”) In addition to drug administration policies, policies on how local anesthesia patients will be monitored must be written. An excellent reference for this is the AORN “Recommended practices for monitoring the patient receiving local ane~thesia.”~
Standarh of Care
preoperative nursing assessment is essential in planning care for the local anesthesia patient. The nurse can set the tone of how the procedure will go during the preoperative stage. Honest and open conversation about what the patient can expect during the
0
perating room nurses must be prepared to monitor patients receiving local anesthesia. One of the first steps in caring for local anesthesia patients is to establish criteria
Nursing Responsibilities
A
d+ 843
NOVEMBER 1986, VOL. 44, NO 5
AORN JOURNAL
American Society of Anesthesiologists’ Classification of Patients ASA-Class I No organic, physiological, biochemical or psychiatric disturbance The pathology that requires surgery should be localized in the healthy patient. Example: Inguinal hernia, dilatation and curettage ASA-Class I1 Mild to moderate systemic disturbance caused by the condition requiring surgery or by other pathologic processes Example: Moderate obesity, pill or diet-controlled diabetes, mild essential hypertension, chronic bronchitis
Rather severe systemic disturbances or pathology Example: Insulin-controlled diabetes, pulmonary insufficiency, angina procedure can prevent the patient from overreacting during surgery. Patients should not be told that they will not feel a thing. If nothing else, they will feel the needle stick from the local anesthesia. Tell them they can be given medication for pain and to make them drowsy through an IV line that will be inserted preoperatively. Good preoperative preparation may reduce the need for large amounts of intraoperative sedation. In addition to knowing the patient, the nurse must know the drugs that will be used during the procedure. The surgeon determines the type and amount of the drug to be administered, but the nurse must be able to recognize an adverse reaction and know how to assist if a reaction occurs. All nursing care given during local anesthesia must be documented. An easy way to do this is for the nurse to document it on the anesthesia record. The nurse should write local anesthesia in large letters somewhere on the record. Intraoperative vital signs can also be documented on the anesthesia record. 846
Nurses who monitor local anesthesia patients must be prepared to handle cardiac or respiratory arrests. If an anesthesiologistis not readily available for emergencies, the nursing staff must have a plan that involves other hospital departments. In a freestanding center, not in close proximity to a hospital, the available staff will have to handle the emergency. Familiarity with the cardiopulmonary resuscitation procedure, the defibrillator, and the crash cart are essential. A detailed description of each member’s responsibility will assist everyone involved. Clear documentation of arrests is also essential. A prepared and knowledgeable staff is the first step in avoiding a death in the ambulatory surgery unit. Teamwork and careful planning of care are essential for monitoring the local anesthesia 0 patient. Notes 1. “Physical status classification,” Relative Value Guide (Chicago: American Society of Anesthesiologists, 1985) V.
AORN J O U R N A L
NOVEMBER 1986, VOL. 44. NO 5
Example of Protocol for Diazepam and Meperidine Policy: Anesthesia support will be required for those patients, in the outpatient surgery department, who receive doses of intravenous diazepam and meperidine that exceed the manufacturers’ recommended dose.
Young adults are defined as those patients less than 40 years of age. Those patients between 40 and 60 years of age who are not seriously ill or debilitated, as assessed by the attending physician, can be given intravenous diazepam as recommended for the young adult patient.
Procedure: The manufacturer’s recommended dosage for diazepam administered concomitantly with meperidine is: young adult-5 mg to 10 mg of diazepam, 75 mg to 100 mg of meperidine, older, debilitated, precomatose, seriously ill-1 mg to 4 mg diazepam, 20 mg to 50 mg meperidine, alcoholic-10 mg to 15 mg diazepam, 75 mg to 100 mg meperidine, and extremely agitated or apprehensive10 mg to 15 mg diazepam, 100 mg to 125 mg meperidine. Pediatric patients less than 14 years of age will be monitored by the anesthesia department if intravenous (IV) diazepam or meperidine is to be administered.
2. “General anesthesia for pacemaker implants,” Prudential Medicare Bulletin (Buford, Ga: Prudential Insurance Company, Medicare B Division, April 1986)
Older, debilitated, precomatose, seriously ill patient types will be defined as such by the attending physician. Generally 10 mg, or less, of IV diazepam is recommended, when use of concomitant narcotics is omitted, to relieve apprehension, anxiety or acute stress reactions in patients undergoing endoscopic examination. The initial dose of IV diazepam will not exceed 5 mg. Supplemental IV diazepam will be administered slowly, over three to five minutes, not to exceed the manufacturer’s recommended dose. Monitoring by the anesthesia department will be required for those patients who receive doses of diazepam that exceed the manufacturer’s recommended dose.
Schultz, R. Outpatient Surgery. Philadelphia: Lea & Febiger, 1979, 39-40.
1.
3. “Recommended practices for monitoring the patient receiving local anesthesia,” AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1986) III:16-I to 16-2.
Suggested reading Mauldin, B. Ambulatory Surgery, A Guide to Perioperative Nursing Care. New York: Grune & Stratton, 1983, 141-142. 847
NOVEMBER 1986, VOL. 44, NO 5
Monitoring Patients for Local Cases v
NURSINGRESPONSIBILITIES Brenda C. Mauldin, RN It is 7:45 AM on a weekday, and all 8 AMpatients are in the OR suite ready for surgeiy. All OR rooms have full schedules from 7 AM to 3:30 PM-the only sh$ with an assigned stajJ In the bustle of morning preparations, the charge nurse notices that an anesthesiologist has not reported for work. When he is called, he says he is very ill and unable to work. It appears that a full room of surgery will have to be reassigned into other rooms, and the staff will have to work overtime. When the jrst surgeon arrives and fin& his patient in another room and the starting time delayed the nursing and anesthesia stafls suggest using local anesthesia with intravenous (IV) sedation. All three of his patients are scheduled for procedures amenable to local anesthesia, so
he agrees with the suggestion and discusses the change ofpans with hispatients. Hispatientsagree to have local anesthesia One nurse is assigned to monitor the patients under local anesthesia, and the remainder of rhe day proceeds according to the original schedule. All of thepatients were kept comfortable with local anesthesia and intermittentsedation ordered by the surgeon and administered by the nurse. What could have been a disastrousday worked out wellfor all The added bonus is that the patients who received local anesthesia did not have to recover from general anesthesia.
Hktoiy
S
Brenda C. Mauldin, Rh? BS, is the director of surgical services, Doctors Hospital, Tucker, Ga She earned her associate degree in nursing from DeKalb Community College, Clarkston, Ga, and her bachelor of science degree in health and human resources from Georgia State University,Atlanta
urgery without the benefit of anesthesia is not a new concept. Surgical Operation, a painting by David Teniers, the Younger (1610-1690), gives us a glimpse of how things were done in the past (Fig 1). Throughout the evolution of outpatient surgery, ambulatory surgery practitioners have recommended that candidates for outpatient surgery be generally healthy (ie, American Society of Anesthesiologists (ASA) Class I or I1 patients).’ But with the advent of diagnosis related groups (DRGs), there has been a tendency towards an increase in the number of ASA Class 111 patients having surgery on an outpatient basis. (See “American Society of Anesthesiologists’ Classification of Patients.”) Local anesthesia has always been an option for many procedures, and it has been common practice to have anesthesia standby for longer, 841
AORN JOURNAL
NOVEMBER 1986, VOL. 44. NO 5
Fig I . Surgical Operation by David Teniers, the Younger (1 610- 1690). Neither anesthesia nor hygiene had been discovered. more involved local procedures, such as rhytidectomy. These patients are usually given some additional sedation; it is unreasonable to expect a patient to lie still on an OR bed for several hours without it. In April 1986, the Medicare division of the Prudential Insurance Company sent out a notice that routine payment for general or local/standby anesthesia on pacemaker insertion would no longer be allowed in the state of Georgia.2 This has far-reaching implications for OR nursing in both inpatient and outpatient settings. Pacemakers are not usually implanted on an outpatient basis; however, pacemaker battery changes are done on an outpatient basis under local anesthesia.
or standards of care. Policies and procedures for local anesthesia must be written and must include protocols specifying the types of medications nurses can administer during local procedures and safe medication doses that can be given in a short period of time. (See “Example of Protocol for Diazepam and Meperidine.”) In addition to drug administration policies, policies on how local anesthesia patients will be monitored must be written. An excellent reference for this is the AORN “Recommended practices for monitoring the patient receiving local ane~thesia.”~
Standarh of Care
preoperative nursing assessment is essential in planning care for the local anesthesia patient. The nurse can set the tone of how the procedure will go during the preoperative stage. Honest and open conversation about what the patient can expect during the
0
perating room nurses must be prepared to monitor patients receiving local anesthesia. One of the first steps in caring for local anesthesia patients is to establish criteria
Nursing Responsibilities
A
d+ 843
NOVEMBER 1986, VOL. 44, NO 5
AORN JOURNAL
American Society of Anesthesiologists’ Classification of Patients ASA-Class I No organic, physiological, biochemical or psychiatric disturbance The pathology that requires surgery should be localized in the healthy patient. Example: Inguinal hernia, dilatation and curettage ASA-Class I1 Mild to moderate systemic disturbance caused by the condition requiring surgery or by other pathologic processes Example: Moderate obesity, pill or diet-controlled diabetes, mild essential hypertension, chronic bronchitis
Rather severe systemic disturbances or pathology Example: Insulin-controlled diabetes, pulmonary insufficiency, angina procedure can prevent the patient from overreacting during surgery. Patients should not be told that they will not feel a thing. If nothing else, they will feel the needle stick from the local anesthesia. Tell them they can be given medication for pain and to make them drowsy through an IV line that will be inserted preoperatively. Good preoperative preparation may reduce the need for large amounts of intraoperative sedation. In addition to knowing the patient, the nurse must know the drugs that will be used during the procedure. The surgeon determines the type and amount of the drug to be administered, but the nurse must be able to recognize an adverse reaction and know how to assist if a reaction occurs. All nursing care given during local anesthesia must be documented. An easy way to do this is for the nurse to document it on the anesthesia record. The nurse should write local anesthesia in large letters somewhere on the record. Intraoperative vital signs can also be documented on the anesthesia record. 846
Nurses who monitor local anesthesia patients must be prepared to handle cardiac or respiratory arrests. If an anesthesiologistis not readily available for emergencies, the nursing staff must have a plan that involves other hospital departments. In a freestanding center, not in close proximity to a hospital, the available staff will have to handle the emergency. Familiarity with the cardiopulmonary resuscitation procedure, the defibrillator, and the crash cart are essential. A detailed description of each member’s responsibility will assist everyone involved. Clear documentation of arrests is also essential. A prepared and knowledgeable staff is the first step in avoiding a death in the ambulatory surgery unit. Teamwork and careful planning of care are essential for monitoring the local anesthesia 0 patient. Notes 1. “Physical status classification,” Relative Value Guide (Chicago: American Society of Anesthesiologists, 1985) V.
AORN J O U R N A L
NOVEMBER 1986, VOL. 44. NO 5
Example of Protocol for Diazepam and Meperidine Policy: Anesthesia support will be required for those patients, in the outpatient surgery department, who receive doses of intravenous diazepam and meperidine that exceed the manufacturers’ recommended dose.
Young adults are defined as those patients less than 40 years of age. Those patients between 40 and 60 years of age who are not seriously ill or debilitated, as assessed by the attending physician, can be given intravenous diazepam as recommended for the young adult patient.
Procedure: The manufacturer’s recommended dosage for diazepam administered concomitantly with meperidine is: young adult-5 mg to 10 mg of diazepam, 75 mg to 100 mg of meperidine, older, debilitated, precomatose, seriously ill-1 mg to 4 mg diazepam, 20 mg to 50 mg meperidine, alcoholic-10 mg to 15 mg diazepam, 75 mg to 100 mg meperidine, and extremely agitated or apprehensive10 mg to 15 mg diazepam, 100 mg to 125 mg meperidine. Pediatric patients less than 14 years of age will be monitored by the anesthesia department if intravenous (IV) diazepam or meperidine is to be administered.
2. “General anesthesia for pacemaker implants,” Prudential Medicare Bulletin (Buford, Ga: Prudential Insurance Company, Medicare B Division, April 1986)
Older, debilitated, precomatose, seriously ill patient types will be defined as such by the attending physician. Generally 10 mg, or less, of IV diazepam is recommended, when use of concomitant narcotics is omitted, to relieve apprehension, anxiety or acute stress reactions in patients undergoing endoscopic examination. The initial dose of IV diazepam will not exceed 5 mg. Supplemental IV diazepam will be administered slowly, over three to five minutes, not to exceed the manufacturer’s recommended dose. Monitoring by the anesthesia department will be required for those patients who receive doses of diazepam that exceed the manufacturer’s recommended dose.
Schultz, R. Outpatient Surgery. Philadelphia: Lea & Febiger, 1979, 39-40.
1.
3. “Recommended practices for monitoring the patient receiving local anesthesia,” AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1986) III:16-I to 16-2.
Suggested reading Mauldin, B. Ambulatory Surgery, A Guide to Perioperative Nursing Care. New York: Grune & Stratton, 1983, 141-142. 847