The content of this section focuses on perianesthesia considerations related to ophthalmic (eye), otologic (ear), rhinologic (nasal), maxillofacial (oral), laryngologic (neck or throat), and reconstructive (plastic) surgical procedures. These issues are considered together because:
• Surgery on the eye, ear, mouth, nose, or throat involves facial and neck structures that may require additional surgical reconstruction
• Special care is needed to promote positive outcomes for eye, facial, and reconstructive procedures that all share common postanesthesia priorities: hemostasis to promote healing, management of airway and positioning, and limiting pressure-increasing activities like coughing, stretching, straining, or vomiting
| ESSENTIAL CORE CONCEPTS | AFFILIATED CORE CURRICULUM CHAPTERS |
|---|---|
| Nursing Process | Chapter 2 |
| Assessment | |
| Planning and Implementation | |
| Evaluation | |
| Ophthalmic Concerns | Chapter 47 |
| Nursing Process | |
| Optic Structures and Physiology | |
| Pathology | |
| Abrasions, Ptosis, and Detachments | |
| Cataracts and Glaucoma | |
| Pharmacology | |
| Miotics and Mydriatics | |
| Cycloplegics and Osmotics | |
| Perianesthesia Priorities | |
| Nausea-Free, Coughless, Bloodless, Painless | |
| Surgical Procedures and Reconstruction | |
| Tumors, Ulcerations, and –plasty’s | |
| Otologic Concerns | Chapter 50 |
| Nursing Process | |
| Otic Structures and Physiology | |
| Function and Innervation | |
| Pathology | |
| Otitis, Trauma, and Tumors | |
| Perianesthesia Priorities | |
| Bleeding and Spinal Fluid Leaks | |
| Instructions and Dressings | |
| Neurologic Weaknesses and Hearing Deficit | |
| Pain and Position | |
| Vertigo and Vomiting | |
| Surgical Procedures and Reconstruction | |
| -ectomy’s, -otomy’s, and –plasty’s | |
| Nasopharyngeal Concerns | Chapter 50 |
| Nasal Structures and Physiology | |
| Nursing Process | |
| Pathology | |
| Mucus, Polyps, Septum, and Sinuses | |
| Perianesthesia Priorities | |
| Airway, Bleeding, and Emesis | |
| Packing, Pain, and Position | |
| Surgical Procedures and Reconstruction | |
| -ectomy’s, -otomy’s, and –plasty’s | |
| Fractures, Reconstructions, and Windows | |
| Maxillofacial and Laryngeal Concerns | Chapters 48, 50 |
| Nursing Process | |
| Oral and Pharyngeal Structures and Physiology | |
| Pathology | |
| Adenoids, Tonsils, and Nodules | |
| Fractures and Tumors | |
| Perianesthesia Priorities | |
| Airway Patency and Oxygenation | |
| Emesis, Hemorrhage, and Mucus | |
| Endocrine Balance and Nerve Function | |
| Extubation, Tracheal Tubes, and Jaw Wires | |
| Position and Communication | |
| Sepsis, Suction, and Drains | |
| Surgical Procedures and Reconstruction | |
| -ectomy’s, -otomy’s, and –plasty’s | |
| -oscopy’s and Laser Excisions | |
| Issues of Reconstructive Surgery | Chapter 52 |
| Coagulation, Healing, and Infection Potential | |
| Nursing Process | |
| Perianesthesia Priorities | |
| Airway Patency and Oxygenation | |
| Bleeding, Ecchymosis, and Edema | |
| Coughing, Straining, and Vomiting | |
| Fluid Volume, Position, and Pain | |
| Surgical Procedures | |
| Augmentations and Reductions | |
| Congenital Clefts and Cosmetic Images | |
| Expanders, Flaps, Grafts, and Implants | |
| Lipectomies, Lifts, and -plasty’s | |
| Repairs and Reconstructions | |
| Repositions and Reshapings |
ITEMS 10.1–10.32
10.1. After surgery to correct strabismus, the anesthesia provider reports that the patient had one intraoperative episode of severe bradycardia requiring treatment with atropine. The most likely reason for the drop in heart rate during eye surgery is:
a. surgical manipulation of the rectus muscle.
b. overdilation of the pupil.
c. temporary loss of vitreous pressures.
d. pain response to ineffective eye block.
10.2. A 68-year-old woman is undergoing a resection of an acoustic neuroma. When she arrives in Phase I PACU after surgery, her vital signs, including blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation, are assessed. Upon the initial assessment she is found to be tachypneic and tachycardic. Her blood pressure is 84/45, and oxygen saturations is 83%. The patient is extremely agitated and disoriented. The most serious complication to explain this assessment is:
a. acute hearing loss.
b. dizziness and tinnitus.
c. air embolism.
d. denervation of the acoustic nerve.
NOTE: Consider items 10.3-10.5 together.
10.3. A 4-year-old male is admitted through same-day surgery for a tonsillectomy and adenoidectomy. All the following are appropriate indications for this surgery except:
a. recurrent otitis media.
b. obstructive sleep apnea.
c. tonsillar enlargement.
d. frequent episodes of tonsillitis.
10.4. As a preschooler, this boy will best be prepared for his surgical experience by:
a. allowing him to handle any equipment or supplies that are nearby.
b. hiding any equipment or supplies so that he is not frightened.
c. focusing on abstract aspects of his procedure.
d. providing two 30-minute teaching sessions.
10.5. Preoperatively this child was diagnosed with obstructive sleep apnea. Diagnostic symptoms include but are not limited to all the following except:
a. excessive mouth breathing.
b. frequent nighttime awakening.
c. encopresis.
d. snoring.
NOTE: Consider items 10.6-10.7 together.
10.6. A male patient was involved in a motor vehicle accident in the past 24 hours and sustained a Le Forte I fracture of the left mandible. He has arch bars to provide jaw stability and is temporarily nasally intubated and therefore unable to speak. This patient is demonstrating symptoms of discomfort including clenching of his fists and grimacing. The plan to provide comfort to him should include:
a. administering benzodiazepines to provide amnesia.
b. offering nonpharmacologic therapies, such as distraction techniques.
c. providing only limited opioids to avoid oversedation.
d. determining a pain-rating goal.
10.7. The patient was maintained under hypotensive anesthesia. The primary reason that hypotensive anesthesia is selected as a technique is to:
a. avert a hypertensive crisis.
b. minimize damage to delicate blood vessels in the mandible.
c. reduce the volume of surgical blood loss.
d. protect the patient from premature cardiac disease.
10.8. After ocular surgery, the optic nerve is protected by:
a. prophylactic antiemetics.
b. supine bedrest for 3 hours.
c. osmotic diuretics.
d. intravenous corticosteroids.
NOTE: Consider items 10.9-10.10 together.
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10.9. A male diabetic patient begins complaining of abdominal pain, nausea, and vomiting after a wide excision of a mid-thigh melanoma. It is noted that the patient has a sweet odor to his breath. His serum glucose is 400 mg/dL. The perianesthesia nurse suspects that he has ketoacidosis and is concerned that he may also develop:
a. potassium depletion.
b. Biot respirations.
c. profound and transient bradycardia.
d. diabetic fibrosis.
10.10. Once the patient has met discharge criteria from the Phase I PACU, he is transferred to the surgical intensive care unit for additional monitoring and treatment of his diabetes. He is now at risk for delayed healing and infection of his surgical wound. Which of the following statements below is true?
a. Elevated blood sugars decrease the risk for peripheral vascular disease.
b. Poor glycemic control impairs the body’s ability to eliminate bacteria.
c. Elevated blood glucose increases the diffusion rate of glucose into the cells.
d. Hyperglycemia increases oxygen demand and blood flow to the tissues.
10.11. The optimal candidate for an endoscopic facelift:
a. has very delicate and thin skin.
b. has multiple expressions of wrinkles.
c. demonstrates moderate skin laxity and a strong desire to avoid facial incisions.
d. possesses “classic” skin changes associated with cigarette smoking.
10.12. According to recommended staffing guidelines, the last and only patient in an ambulatory facility who is still receiving Phase I level of care can expect:
a. two registered nurses, one who is competent in Phase I postanesthesia nursing, to be present in the room with him or her.
b. one registered nurse competent in Phase I postanesthesia nursing and a family member at the bedside.
c. one registered nurse competent in Phase I postanesthesia nursing and a certified respiratory therapist to help with airway management.
d. one registered nurse competent in Phase I postanesthesia nursing and a second registered nurse available in the building by beeper.
10.13. Within 5 minutes of admission to PACU after a uvulopalatopharyngoplasty (UPPP), a previously healthy but drowsy patient is observed to have rocking respirations and abdominal movement. Prompt intervention includes:
a. an antiemetic per protocol.
b. suction of bloody secretions.
c. a semi-Fowler’s position.
d. repositioning the head.
10.14. The immediate discomfort from an augmentation mammoplasty can be reduced or alleviated by:
a. initiating gentle arm circling exercises and passive arm raises to improve circulation.
b. pre-medicating and then applying deep tissue massage to treat pectoralis spasms.
c. withholding medication combinations such as muscle relaxants and oral narcotics to minimize drowsiness.
d. applying 2- or 3-inch ACE wrap bandages around the chest and applying ice packs.
10.15. After radical neck dissection in an attempt to control the spread of squamous cell carcinoma of the larynx, the patient may experience:
a. inability to raise both shoulders against resistance.
c. asymmetric mouth opening.
d. inability to close both eyes tightly.
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