NURSING PROCESS FOCUS:
Patients Receiving Lidocaine (Xylocaine)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Aspiration, risk for, related to effects of
anesthesia
 Obtain complete health history including
allergies, drug history and possible drug
 Comfort, impaired, related to source of
interactions.
condition requiring surgery
 Assess for presence/history of the following
 Injury, risk for, related to loss of
disorders: Stokes-Adams syndrome, severe
sensation during anesthesia
cardiac problems, and/or decreased liver
 Knowledge, deficient, related to lack of
function. This medication is contraindicated
previous experience with local
for those with this disorder. Assess for
anesthesia
allergies to amide-type local anesthetics
 Check for the presence of broken skin,
infection, burns and wounds where
medication is to be used.
 Assess for character, duration, location, and
intensity of pain where medication is to be
used
Planning: Patient Goals and Expected Outcomes
Patient will:
 Demonstrate absence of pain during surgical procedure
 Demonstrate absence of side effects/adverse reactions
 Demonstrate knowledge of drug action and potential side effects
 Avoid physical injury while anesthetic is in effect
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
Instruct patient to:
 Observe for proper use (to avoid injury, or
improper absorption of drug).
 Swish and spit out if using for relief of
mouth discomfort or pharyngeal
discomfort
 Avoid applying to broken or abraded
skin
 Avoid contact of medication with eyes
Instruct patient to:
 Monitor for cardiovascular problems.
(Could indicate toxicity)
 Report any unusual heart palpitations.
 See their health care provider regularly
if using medication on a regular basis..
 Observe skin or mucous membranes for
 Instruct patient to report irritation or
infection or inflammation. (Condition could
increase in discomfort in areas
be worsened.)
medication used.
 Monitor length of effectiveness (Lidocaine
 Instruct patient to report any discomfort
is effective for 1-3 hours. Injury could
during procedure.
occur during period of anesthesia.)
 Provide patient safety. ( Injury may occur to  Instruct patient that he/she will have no
affected area due to lack of sensation)
feeling in anesthetized area, so must
take extra caution to avoid injury,
including heat-related injury.
 Observe for return of gag reflex. (Xylocaine Instruct patient:
viscous may interfere with swallowing
 Not to eat within 1 hour of
reflex.)
administration
 Not to chew gum while any portion of
mouth or throat is anesthetized to
prevent biting injuries
 Use cautiously in patients with CHF, renal
 Instruct the patient to notify the health
disease, or respiratory depression.
care provider at the first sign of any
changes in health condition.
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected
outcomes have been met (see “Planning”).
NURSING PROCESS FOCUS: Patients Receiving Nitrous Oxide
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Anxiety, related to upcoming surgery, loss
of control secondary to anesthesia
 Obtain complete health history,
including allergies, drug history and
 Gas exchange, impaired, risk for, related to
possible drug interactions.
respiratory depression
 Assess for presence/history of severe
 Knowledge, deficient, related to no prior
respiratory, cardiac, renal or liver
surgical or anesthesia experience
disorders
 Nausea, related to after-effects of
 Obtain baseline vital signs, especially
anesthesia
blood pressure, pulse and respirations
 Sensory perception, disturbed, related to
 Obtain blood work: complete blood
CNS depression secondary to anesthesia
count and chemistry panel
 Assess for hypersensitivity
 Assess patient’s knowledge of
procedure and level of anxiety
Planning: Patient Goals and Expected Outcomes
Patient will:
 Demonstrate adequate anesthesia during surgical procedure
 Have no side effects or adverse reaction to anesthesia
 Demonstrate understanding of perioperative procedures
 Maintain adequate ventilation during surgical procedrue
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning

Monitor for cardiovascular disease,
 Teach patients about possible side effects.
especially along with increased
intracranial pressure. (Hypnotic effects of
nitrous oxide may be prolonged or
potentiated)

Obtain history of myasthenia gravis.
 Advise patient of the importance of
(Patient may need extra support during
complete disclosure of medical history, to
surgery and longer monitoring after, to
ensure maximum safety.
ensure adequate respiratory function
nitrous oxide may cause respiratory
depression. Hypnotic effects of nitrous
oxide may be prolonged or potentiated.)

Monitor for respiratory difficulty.
 Instruct patient to report any breathing
(Monitor more closely for adequate O2difficulty.
CO2 exchange, and for elimination of
nitrous oxide.)

Monitor emotional state. (Patients who
 Teach patient stress reduction techniques
are fearful, extremely anxious may have
such as deep breathing, imagery, and
a more difficult time becoming
distraction.
anesthetized and staying anesthetized.)

Monitor post-operative recovery, i.e.
 Advise patients about routine and possible
LOC, nausea and vomiting, and pain.
side effects.

Evaluate knowledge level prior to
 Advise patient what is necessary for him to
surgery. (Determine what patient already
have a satisfactory surgical experience.
knows about pre and post-op procedures
and how much is accurate information)
Evaluation of Patient Outcomes
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected
outcomes have been met (see “Planning”)
NURSING PROCESS FOCUS:
Patients Receiving Thiopental (Pentothal)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Anxiety related to impending surgery
 Obtain complete health history including
 Aspiration, risk for, related to increased
allergies, drug history and possible drug
secretions, respiratory depression
interactions.
 Breathing pattern, ineffective, risk for,
 Assess for presence/history of
related to side effects of anesthesia
respiratory and cardiac disorders,
 Knowledge, deficient, related to lack of
seizure disorders, increased intracranial
prior experience with surgery or general
pressure, myxedema, pregnancy, and
anesthesia
underlying neurological disorders. Use with
 Sensory perception, disturbed, related to
caution
CNS depression secondary to anesthesia
 Obtain baseline vital signs, esp. blood
pressure, pulse and respirations
 Obtain blood work: complete blood count,
liver studies
 Assess for hypersensitivity
 Assess patient’s knowledge of procedure
and level of anxiety.
Planning: Patient Goals and Expected Outcomes
Patient will:
 Experience no pain during surgery
 Demonstrate no side effects during post-operative period
 Maintain adequate ventilation during surgery
 Avoid injury during surgical procedure
Implementation
Interventions and (Rationales)




Observe for anxiety. (Anxiety prior to
surgery is not uncommon. Patient may
need sedative, anti-anxiety medication
prior to immediate pre-op period.)
Monitor for side effects. (Shivering and
trembling are most common. Patient may
also experience nausea/vomiting,
headache, and somnolence.)
Monitor LOC and for adverse reactions
called emergence delirium postoperatively. (Symptoms include
hallucinations, confusion, excitability.).
Report immediately.
Monitor vital signs initially every 3-5
Patient Education/Discharge Planning

Educate patient concerning pre and post-op
care.

Inform patients to report to the health care
provider any side effects.

Inform patients of possible side effects.

Advise patient to report to the health care
minutes, then every 4 hours. (May lead to
provider any side effects.
dysrthythmias, tachycardia, bradycardia,
myocardial depression, and respiratory
depression so severe patient may need
ventilatory assistance.)

Observe for allergic response.
 Teach patient any signs and symptoms of
(Symptoms include hypotension,
side effects and to report to the health care
bronchospasm, hives, facial edema).
provider any side effects.
Report immediately.

Monitor for thrombophlebitis. (As an
 Inform patients to report immediately to
intravenous anesthetic, extravasation may
health care provider of symptoms of
cause thrombophlebitis.)
thrombophlebitis
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected
outcomes have been met (see “Planning”).
NURSING PROCESS FOCUS:
Patients Receiving Halothane (fluothane)
Assessment
Prior to administration:
 Obtain complete health history
including allergies, drug history and
possible drug interactions.
 Assess for presence/history of
pregnancy, diminished hepatic
functioning, cardiac disorders
hypotension
 Assess for the use of the same
anesthesia use within 21 days
 Assess other medications patient is
taking. May influence effectiveness of
gas or increase respiratory depression
 Obtain baseline vital signs, especially.
blood pressure, pulse andrespirations
 Obtain blood work: complete blood
count, liver studies
 Assess for hypersensitivity






Potential Nursing Diagnoses
Breathing pattern, ineffective, risk for, R/T
side effects of halothane
Cardiac output, decreased, risk for, R/T
side effects of halothane
Gas exchange, impaired, risk for, R/T
respiratory depression secondary to
halothane
Knowledge, deficient, R/T no prior
experience with surgery or general
anesthesia
Nausea, post-operative, risk for, R/T aftereffects of halothane
Sensory perception, disturbed, related to
CNS depression secondary to anesthesia
Planning: Patient Goals and Expected Outcomes
Patient will:
 Experience no pain during surgery
 Report no side effects of halothane during peri- or post-operative period
 Demonstrate understanding of the perioperative phase of their surgical experience
 Maintain adequate ventilation during the surgical procedure
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning


Obtain history of previous use of
halothane. (If used within 14-21 days,
halothane cannot be used. Too frequent
use of halothane may lead to halothane
hepatitis, potentially fatal adverse
reaction which is more common in
elderly or obese patients; not seen in
children.)
Monitor vital signs during procedure
and post-operatively, esp. for
hypotension, bradycardia, and
dysrhythmias. (Halothane can decrease
blood pressure. Sensitizes myocardium
Instruct patient:
 To recognize warning signs of halothane
hepatitis including unexplained rash, fever.
 Symptoms of halothane hepatitis usually
occur within two weeks of use
 To obtain follow-up lab studies

Advise patient regarding possible side
effects.



to effects of catecholamines or
sympathomimetics, which could lead to
serious dysrhythmias.)
Monitor for decreased hepatic

functioning. (Halothane is metabolized
in the liver. Halothane has an increased
risk of causing hepatic toxicity.)
Monitor for nausea/vomiting post-op.

(Common side effects with use of
halothane.)
Monitor LOC post-op.

Advise patient to keep all appointments for
lab work.
Advise patient to immediately report side
effects.
Instruct patient not to drive or do activities
requiring mental alertness for at least 24
hours after surgery.
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected
outcomes have been met (see “Planning”).