Recommended practices for managing the patient receiving local anesthesia

AORN Journal,  May, 2007  

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The following recommended practices were developed by the AORN Recommended Practices Committee and have been approved by the AORN Board of Directors. They were presented as proposed recommended practices for comments by members and others. They are effective January 1, 2007.

These recommended practices are intended as achievable recommendations representing what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the recommended practices can be implemented.

AORN recognizes the numerous types of settings in which perioperative registered nurses practice. These recommended practices are intended as guidelines adaptable to various practice settings. These practice settings include traditional operating rooms, ambulatory surgery centers, physicians' offices, cardiac catheterization suites, endoscopy suites, radiology and interventional radiology departments, and all other areas where operative and other invasive procedures may be performed.

PURPOSE. These recommended practices provide guidelines for perioperative registered nurses managing patients receiving local infiltration or topical anesthesia, without the use of sedation or regional anesthesia. If any sedation is used, AORN's "Recommended practices for managing the patient receiving moderate sedation/analgesia" should be followed. (1) It is not the intent of these recommended practices to address situations that require the services of anesthesia care providers or to substitute the services of perioperative registered nurses in those situations that require the services of anesthesia care providers, regardless of the complexity of the surgical procedure.

RECOMMENDED PRACTICE I

Patients should be assessed preoperatively by a perioperative registered nurse and an individualized plan of care developed. (2)

1. The criteria for the selection of patients to receive local anesthesia should be established through consensus and collaboration of the perioperative registered nurse, physicians, and other health care professionals within the organization where care is provided. (2-4) Although it has been shown that a variety of patients can be successfully managed with a local anesthetic, local anesthesia is not appropriate for every patient or all types of surgical procedures. (4,5) Highly nervous, apprehensive, or excitable patients, or those who are unable to cooperate because of their mental state or age may not be appropriate candidates for local anesthesia. (6)

(2.) A perioperative registered nurse should perform a preoperative nursing assessment for all patients undergoing local anesthesia. (3) The perioperative registered nurse should review the patient's history, physical examination findings, laboratory results, and other diagnostic test results as indicated. At a minimum, the perioperative registered nurse should assess the patient for

* pulse, blood pressure, arterial oxygen percent saturation, skin integrity, level of consciousness, temperature, and respiration; (2)

* allergies and sensitivities (eg, food, medications, tape, latex, prep solutions); (2)

* age;

* current medications and use of alternative/ complementary therapies;

* NPO status (ie, when the patient last consumed solids and/or liquids by mouth);

* any chronic conditions such as coughs or tremors that may impede the ability of the surgeon to perform the procedure; (5)

* ability to tolerate the required operative position for the duration of the procedure, as well as draping that may cover the face; (5,6)

* past or present substance abuse (these conditions may require dosage adjustments for the anesthetics used); (2,7)

* weight, particularly in children; (8)

* the need for IV access and/or fluids based upon patient assessment data and plan of care; (9)

* understanding of the plan of care;

* ability to understand expectations for participation and ability to cooperate; (6)

* preoperative pain level and expectation of intraoperative and postoperative pain control; and

* signs and symptoms of anxiety and fear. (2)

Significant assessment findings allow the surgical team to make adjustments in patient care to provide the safest approach to the procedure and anesthesia. (3)

Each patient has a variety of unique physical characteristics that can influence his or her response to medications. Considerations include, but are not limited to, the patient's weight, age, presence of comorbidities, medication tolerance. (3,4)

3. The appropriate staffing for the care of the patient should be based on the competency of the staff member and individualized patient assessment. The patient's clinical assessment or behavior may require the presence of a perioperative registered nurse whose sole responsibility is to monitor the patient.

RECOMMENDED PRACTICE II

The perioperative registered nurse should provide information to the patient regarding expected outcomes, benefits, risks, surgical experience, and recovery process related to the operative or invasive procedure.