CRITICAL THINKING SCENARIO

Answer the Scenario with the following Questions:

THE SITUATION
 A.M., a 32-year-old male athlete with a history of asthma (which could indicate
pulmonary dysfunction), was admitted to the hospital for an inguinal hernia repair. At the
patient’s request, the surgeon elected to use a local anesthetic employing spinal
anesthesia. Because the extent of the repair was unknown (A.M. had undergone two
previous repairs), bupivacaine, a long-acting anesthetic, was selected. He remained alert
(blood pressure 120/64 mm Hg, pulse 62 beats/min, respiration rate 10/min) and stable
throughout the procedure. Two hours after the conclusion of the procedure, A.M.
appeared agitated (blood pressure 154/68 mm Hg, pulse 88 beats/min, respiration rate
12/min). Although he did not complain of discomfort, he did state that he still had no
feeling and had only limited movement of his legs.
CRITICAL THINKING
In your discussion please include:
 What safety precautions need to be taken?
 What nursing interventions should be done at this point?
 How could the patient be reassured? Think about the anxiety level of the patient—an
athlete who elected to have local anesthesia may have a problem with control and feel
somewhat invincible. Consider the anxiety that loss of mobility and sensation in the legs
may cause in a person who makes his living as an athlete.
 In addition, consider the expected duration of action of bupivacaine and the rate of return
of function.
 Provide a discussion for the following:
 NURSING CARE GUIDE : Local Anesthesia
 Assessment: History and Examination
 Nursing Diagnoses (give at least 4)
 Implementation
 Evaluation
 PATIENT TEACHING

DISCUSSION:
 Levobupivacaine is a long-acting anesthetic with effects that may persist for several
hours. The timing of the drug’s effects should be explained to A.M., and he should be monitored
for a period of time to determine whether his agitated state and slightly elevated vital signs are a
result of anxiety or an unanticipated reaction to the surgery or the drug. Life support equipment
should be on standby in case his condition is a toxic drug reaction or some unanticipated problem
occurring after surgery.
The nurse is in the best position to perform the following interventions: explaining the effects of
the drug and the anticipated recovery schedule; keeping the patient as flat as possible to decrease
the headache usually associated with spinal anesthesia; encouraging the patient to turn from side
to side periodically to allow skin care to be performed and to alleviate the risk of pressure sore
development; and staying with the patient as much as possible to reassure him, to answer his
questions, and to encourage him to talk about his feelings and reaction.
If the agitated state is caused by a stress reaction, the patient should return to normal; comfort
measures, teaching, and reassurance should be provided. An elevated systolic pressure with a
normal diastolic pressure often is an indication of a sympathetic stress response. An athlete is
more likely than most people to suffer great anxiety and fear if his legs become numb and he is
unable to move them. Teaching and comfort measures may be all that is needed to relieve the
anxiety and ensure a good recovery

NURSING CARE GUIDE : Local Anesthesia

 Assessment: History and Examination
 Assess for allergies to local anesthetics or to parabens, cardiac disorders, vascular
problems, hepatic dysfunction; also assess for concurrent use of succinylcholine.
 Focus physical examination on the following:
 CV: blood pressure, pulse, peripheral perfusion, ECG
 CNS: orientation, affect, reflexes, vision
 Skin: color, lesions, texture, sweating
 Respiratory: respiration, adventitious sounds
 Laboratory tests: liver function tests, plasma esterases

 Nursing Diagnoses (give at least 4)

 Disturbed Sensory Perception (Kinesthetic, Tactile) related to anesthesia
 Anxiety related to drug effects
 Impaired Skin Integrity related to immobility
 Risk for Injury related to loss of sensation, and mobility
 Deficient Knowledge regarding drug therapy

 Implementation
 Provide comfort and safety measures: positioning, skin care, side rails, pain
medication as needed, maintain airway, antidotes on standby.
  Provide support and reassurance to deal with loss of sensation and mobility.
 Provide patient teaching about procedure being performed and what to expect.
 Provide life support as needed.

 Evaluation
 Evaluate drug effects: loss of sensation, loss of movement.
 Monitor for adverse effects: cardiovascular effects (blood pressure changes,
arrhythmias), respiratory depression, GI upset, CNS alterations, skin breakdown,
anxiety, and fear.
 Monitor for drug–drug interactions as indicated for each drug.
 Evaluate the effectiveness of the patient teaching program and comfort and safety
measures.
 Constantly monitor vital signs and muscular function and sensation as it returns.

 PATIENT TEACHING
 Teaching about local anesthetics is usually incorporated into the overall teaching
plan about the procedure that the patient will undergo. Things to highlight with the
patient would include the following:
Discussion of the overall procedure:
 What it will feel like (any numbness, tingling, inability to move, pressure,
pain, choking?)
 Any anticipated discomfort
 How long it will last
 Concerns during the procedure: Report any discomfort and ask any
questions as they arise
Discussion of the recovery:
 How long it will take
 Feelings to expect: tingling, numbness, pressure, itching
 Pain that will be felt as the anesthesia wears off
 Measures to reduce pain in the area
 Signs and symptoms to report (e.g., pain along a nerve route, palpitations,
feeling faint, disorientation)