Spinal, Epidural, Caudal

Definition:

Central nerve blocks performed by injecting anesthetic solutions intrathecally (into the subarachnoid space), into the epidural space, or into the caudal canal (an extension of the epidural space).

Discussion:

These anesthetics are employed for procedures on the lower abdomen and lower extremities. The composition and concentration of the anesthetic solution will determine the duration of the block. The position of the patient immediately following the injection of the anesthetic solution influences the level and distribution of the block.

Preparation of the Patient:

Position of the patient is determined by the type of block being administered, procedure being performed, condition of the patient, and preference of the anesthetist. Position may be sitting, lateral, or prone.

• Sitting: With back arched and feet supported on a stool (spinal or epidural)
• Lateral: With knees, hips, back, and neck flexed (spinal or epidural)
• Prone: Flexed at the waist (caudal or hypobaric spinal)

Following the injection of the agent (after an interval determined by anesthetist), the patient is placed in the selected operative position.

For prolonged procedures or for post-operative analgesia, continuous epidural or caudal anesthesia is established by inserting a catheter into the appropriate space at the time of the initial needle placement. Increments of anesthetic solution may then be administered.

Skin Preparation and Draping:

Usually performed by the anesthetist. These materials may be included in the prepackaged disposal tray.

Equipment:

• Stool (for patient’s feet, sitting position)
• Sitting tool (for anesthetist)

Supplies:

• Appropriate sterile disposable tray (spinal, epidural, caudal)
• Additional agents, needles, catheters, etc (as requested)

Nursing Considerations:

• The circulator may be requested to set up an intravenous line.
• The circulator is usually requested to assist in maintaining the patient’s position during administration of the block.
• The circulator (in addition to anesthetist) should closely observe the patient for signs of respiratory distress caused by the sedation or by the inadvertent administration of a “high” spinal, which would result in depression or paralysis of the respiratory muscles and require immediate intubations and ventilation.
• Special care must be taken to protect the patient in order to avoid injuries, that is, burns, neurological damage, pressure sores, or other traumas to the patient who is unable to sense the injuries while receiving an anesthetic.
• According to some authorities, in order to avoid post spinal headache, patients may be instructed preoperatively and reminded postoperatively that they should remain at bedrest without raising their heads for 24 to 48 hours.
• Adhesive tape secures intravenous line and anesthetic catheter.
• Do not dispose of the tray until the anesthetist has the appropriate information needed for the anesthetic record.
• The patient, although often sedated, may be alert enough to hear; therefore, discussion of the diagnosis, other medical information, and idle conversation should be limited accordingly.
• The patient’s privacy should always be maintained.

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A route of drug administration is the path by which a drug or other substance is brought into contact with the body. Drugs are introduced into the body by several routes. When administering a drug, the nurse should ensure that the pharmaceutical preparation is appropriate for the route specified.

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1. What is meningococcemia?
   • Meningococcemia or meningococcal meningitis is an acute communicable infection caused by gram-negative bacteria. Neisseria meningitidis. There are several groups and sub-types of this organism. The bacteria are sensitive to sunlight and changes in temperature. They do not survive for 30 minutes. The disease usually occurs sporadically in the Philippines. Epidemics rarely occur.
2. What are the signs and symptoms of meningococcemia?
   • Meningococcemia is usually characterized by a sudden onset of fever, nausea, vomiting and frequently, a petechial rash which becomes bigger with reddish or purplish color located mainly on the extremities. The patient usually becomes prrogressively sicker. Meningitis with symptoms such as stiff neck, intense headache, back pain and mental status changes is the most common localized manifestation. Meningococcal infection may also be asymptomatic, or may produce only acute nasopharyngitis.
3. Is meningococcemia fatal?
   • Yes. Up to 50% of cases are expected to die especially with the serious type of the disease, but this is drastically reduced to less than 10% with early dignosis and appropriate treatment.
4. How does meningococcemia spread?
   • Meningoceccemia is transmitted by direct contact with droplet secretions from the nose and throat of infected persons. This is called person to person transmission, which often occurs through sneezing, coughing, kissing or sharing of eating utensils. Contact with materials soiled by these discharges may also transmit the infection.
5. Can we get it from animals?
   • No. The bacteria only live in the nasopharynx of infected humans. Patients and carriers (infected individuals individuals whoa re apparently well) transmit the disease.
6. Who are commonly affected?
   • Meningococcemia commonly affects children, but it can occur among adults especially in crowded living conditions.
7. How long will the first sign or symptom appear after being exposed to the infectious secretions?
   • The incubation period varies from 2 to 10 days, commonly 3-4 days.
8. How long can patients or carriers transmit the disease?
   • Infected persons can transmit the disease even before the manifestations of signs and symptoms. Patients under treatment with antibiotics will usually not be infectious after 24 hours and carriers without symptoms continue to shed the bacteria indefinitely until they are detected and treated.
9. Can meningococcemia be treated?
   • Yes. Penicillin is the drug of choice. Ampicillin, chloramphenicol and sulfonamides are also effective.
10. How do we avoid getting sick of meningococcemia?
    • Preventive antibiotic medication
      • This is recommended only for the close contacts of meningococcal patients, because unnecessary and improper use of antibiotics can lead to emergence of drug resistant bacteria.
      • Close contacts are people directly exposed to the respiratory secretions of infected people. These include: a) household members b) visitors who stayed overnight within 7 days before the illness of the case c) stayed in the same room with a case for 4 hours or more d)anyone directly exposed to the patient’s orals secretions.This is given as soon as possible after exposure to a diagnosed case as prescribed by the physician.
      • Recommended medicines for prevention: rifampicin, ciprofloxacin, ceftriaxone, sulfadiazine.
    • Health workers and other close contacts should wear personal protective devices like masks and rubber gloves. Wash hands with soap and water after attending to each patient.
    • Properly dispose of articles soiled with discharges from the nose and throat of patients.
    • Avoid sharing of eating or drinking utensils.
    • Practice healthy lifestyle. Get enough rest and exercise, avoid smoking and eat well balanced diet which includes fruits and vegetables rich in vitamins to build up the immune system.
    • Avoid crowded places to minimize exposure to the disease.
11. Do we need to undergo vaccination?
    • Vaccination is 85% to 95% protective. It starts to be protective after 5 days from the injection. Protection lasts for 2.5 to 3 years. It is not protective to children below 2 years old. It is not a recommended public health measure but it may be taken as a personal protective measure.
12. What should be done in case a person manifests the above signs and symptoms?
    • Immediately consult a physician or visit your nearest health center or hospital.

Source:

DOH, Center for Health Development – CAR

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A. Description

1. Cleft lip (cheiloschisis) is a congenital anomaly that occurs at a rate of 1 in 800 births.

a. If the cleft does not affect the palate structure of the mouth it is referred to as cleft lip.

b. Cleft lip is formed in the top of the lip as either a small gap or an indentation in the lip (partial or incomplete cleft) or it continues into the nose (complete cleft)

c. Cleft lip can be unilateral or bilateral.

d. It is due to the failure of fusion of the maxillary and medial nasal processes (formation of the primary palate).

2. Cleft palate (palatoschisis) is a congenital anomaly that occurs in approximately 1 of every 2000 births, and it is more common in boys than girls.

a. It is a condition in which the two plates of the skull that form the hard palate (roof of the mouth) are not completely joined.

b. It ranges in severity from soft palate involvement alone to a defect including the hard palate and portions of the maxilla.

c. Cleft palate may or may not be associated with cleft lip.

3. Children with these structural disorders may have associated dental malformations, speech problems, and frequent otitis media, the latter resulting from improper functioning of the Eustachian tubes.

B. Etiology

1. Many factors are associated with the development of cleft lip and cleft palate, and cleft lip with or without cleft palate is developmentally and genetically different from isolated cleft palate.

2. Most cases appear to be consistent with the concept of multifactorial inheritance as evidenced by an increase incidence in relatives and monozygotic twins.

C. Pathophysiology

1. During embryonic development the lateral and medial tissues forming the upper lip palates fuse between weeks 7 and 8 of gestation; the palatal tissues forming the hard and soft palates fuse between weeks 7 and 12 gestation.

2. Cleft lip and cleft palate result when these tissues fail to fuse.

D. Assessment findings

1. Clinical manifestations

a. Cleft lip and cleft palate are readily apparent at birth. Careful physical assessment should be performed to rule out other midline birth defects.

b. Cleft lip and cleft palate appear as incomplete or complete defects, and may be unilateral or bilateral.

2. Laboratory and diagnostic study findings. Obstetric ultrasound will reveal cleft lip while the infant is in utero.

E. Nursing management

1. Assess for problems with feeding, breathing parental bonding, and speech.

2. Ensure adequate nutrition and prevent aspiration.

a. Provide special nipples or feeding devices (eg, soft pliable bottle with soft nipple with enlarged opening) for a child unable to suck adequately on standard nipples.

b. Hold the child in a semiupright position; direct the formula away from the cleft and toward the side and back of the mouth to prevent aspiration.

c. Feed the infant slowly and burp frequently to prevent excessive swallowing of air and regurgitation.

d. Stimulate sucking by gently rubbing the nipple against the lower lip.

3. Support the infant’s and parents’ emotional and social adjustment.

a. Help facilitate the family’s acceptance of the infant by encouraging the parents to express their feelings and concerns and by conveying an attitude of acceptance toward the infant.

b. Emphasize the infant’s positive aspects and express optimism regarding surgical correction.

4. Provide preoperative care.

a. Depending in the defect and the child’s general condition, surgical correction of the cleft lip usually occurs at 1 to 3 months of age; repair of the cleft palate is usually performed between 6 and 18 months of age. Repair of the cleft palate may require several stages of surgery as the child grows.

b. Early correction of cleft lip enables more normal sucking patterns and facilitates bonding. Early correction of cleft palate enables development of more normal speech patterns.

c. Delayed closure or large defects may require the use of orthodontic appliances.

d. The responsibilities of the nurse are to:

1. Reinforce the physician’s explanation of surgical procedures.

2. Provide mouth care to prevent infection.

5. Provide postoperative care.

a. Assess airway patency and vital signs; observe for edema and respiratory distress.

b. Use a mist tent, if prescribed, to minimize edema, liquefy secretions, and minimize distress.

c. Position the child with cleft lip on her back, in an infant seat, or propped on a side to avoid injury to the operative site; position the child with a cleft palate on the abdomen to facilities drainage.

d. Clean the suture line and apply an antibacterial ointment as prescribed to prevent infection and scarring. Monitor the site for signs of infection.

e. Use elbow restraints to maintain suture line integrity. Remove them every 2 hours for skin care and range-of-motion exercises.

f. Feed the infant with a rubber-tipped medicine dropper, bulb syringe, Breck feeder, or soft bottle-nipples, as prescribed, to help preserve suture integrity. For older children, diet progresses from clear fluids; they should not use straws or sharp objects.

g. Attempt to keep the child from putting tongue up to palate sutures.

h. Manage pain by administering analgesic as prescribed.

6. Provide child and family teaching.

• Demonstrate surgical wound care.
• Show proper feeding techniques and positions.
• Explain that temperature of feeding formulas should be monitored closely because new palate has no nerve endings; therefore; the child can suffer a burn to the palate easily and without knowing it.
• Explain handling of prosthesis if indicated.
• Stress the importance of long-term follow up, including speech therapy, and preventing or correcting dental abnormalities.
• Discuss the need for, at least, annual hearing evaluations because of the increased susceptibility to recurrent otitis. The child may require myringotomy and surgical placement of drainage tubes.
• Teach infection control measures.

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• Hemorrhoids are vascular masses that protrude into the lumen of the lower rectum or perianal area.
• They result when increased intra-abdominal pressure causes engorgement in the vascular tissue lining the anal canal.
• Loosening of vessels from surrounding connective tissue occurs with protrusion or prolapse into the anal canal.
• There are two main types of hemorrhoids: external hemorrhoids appear outside the external sphincter, and internal hemorrhoids appear above the internal sphincter.
• When blood within the hemorrhoids becomes clotted because of obstruction, the hemorrhoids are referred to as being thrombosed.
• Predisposing factors include pregnancy, prolonged sitting or standing, straining stool, chronic constipation or diarrhea, anal infection, rectal surgery or episiotomy, genetic predisposition, alcoholism, portal hypertension (cirrhosis), coughing, sneezing, or vomiting, loss of muscle tone attributable to old age, and anal intercourse.
• Complications include hemorrhage, anemia, incontinence of stool, and strangulation.
• Hemorrhoids are the most common of a variety of anorectal disorders.

Assessment:

1. Pain (more so with external hemorrhoids), sensation of incomplete fecal evacuation, constipation, and anal itching. Sudden rectal pain may occur if external hemorrhoids are thrombosed.
2. Bleeding may occur during defecation; bright red blood on stool caused by injury of mucosa covering hemorrhoid.
3. Visible and palpable masses at anal area.

Diagnostic Evaluation:

1. External examination with anoscope or proctoscope shows single or multiple hemorrhoids.
2. Barium edema or colonoscopy rules out more serious colonic lesions causing rectal bleeding such as polyps.

Therapeutic Interventions:

1. High-fiber diet to keep stools soft.
2. Warm sitz baths to ease pain and combat swelling.
3. Reduction of prolapsed external hemorrhoid manually.

Pharmacologic Interventions:

1. Stool softeners to keep stools soft and relieve symptoms.
2. Topical creams, suppositories or other preparation such as Anusol, Preparation H, and witch-hazel compresses to reduce itching and provide comfort.
3. Oral analgesics may be needed.

Surgical Interventions:

1. Injection of sclerosing solutions to produce scar tissue and decrease prolapse is an office procedure.
2. Cryodestruction (freezing) of hemorrhoids is an office procedure.
3. Surgery may be indicated in presence of prolonged bleeding, disabling pain, intolerable itching, and general unrelieved discomfort.

Nursing Interventions:

1. After thrombosis or surgery, assist with frequent repositioning using pillow support for comfort.
2. Provide analgesics, warm sitz baths, or warm compresses to reduce pain and inflammation.
3. Apply witch-hazel dressing to perianal area or anal creams or suppositories, if ordered, to relieve discomfort.
4. Observe anal area postoperatively for drainage and bleeding.
5. Administer stool softener or laxative to assist with bowel movements soon after surgery, to reduce risk of stricture.
6. Teach anal hygiene and measures to control moisture to prevent itching.
7. Encourage the patient to exercise regularly, follow a high fiber diet, and have an adequate fluid intake (8 to 10 glasses per day) to avoid straining and constipation, which predisposes to hemorrhoid formation.
8. Discourage regular use of laxatives; firm, soft stools dilate the anal canal and decrease stricture formation after surgery.
9. Tell patient to expect a foul-smelling discharge for 7 to 10 days after cryodestruction.
10. Determine the patient’s normal bowel habits and identify predisposing factors to educate patient about preventing recurrence of symptoms.

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Goals:

• To establish, maintain and support respirations.
• To provide warmth and prevent hypothermia.
• To ensure safety, prevent injury and infection.
• To identify actual or potential problems that may require immediate attention.

Establish respiration and maintain clear airway

The most important need for the newborn immediately after birth is a clear airway to enable the newborn to breathe effectively since the placenta has ceased to function as an organ of gas exchange. It is in the maintenance of adequate oxygen supply through effective respiration that the survival of the newborn greatly depends.

Newborns are obligatory nose breathers. The reflex response to nasal obstruction, opening the mouth to maintain airway, is not present in most newborns until 3 weeks after birth.

To establish and maintain respirations:

1. Wipe mouth and nose of secretions after delivery of the head.

2. Suction secretions from mouth and nose.

• Compress bulb syringe before inserting
• Suction mouth first, then, the nose
• Insert bulb syringe in one side of the mouth

3. A crying infant is a breathing infant. Stimulate the baby to cry if baby does not cry spontaneously, or if the cry is weak.

• Do not slap the buttocks rather rub the soles of the feet.
• Stimulate to cry after secretions are removed.
• The normal infant cry is loud and husky. Observe for the following abnormal cry:
  • High, pitched cry – indicates hypoglycemia, increased intracranial pressure.
  • Weak cry – prematurity
  • Hoarse cry – laryngeal stridor

4. Oral mucous may cause the newborn, to choke, cough or gag during the first 12 to 18 hours of life. Place the infant in a position that would promote drainage of secretions.

• Trendelenburg position – head lower than the body
• Side lying position – If trendelenburg position is contraindicated, place infant in side lying position to permit drainage of mucus from the mouth. Place a small pillow or rolled towel at the back to prevent newborn from rolling back to supine position.

5. Keep the nares patent. Remove mucus and other particles that may be cause obstruction. Newborns are obligatory nose breathers until they are about 3 weeks old.

Care of the Eyes

It is part of the routine care of the newborn to give prophylactic eye treatment against gonorrhea conjunctivitis or opthalmia neonatorum. Neisseria gonorrhea, the causative agent, may be passed on the fetus from the vaginal canal during delivery. This practice was introduced by Crede, a German gynecologist in1884. Silver nitrate, erythromycin and tetracycline ophthalmic ointments are the drugs used for this purpose.

Erythromycin or tetracycline Opthalmic Ointment:

1. These ointments are the ones commonly used now a days for eye prophylaxis because they do not cause eye irritation and are more effective against Chlamydial conjunctivitis.
2. Apply over lower lids of both eyes, then, manipulate eyelids to spread medication over the eyes.

Vitamin K or Aquamephyton

The newborn has a sterile intestine at birth, hence, the newborn does not possess the intestinal bacteria that manufactures vitamin K which is necessary for the formation of clotting factors. This makes the newborn prone to bleeding. As a preventive measure, .5 (preterm) and 1 mg (full term) Vitamin K or aquamephyton is injected IM in the newborn’s vastus lateralis (lateral anterior thigh) muscle.

Care of the cord

The cord is clamped and cut approximately within 30 seconds after birth. In the delivery room, the cord is clamped twice about 8 inches from the abdomen and cut in between. When the newborn is brought to the nursery, another clamp is applied ½ to 1 inch from the abdomen and the cord is cut at second time. The cord and the area around it are cleansed with antiseptic solution. The manner of cord care depends on hospital protocol. What is important is that the principles are followed. Cord clamp maybe removed after 48 hours when the cord has dried. The cord stump usually dries and fall within 7 to 10 days leaving a granulating area that heals on the next 7 to 10 days.

Instruction to the mother on cord care:

1. No tub bathing until cord falls off. Do not sponge bath to clean the baby. See to it that cord does not get wet by water or urine.
2. Do not apply anything on the cord such as baby powder or antibiotic, except the prescribed antiseptic solution which is 70% alcohol.
3. Avoid wetting the cord. Fold diaper below so that it does not cover the cord and does not get wet when the diaper soaks with urine.
4. Leave cord exposed to air. Do not apply dressing or abdominal binder over it. The cord dries and separates more rapidly if it is exposed to air.
5. If you notice the cord to be bleeding, apply firm pressure and check cord clamp if loose and fasten.
6. Report any unusual signs and symptoms which indicates infection.
   • Foul odor in the cord
   • Presence of discharge
   • Redness around the cord
   • The cord remains wet and does not fall off within 7 to 10 days
   • Newborn fever

THE APGAR SCORING SYSTEM

The APGAR Scoring System was developed by Dr. Virginia Apgar as a method of assessing the newborn’s adjustment to extrauterine life. It is taken at one minute and five minutes after birth. With depressed infants, repeat the scoring every five minutes as needed. The one minute score indicates the necessity for resuscitation. The five minute score is more reliable in predicting mortality and neurologic deficits. The most important is the heart rate, then the respiratory rate, the muscle tone, reflex irritability and color follows in decreasing order. A heart rate below 100 signifies an asphyxiated baby and a heart rate above 160 signifies distress.

Score:

• 7 – 10 Good adjustment, vigorous
• Moderately depressed infant, needs airway clearance
• Severely depressed infant, in need of resuscitation.

ASSESSING THE AVERAGE NEWBORN

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Update: Deadlines in filing of application for November 2009 Nursing Board Exam has been CHANGED.

The PROFESSIONAL REGULATION COMMISSION (PRC) announces that the filing of applications for the November 29-30, 2009 (Sunday-Monday) Nursing Board Exam is now on-going in the Central Office and in the Regional Offices of PRC.

The following are the NEW deadlines of filing of applications:

1. NEW / FIRST TIMERS   -  OCTOBER 16, 2009
2. REPEATERS                  -  SEPTEMBER 16, 2009

Applications shall no longer be accepted after these deadlines.

source: prc.gov.ph

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• Is an entrapment syndrome resulting from compression of the median nerve in the tendon sheath within the ventral surface of the wrist.
• Similarly, tarsal tunnel syndrome is a group of symptoms caused by pressure on the posterior tibial nerve in the medial aspect of the ankle and cubital tunnel syndrome is caused by pressure on the ulnar nerve at the medial epicondyle of the elbow.
• Compression symptoms due to entrapment include paresthesias, numbness, pain, weakness, and muscle atrophy.
• Compression results from repetitive motion of the wrist, trauma, local tenosynovitis, and mass, such as ganglion or neuroma.
• Repetitive motion causing carpal tunnel include the use of computer, typing, and use of a jackhammer.
• Carpal tunnel syndrome is more common in those over age 50, in women, in pregnant women in the first trimester, and in those with rheumatoid arthritis.
• Complications include chronic pain and loss of function of the extremities.

Assessment:

1. Progressive sensory changes including paresthesias and numbness of the thumb, index finger, and ring finger of the involved hand; leads to pain waking the patient up at night.
2. Motor changes beginning with clumsiness and progressing to weakness; edema and thenar atrophy may be noted.
3. Positive Tinel’s sign: Increased paresthesias on tapping of tendon sheath (ventral surface of central wrist).
4. Positive Phalen test: Increased symptoms with acute palmar flexion for 1 minute.

Diagnostic Evaluation:

1. Electromyogram shows weakened response to median nerve stimulation.

Therapeutic and Pharmacologic Interventions:

1. Wrist splint in slight extension (cock-up splint) to relieve pressure aggravated by wrist flexion: worn at night, and during day if symptomatic.
2. Avoidance of flexion and twisting motion of the wrist.
3. Work or activity modification to relieve repetitive strain.
4. Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen 600 to 800 mg tid to relieve inflammation and pain.
5. Corticosteroid injection into tendon sheath to relieve inflammation.

Surgical Interventions:

1. Surgery is indicated when conservative measures fail to relieve symptoms.
2. Procedure is release of carpal ligament and tendon to relieve pressure on median nerve.

Nursing Interventions:

1. Monitor level of pain, numbness, paresthesias, and functioning.
2. Monitor for adverse effects of NSAID therapy, especially in elderly. GI distress or bleeding, dizziness, or increased serum creatinine.
3. After surgery, monitor neurovascular status of affected extremity: pulses, color, swelling, movement, sensation, or warmth.
4. Apply wrist splint so wrist is in neutral position, with slight extension of wrist and slight abduction of thumb; make sure that it fits correctly without constriction.
5. Administer NSAIDs and assist with tendon sheath injections as required.
6. Apply ice or cold compress to relieve inflammation and pain.
7. Teach patient the cause of condition and ways to alter activity to prevent flexion of wrists; refer to an occupational therapist as indicated.
8. Advise patient of NSAID therapy dosage schedule and potential adverse effects; instruct patient to report GI pain and bleeding.
9. Teach patient to gentle range-of-motion exercises; refer to a physical therapist as indicated.

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The Philippine Overseas Employment Administrator (POEA) announced yesterday that the Ministry of Health of the Kingdom of Saudi Arabia is in urgent need of 1,000 Female Nurses to be deployed in government hospitals is Saudi.

Qualifications:

• Applicants must be a licensed female nurse with at least one year hospital experience
• Not be more than 45 years old.

Requirements:

• detailed resume with job description
• school credentials
• employment certificates
• copy of passport
• two pieces of 2×2 recent photo at the Manpower Registry Division, Window M at the ground floor lobby of the POEA building.

Benefits:

• annual paid vacation
• free economy round trip ticket
• housing and transportation allowance
• and yearly renewal of contract.

Qualified nurses may personally submit their documents to:

Philippine Overseas Employment Administrator (POEA)
EDSA cor Ortigas Ave. Mandaluyong City
Philippines

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