Review of today s topics

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1 Perianesthesia Basics Part II Mary Briggs RN BAN CAPA Clinical Learning Specialist University of Minnesota Health Review of today s topics Review of topics, with certification preparation in mind: Pharmacology Perianesthesia Review-Part I PACU head-to-toe assessment Perianesthesia Review-Part II Pediatric, geriatric, cultural & language, preop topics Test taking preparation ASPAN Position Statement on the Pediatric Patient Family-centered care, reuniting families in a timely manner Pediatric standardized preop screening tool Pediatric considerations in research, education and clinical practice PALS certification for any perianesthesia RN caring for peds patients Drain s Perianesthesia Nursing: A Critical Care Approach Chapter 49: Care of the Pediatric Patient In PACU, the nurse must be constantly vigilant and aware of any minor changes in the pediatric patient that may be early signs and symptoms of problems. The nurse must be skilled in airway assessment and the provision of basic airway support and management, in the use of oral and nasopharyngeal airways, bag-mask ventilation, and assistance with intubation and extubation prepared to manage emergence delirium and postop pain, and potentially assist with basic and advanced life support measures. All these tasks must be performed while providing age-appropriate level of comfort and reassurance to a frightened child. Stages of Development--Erik Erikson Trust vs. Mistrust Birth to 1 yr of age Autonomy vs. Shame/doubt Toddlers 1-3 years Initiative vs. Guilt Preschoolers 3-5 years Industry vs. Inferiority School age 5-10 years Identity vs. Role confusion Adolescents Cognitive Development--Piaget Sensorimotor: Birth to 2 years. They learn about their world through their senses. Preoperational : Toddler to school age. Learn through experiences, such as developing a sense of time through daily routine. (meals, naps, playtime) Concrete : School age to adolescence. Learn rules and logic and empathy. Formal operation: Adulthood. Abstract thought and increasing communication skills. Understanding stages helps to relate to children s thought processes and how to approach procedures and hospitalization. How to explain behaviors to parents.

2 Neonate: the first 28 days of life Head 25% of body length and 33% of weight Ribs are mostly cartilage Obligate nose breathers Limited glycogen stores Immature respiratory center in brain Predisposed to hypothermia due to small muscle mass and inability to shiver Fully developed parasympathetic NS and underdeveloped sympathetic NS Large body surface area Infant Chest wall is thin, rib cage is soft and pliable, breathing is predominantly done from diaphragmatic movement Circulating blood volume comparisons Blood volume can be estimated as approximately ml/kg for adults, 80 ml/kg in infants and 85-95mL/kg in neonates. (Stanford SOM) Underdeveloped cervical ligaments with relatively weak neck muscles (very susceptible to hyperextension of neck) Trachea Distal end of trachea splits into the left and right bronchi The right bronchus is shorter and more vertical compared to the left = increased risk for aspiration or pneumonia in right lung Internal diameter (4 mm) Remember 1mm edema reduces airflow/diameter by 50%! Trachea short (4-5 cm) and infants have less cartilage in the trachea, making them floppier! Preschooler: 3-6 years of age O2 consumption requirements are about twice that of adolescents or adults (6-8 ml/kg vs 3-4 ml/kg) Cannot sustain rapid respiratory rates for long periods of time due to immature intercostal muscles Smaller functional residual capacity with smaller oxygen reserves, consequently prone to hypoxia Liver and spleen in lower abdomen are less protected by rib cage and more prone to injury Spinal cord more vulnerable even though vertebral column may withstand traction and tension types of trauma without evidence of deformity The child s chest wall is softer than an adult s and more compliant due to bone immaturity. Young children are abdominal (diaphragmatic) breathers until about 8 years of age. School-age: 6-12 years of age Bones begin to lose flexibility at approx. 6 years when bone cortex begins to thicken and become hardened Tracheal shape changes from tunnel to cylindrical Lung volume increases to 200 ml by age 8 Bronchial tree has attained 16 divisions as in an adult By age 10, size and flexibility of airway matches adult

3 Adolescent: years of age Faster growth than any other period except infancy Bone growth ends at age 29, when epiphyses close By age 15, cardiac output is equal to adult By age 15, the body s response to shock is similar to that of an adult AIRWAY Epiglottis is much floppier (lack of cartilage) and larger in proportion than adults. The mandible is less developed in younger children. Newborns up to the age of 2 to 4 months are obligate nose breathers. Infants and young children are at increased risk of developing respiratory distress if the nose becomes congested or obstructed with mucous or secretions. The nose is responsible for 50% of total airway resistance in children of all ages Airway Obstruction edema Post-intubation croup caused by glottic or tracheal edema Laryngeal swelling of 1mm in an infant can reduce airway diameter by up to 75% Croupy cough may quickly progress!hoarseness! inspiratory stridor!aphonia Increased restlessness, tachypnea, use of accessory muscles of respiration, retraction of suprasternal notch and intercostal spaces, drawing in of abdomen Needs immediate response and action! O2, racemic epi neb, dexamethasone, possible intubation Drain s Perianesthesia Nursing: A Critical Care Approach 6th ed. Airway edema comparison infant and adult 4TOINFJ.pdf Airway obstruction--laryngospasm Laryngospasm v=gmnwpjf1zuq&nofeather=true Laryngospasm as a cause of airway obstruction is more common in pediatric patients, but it can also occur in adults. Laryngospasm can occur abruptly following extubation in the patient who is no longer deeply anesthetized and not indifferent to laryngeal stimulation, but not awake enough to counteract the laryngeal reflex that results from vocal cord irritation (eg, tube removal, edema, aspirate blood). Laryngospasm can also occur upon cessation of positive pressure ventilation via face mask, presumably due to sudden airway collapse. The treatment of laryngospasm is positive pressure ventilation. If bag-mask ventilation is not successful, a small dose of succinylcholine (0.1 mg/kg IV) can be given to relax the cords. Metabolic Rates Basal metabolic rates are higher in children. Extensive growth and development processes requires more energy (caloric expenditures 3-4 times an adult). Children consume twice as much oxygen per kilogram compared to adults. Children are prone to hypoxia and require supplemental oxygen when critically ill or injured. Illness and stress can accelerate the metabolic rate, and lead to respiratory failure and shock. Infants and young children lose more body heat and water through the surface of the skin and are prone to hypothermia and dehydration. Children have higher fluid requirements. A newborn's total body weight is 70 to 80% water whereas an adult s accounts for only 50 to 60%. Children are also prone to dehydration when there is increased fluid loss due to diarrhea, vomiting, or in conditions that increase the metabolic rate.

4 Cardiac Assessment HEART RATE Point of maximal impulse (PMI) is located at the 4 th ICS, midclavicular line until age 4, then it is at the 5 th ICS, MCL Bradycardia: most often secondary to hypoxia Tachycardia: assess, r/o causes (e.g., fever, hypovolemia) RHYTHM Irregular vs. regular. Always listen for 1 full minute if questioning any irregularities. MURMURS = turbulent blood flow Innocent vs. pathologic Remembering blood flow takes the path of least resistance Cardiovascular Children have a higher cardiac output and oxygen consumption per kilogram than adults. They support this higher output with a higher baseline heart rate. Infants are heart rate dependent for their cardiac output. They have a fixed stroke volume, and must increase their heart rate to increase cardiac output. They may respond to stress, such as hypoxia, by becoming bradycardic, and therefore decreasing CO. This can make resuscitation quite difficult. Cardiovascular Differences Heart muscle less compliant, stiffer, & smaller mass (increases O2 demand) Unable to stroke volume to maintain cardiac output as heart rate increases. Heart rate >200 leaves little or no time to fill, so CO drops. Little reserve, so stressors such as hypothermia or sepsis or volume overload lead to rapid acute deterioration Cyanotic cardiac anomalies SpO2 may be lower than the normal range in a patient with an uncorrected congenital cardiac anomaly, where there is abnormal mixing of oxygenated and unoxygenated blood. The patient may have physiologically adapted to this condition. Physicians, other team members, and parents can provide information about what is normal for this patient. Do not apply oxygen without a physician order. Cardiac diseases website Johns Hopkins Temperature Regulation Pediatric patients lose heat to the environment more readily than adults. This is due to an increased surface area per kilogram. Hypothermia is a serious problem which can result in cardiac irritability and respiratory depression. Infants cannot shiver, but must metabolize brown fat to maintain temperature. It is important to PREVENT heat loss. Emergence Delirium The incidence of emergence agitation in children can be as high as 30 percent and is most common in children ages two to four. Emergence agitation is likely a response to a disorienting situation. Parental presence can smooth this transition and the child usually calms in less than 15 minutes. Pediatric emergence agitation has been attributed to the increased use of the rapid onset low-solubility inhaled anesthetic agents. UpToDate source=search_result&search=anesthesia+delirium&selectedtitle=1%7e150#h

5 Emergence Delirium Emergence delirium can be a result of pain, hypoxia, hypercarbia, urinary retention, electrolyte imbalance (especially hyponatremia), and central, drug-induced anticholinergic activity. Case Study Scenario: Infant in PACU, intubated, vent on PS, not waking up What s going on? Ventilation and perfusion adequate? ABC Consider factors contributing to delayed wake-up baseline LOC anesthetic agents when and how much? MD assessment and treatment required Labs needed venous gases and glucose In this situation,muscle relaxant was given near end of case Inadequate muscle strength, inadequate vent settings in PACU Lack of effective assessment and action Outcome: complete recovery due to actions taken in time Consider H s and T s in postop assessment? Avoidance of PEA? (or brady <60) Hypoxia Hypovolemia Hypothermia Hydrogen ion (acidosis) hypercapnea? Hypo-/hyperkalemia Hypoglycemia Toxins (medication dosage and side effects) Trauma (surgery) PneumoThorax Tamponade, cardiac Thrombosis, coronary or pulmonary ACLS handbook Pediatric scheduling considerations Infants and young children should be scheduled early in the day To minimize dehydration, hypoglycemia, irritability ASA guidelines 2 hours clear; 4 hours breast milk; 6 hours formula, nonhuman milk and/or light meal Ask the child to verbalize last food or drink taken Delays Consult with MDA to provide a drink of clear liquids Younger than age 2, monitor blood sugar especially if delayed or NPO for a long time While hospitalization (surgical intervention) is frightening both to children and to their parents, it can also be a positive experience. With a nurturing atmosphere a child can grow in self-esteem and maturity by learning to conquer the fears and anxiety of a stay in the hospital. T. Berry Brazelton, MD, touchpoints: the essential reference Patient and Family- Centered Care Scenario: Request by family for therapy dog companionship in PACU for a preadolescent patient routed through Volunteer Services to PeriAnesthesia Nurse Manager. (Friday afternoon request for Tuesday encounter). NM, Volunteer Services, and Child Family Life Monday afternoon Chad will bring in his therapy dog, Gopher, a golden retriever. He is one of the best! We ll get him up to Peds PACU on Tuesday afternoon between 1-2PM. Thanks to everyone who worked on this. This patient and his family will be extremely grateful! Result: a smashing success! an innovative care plan

6 Geriatrics Physiologic Changes of Aging Cardiac Decreased intrinsic HR and max HR Blunted baroreflex Increased AV conduction time and ectopy Decreased EF, more AFib, CHF (fluid overload) Increased PVR Pulmonary Decreased VC, lung elasticity, residual vol., ventilation/perfusion mismatch Geriatrics Physiologic Changes of Aging Body composition Decreased lean body, skeletal and muscle mass, decreased strength Decreased total body water--tendency toward dehydration Peripheral nervous system Tendency toward syncope, decreased response to Beta blockers Digestive, renal, GU, endocrine, heme/ immune Geriatric Assessment Assess: Baseline VS Fluid volume status, I&O, blood loss Integumentary Sensory norms Cognition norms Skeletal/neuromuscular status Polypharmacy Elder abuse S/S Effective handoff to next caregiver Resources: ASPAN CBO, RediRef, and Core Curriculum Transcultural Nursing/Diversity Cultural assessment Communication (TJC and legal standards) Personal space (security, privacy, self-identity) Social organization (patterns, beliefs, holistic) Respecting differences Time perceptions Environmental control (alternative therapies) Biological variations (genetic, metabolic) Care plan based on the assessment Evaluate the plan Communicate and document ASPAN CBO 2014 Chapter 21 Transcultural Nursing/Diversity Care Resources for cultural and language competency Day of Surgery Preparation NPSG 2 identifiers, verify informed consent, valid H&P, site marking by surgeon, NPO, nursing assessment (PAT, systems review) Baseline VS, O2 sat, Ht&wt, pt understanding Changes in health history since preadmission assessment ID pt coping, reduce stress, anxiety, pain Verify responsible adult, home care

7 Day of Surgery Preparation Evaluate risk factors Current condition, increased risk today, now? OSA, anticoagulation, diabetes, URI, pregnancy Documented and communicated to surgeon and MDA Patient Preparation Preop orders surg site prep, IV, Abx, SCIP, DVT Preprocedural education Patient and family understanding, misconceptions, answer questions Document teaching Day of Surgery Preparation CAPA exam question QUESTION OF THE WEEK October 28, 2015 In a preoperative visit, essential information to be collected by the nurse includes: 1. type of surgery to be performed, previous surgical history, age, and next of kin. 2. patient s knowledge of the procedure, whether the patient has signed the consent form, and type of anesthesia to be used. 3. preexisting diseases, laboratory values, patient and family history, current medications, and mobility issues. 4. cardiac status, vaccination status, respiratory status, and location of patient s family postoperatively. Content Area: Deliver, document, and communicate care based on accepted national standards of perianesthesia nursing practice and applicable laws, guidelines, and regulations Litwack, K. Clinical Coach for Effective Perioperative Nursing Care, F.A. Davis Co., Pg 6-8. Day of Surgery Preparation CAPA exam question--answer QUESTION OF THE WEEK October 28, 2015 In a preoperative visit, essential information to be collected by the nurse includes: 1. type of surgery to be performed, previous surgical history, age, and next of kin. 2. patient s knowledge of the procedure, whether the patient has signed the consent form, and type of anesthesia to be used. 3. preexisting diseases, laboratory values, patient and family history, current medications, and mobility issues. 4. cardiac status, vaccination status, respiratory status, and location of patient s family postoperatively. Content Area: Deliver, document, and communicate care based on accepted national standards of perianesthesia nursing practice and applicable laws, guidelines, and regulations Litwack, K. Clinical Coach for Effective Perioperative Nursing Care, F.A. Davis Co., Pg 6-8. Preparation for certification ABPANC--American Board of PeriAnesthesia Nursing Certification, Inc. Webinars--Offer useful tips for taking the CPAN or CAPA exam. Identify and overcome symptoms of test anxiety and fear of failure. CPAN and CAPA Certification Handbook in its entirety to be adequately prepared for the certification exams. This handbook includes detailed information about exam administration and testing blueprints to help you organize your study plan. Appendix D is the only approved list of study reference materials used to verify answers to the exam questions. ABPANC recommends you study from a variety of references in Appendix D based on your own learning needs. Many test candidates who failed the examination have told us they studied from just one or two books and were not adequately prepared. CPAN /CAPA Study Tools Certification Handbook Test Blueprint Study References Study Plan CPAN Question of Week CAPA Question of Week Practice Exams Study Tips Webinars Mind Mapping Guide Preparation for certification CPAN / CAPA Examination Study Plan Based on the CPAN and/or CAPA test blueprints Built around a 12-week schedule, which can be modified based on individual needs Reviews all study materials thoroughly Focus on your own weak areas Study plan based on four hours per week ASPAN CBO 2014

8 Practice Exams Please note: ABPANC does not provide the rationale for the correct answer. It is a better study process for you to determine the rationale by reviewing the information in the reference. The target audience includes CPAN and CAPA certification examination candidates, any perianesthesia nurse interested in assessing their knowledge related to perianesthesia patient needs, and CPAN and CAPA certified nurses who wish to acquire ABPANC contact hours for CPAN and CAPA recertification. ASPAN Standards The edition of the ASPAN Standards contains principles of safety and ethics in perianesthesia practice, perianesthesia practice standards, evidence-based clinical practice guidelines, practice recommendations, position statements, resources from partnering organizations and interpretive statements which provide clarity and definition to key elements of the standards. New content in this publication includes: o updated practice recommendation for care of the adult patient with obstructive sleep apnea o new practice recommendation for the prevention of unwanted sedation in the adult patient o position statement on social media and perianesthesia practice o position statement on care of the perinatal patient o position statement on the nurse of the future ASPAN Clinical practice guidelines: PONV, Pain, Normothermia PONV Avoid early or forced admin of PO liquids Pain Analgesia is a right and a priority Multimodal management advocated Normothermia Oral temp=core temp, axillary temp is not accurate CPGs found on ASPAN website CAPA Exam: ASPAN standards/safety CAPA Exam: ASPAN standards/safety CAPA Exam: Clinical Practice QUESTION OF THE WEEK January 13, 2016 In PACU, phase II, the perianesthesia nurse has one patient pending discharge. The only other staff in the area is the unit secretary. Based on ASPAN's definition of "two competent personnel" for staffing, the unit secretary: 1. possesses the minimum clinical competency. 2. does not fit the definition of a licensed personnel. 3. does not have the recommended competency. 4. can assist under the direction of the nurse. Content Area: Deliver, document, and communicate care based on accepted national standards of perianesthesia nursing practice and applicable laws, guidelines, and regulations. American Society of PeriAnesthesia Nurses. Perianesthesia Nursing Standards, Practice Recommendations, and Interpretive Statements ASPAN, Cherry Hill, NJ, Pg 36. Odom-Forren, J. Drain s PeriAnesthesia Nursing: A Critical Care Approach. 6th Ed. Elsevier Saunders, Pg 32. QUESTION OF THE WEEK January 13, 2016 In PACU, phase II, the perianesthesia nurse has one patient pending discharge. The only other staff in the area is the unit secretary. Based on ASPAN's definition of "two competent personnel" for staffing, the unit secretary: 1. possesses the minimum clinical competency. 2. does not fit the definition of a licensed personnel. 3. does not have the recommended competency. 4. can assist under the direction of the nurse. Content Area: Deliver, document, and communicate care based on accepted national standards of perianesthesia nursing practice and applicable laws, guidelines, and regulations. American Society of PeriAnesthesia Nurses. Perianesthesia Nursing Standards, Practice Recommendations, and Interpretive Statements ASPAN, Cherry Hill, NJ, Pg 36. Odom-Forren, J. Drain s PeriAnesthesia Nursing: A Critical Care Approach. 6th Ed. Elsevier Saunders, Pg 32. QUESTION OF THE WEEK December 09, 2015 A perianesthesia nurse distinguishes best available clinical practice that promotes safe and quality patient care by the conscientious use of: 1. evidence based care. 2. medical based research. 3. patient driven care plans. 4. qualitative research. Content Area: Appropriate resources and referrals (including, but not limited to, medical equipment, pharmaceutical care, pastoral care, nutritional education, physical/ occupational therapy, case management/social services) Odom-Forren, J. Drain s PeriAnesthesia Nursing: A Critical Care Approach. 6th Ed. Elsevier Saunders, Pg

9 CAPA Exam: Clinical Practice QUESTION OF THE WEEK December 09, 2015 A perianesthesia nurse distinguishes best available clinical practice that promotes safe and quality patient care by the conscientious use of: 1. evidence based care. 2. medical based research. 3. patient driven care plans. 4. qualitative research. Content Area: Appropriate resources and referrals (including, but not limited to, medical equipment, pharmaceutical care, pastoral care, nutritional education, physical/ occupational therapy, case management/social services) Odom-Forren, J. Drain s PeriAnesthesia Nursing: A Critical Care Approach. 6th Ed. Elsevier Saunders, Pg CPAN question of the week QUESTION OF THE WEEK November 25, 2015 Physiologic anemia is a normal syndrome in infants at the age of: 1. 3 months month months months. Domain: Physiological Needs Content Area: Stability of cardiovascular/peripheral vascular/hematological systems Hockenberry, M., Wilson, D. Wong s Nursing Care of Infants and Children. 10th Ed. CV. Mosby, Pg 416. Odom-Forren, J. Drain s PeriAnesthesia Nursing: A Critical Care Approach. 6th Ed. Elsevier Saunders, Pg 692. CPAN question of the week QUESTION OF THE WEEK November 25, 2015 Physiologic anemia is a normal syndrome in infants at the age of: 1. 3 months month months months. Domain: Physiological Needs Content Area: Stability of cardiovascular/peripheral vascular/hematological systems Hockenberry, M., Wilson, D. Wong s Nursing Care of Infants and Children. 10th Ed. CV. Mosby, Pg 416. Odom-Forren, J. Drain s PeriAnesthesia Nursing: A Critical Care Approach. 6th Ed. Elsevier Saunders, Pg 692.