Here is a table of commonly encountered anesthetic agents, their generic

names, and brand names:

Classifications Generic Name Brand Name

General Anesthetic Agents

methohexital Brevital
Barbiturate Anesthetics
thiopental Pentothal

droperidol Inapsine

etomidate Amidate

fospropofol Lusedra
Nonbarbiturate General
Anesthetics
ketamine Ketalar

midazolam *only in generic form

propofol Diprivan

Anesthetic Gases nitrous oxide (blue)

desflurane Suprane

enflurane Ethrane

Volatile Liquids halothane Fluothane

isoflurane –

sevoflurane Ultane

Local Anesthetic Agents

 benzocaine Dermoplast, Lanacane

chloroprocaine Nesacaine
Esters
procaine Novocaine

tetracaine Pontocaine

bupivacaine Marcaine, Sensorcaine

dibucaine Nupercainal

Dilocaine, Xylocaine, Solarcaine,

lidocaine
Lidoderm, Octocaine
Amides

mepivacaine Carbocaine, Isocaine, Polocaine

prilocaine Citanest

ropivacaine Naropin

Other pramoxine Tronothane, PrameGel, Itch-X

General and Local Anesthesia

General Anesthesia

General anesthesia involves the administration of combined different general

anesthetic agents with the fewest adverse effects to achieve analgesia (loss
of pain perception), unconsciousness (loss of awareness of one’s own
surroundings), and amnesia (inability to recall what took place).
It also blocks the autonomic reflexes governing involuntary reflex response of
the body to injury which can compromise cardiac, respiratory, gastrointestinal,
and immune status.

Muscle reflexes are also blocked to prevent jerking movements that might
interfere with surgical procedures.

Risk Factors Associated with General Anesthesia

Widespread CNS depression can occur in individuals with the following risk
factors:

 CNS Factors: neurological diseases that may produce an abnormal

reaction to the CNS-depressing and muscle-relaxing effects of general
anesthetic agents like epilepsy, stroke, and myasthenia gravis.
 Cardiovascular (CV) Factors: underlying CV diseases which can can
be worsened by severe reactions to anesthesia (shock, hypotension,
dysrhythmia, and ischemia) like coronary artery disease (CAD).
 Respiratory Factors: obstructive pulmonary diseases that can
complicate delivery of gas anesthetics, intubation, and mechanical
ventilation like asthma, chronic obstructive pulmonary disease (COPD),
and bronchitis.
 Renal and hepatic function: conditions that interfere with
metabolism and excretion of anesthetics that could lead to prolonged
anesthesia like acute renal failure and hepatitis.

Administration of General Anesthesia

Patient undergo predictable stages during administration of anesthesia. These

steps are referred to as the depth of anesthesia:

 Stage 1 – Analgesia Stage: Characterized by loss of pain sensation

and with the patient still conscious and able to communicate.
  Stage 2 – Excitement Stage: Period of excitement and often
combative behavior with many signs of sympathetic stimulation.
 Stage 3 – Surgical Anesthesia: Involves muscle relaxation, regular
respirations, progressive loss of eye reflexes and pupil dilation. It is the
stage in which surgery can be safely performed.
 Stage 4 – Medullary Paralysis: Very deep CNS depression with loss
of respiratory and vasomotor center stimuli, in which death can occur
rapidly. It is considered a critical period because anesthesia has
become too intense.

Administration of general anesthesia is divided into three phases:

 Induction: from beginning of anesthesia to stage 3. The most

dangerous period of induction is stage 2 because of the systemic
stimulations that occur.
 Maintenance: from stage 3 to completion of surgical procedure.
 Recovery: from discontinuation of anesthetic to regained
consciousness, movement, and ability to communicate of the patient.

Local Anesthesia

Refers to a loss of sensation in limited areas of the body. Can be achieved by

different methods:

 Topical administration: involves the application of cream, lotion,

ointment, or drop of local anesthetic to traumatized skin to
relieve pain. It can also involve application of these forms to the
mucous membranes in the eyes, nose, throat, mouth, urethra, anus, or
rectum.
 Infiltration: involves injecting the anesthetic directly into the tissues
to be treated. It brings the anesthetic into contact with the nerve
endings in the area and prevents them from transmitting nerve
impulses to the brain.
  Field Block: involves injecting the anesthetic all around the area that
will be affected by the surgery. Anesthesia comes in contact with all of
the nerve endings surrounding the area. It is often used for tooth
extraction.
 Nerve Block: involves injecting the anesthetic at some point along the
nerve(s) that run to and from the region in which the loss
of pain sensation or muscle paralysis is desired. Several types of nerve
blocks include: peripheral nerve block, central nerve block, epidural
anesthesia, caudal block, and spinal anesthesia.

General Anesthetic Agents

General anesthetic agents can be classified into: barbiturate anesthetics,

nonbarbiturate general anesthetics, anesthetic gases, and volatile liquids.

Barbiturate Anesthetics

Description

 Barbiturate anesthetics are intravenous drugs used to induce rapid

anesthesia, which is then maintained with an inhaled drug.

Therapeutic Action

The desired and beneficial actions of barbiturate anesthetics are as follows:

 Barbiturate anesthetics depress the CNS to produce hypnosis and

anesthesia without analgesia.

Indications

Barbiturate anesthetics are indicated for the following medical conditions:

  Thiopental is the most widely used intravenous anesthetics.
 Both thiopental and methohexital do not have analgesic properties
so patients would require analgesics post-operation.
 These drugs are indicated for induction and maintenance of anesthesia
as well as for induction of hypnosis.

Here are some important aspects to remember for indication of barbiturate

anesthetics in different age groups:

Children

 At greater risk for complications after anesthesia (e.g. laryngospasm,

bronchospasm, aspiration, etc.)
 Nursing care should include support and reassurance; assessment of
child for any skin breakdown related to immobility, and safety
precautions.

Adults

 They should receive education about what will happen during

administration of anesthesia. Expected body reactions should also be
explained.
 Continuously reassure adult patients during the time that they are
aware of their surroundings but they are unable to speak.
 Most general anesthetics are not recommended during pregnancy
because of potential adverse effects to the fetus.
 A period of 4-6 hours after receiving anesthetic is required for lactating
women before they can start nursing.

Older adults

 They are more susceptible to adverse effects (e.g. CNS, CV, and
dermatological effects).
  At risk for developing toxicity because of possible hepatic and renal
impairment.
 Safety measures should be instituted (e.g. side rails, call light,
ambulation assistance, and skin care).
 Longer monitoring and regular orienting and reassuring is essential.
 After general anesthesia, it is important for nurses to promote vigorous
pulmonary toilet to decrease the risk of pneumonia.

Pharmacokinetics

Here are the characteristic interactions of barbiturate anesthetics and the body
in terms of absorption, distribution, metabolism, and excretion:

Route Onset Peak Duration

IV 1 min N/A 20-30 min

T1/2: 3-8 h
Metabolism: liver
Excretion: kidney (urine)

Contraindications and Cautions

The following are contraindications and cautions for the use of barbiturate
anesthetics:

 Silicon (e.g. Rubber stoppers, disposable syringes). Methohexital

will cause an immediate breakdown of the silicone.
 Pregnancy, lactation. CNS depressive effects to baby and fetus.
 Neither drug should be used until the anesthesiologist nor are staff
ready and equipped for intubation and respiratory support. The rapid
onset of action of these drugs can cause respiratory depression and
apnea.
Adverse Effects

Use of barbiturate anesthetics may result to these adverse effects:

 CNS: CNS suppression

 CV: bradycardia, hypotension
 Respiratory: respiratory depression
 GI: decreased GI activity
 Nausea and vomiting are common after recovery.

Interactions

The following are drug-drug interactions involved in the use of barbiturate

anesthetics:

 Theophylline, oral anticoagulants, beta-blockers, corticosteroids,

hormonal contraceptives, phenylbutazones, metronidazole,
quinidine, carbamazepine: decreased effectiveness of these drugs
with barbiturates
 Narcotics: increased risk for apnea

Nonbarbiturate Anesthetics

Description

 Nonbarbiturate anesthetics are the other parenteral drugs used for

intravenous administration in anesthesia.

Therapeutic Action

The desired and beneficial actions of nonbarbiturate anesthetics are as follows:

  Nonbarbiturate anesthetics are very potent amnesiacs that are thought
to be acting in the reticular activating system and limbic system to
potentiate the effects of GABA.
 It has little effect on cortical function.

Indications

Nonbarbiturate anesthetics are indicated for the following medical conditions:

 Midazolam, the prototype nonbarbituare anesthetic, is widely used to

produce amnesia or sedation for many diagnostic, therapeutic, and
endoscopic procedures. It can also be used to induce anesthesia and to
provide continuous sedation for intubated and mechanically ventilated
patients.
 Droperidol produces marked sedation and produces a state of mental
detachment. It also has antiemetic effect which reduces the incidence
of nausea and vomiting in surgical and diagnostic procedures.
 Ketamine is useful in situations when cardiac depression is dangerous
because it causes sympathetic stimulation with increase
in blood pressure and heart rate.
 Propofol is used for short procedures because it has a very rapid
clearance and produces much less of a hangover effect and allows for
quick recovery.

Here are some important aspects to remember for indication of nonbarbiturate

anesthetics in different age groups:

Children

 At greater risk for complications after anesthesia (e.g. laryngospasm,

bronchospasm, aspiration, etc.)
  Nursing care should include support and reassurance; assessment of
child for any skin breakdown related to immobility; and safety
precautions.
 Propofol is widely used for diagnostic tests and short procedures in
children older than 3 years of age because of its rapid onset and
metabolism.
 Etomidate is not recommended for use in children younger than 10
years of age.

Adults

 They should receive education about what will happen during

administration of anesthesia. Expected body reactions should also be
explained.
 Continuously reassure adult patients during the time that they are
aware of their surroundings but they are unable to speak.
 Most general anesthetics are not recommended during pregnancy
because of potential adverse effects to the fetus.
 A period of 4-6 hours after receiving anesthetic is required for lactating
women before they can start nursing.

Older adults

 They are more susceptible to adverse effects (e.g. CNS, CV, and
dermatological effects).
 At risk for developing toxicity because of possible hepatic and renal
impairment.
 Safety measures should be instituted (e.g. side rails, call light,
ambulation assistance, and skin care).
 Longer monitoring and regular orienting and reassuring is essential.
 After general anesthesia, it is important for nurses to promote vigorous
pulmonary toilet to decrease the risk of pneumonia.
Pharmacokinetics

Here are the characteristic interactions of nonbarbiturate anesthetics and the

body in terms of absorption, distribution, metabolism, and excretion:

Route Onset Peak Duration

Oral 30-60 min 12 h 2-6 h

IM 15 min 30 min 2-6 h

IV 3-5 min <30 min 2-6 h

T1/2: 1.8-6.8 h
Metabolism: liver
Excretion: kidney (urine)

Contraindications and Cautions

The following are contraindications and cautions for the use of nonbarbiturate
anesthetics:

 Conditions that can be compromised by vomiting. Midazolam is

more likely to cause nausea and vomiting than other anesthetics.
 Renal or hepatic failure, prolonged QT intervals. Contraindicated
with use of droperidol.
 Respiratory depression and arrest is associated with use of
nonbarbiturate anesthetics so life support equipment should be readily
available always.

Adverse Effects

Use of nonbarbiturate anesthetics may result to these adverse effects:

 Midazolam: CNS suppression, respiratory depression

  Droperidol: chiils, hypotension, hallucinations, drowsiness, QT
prolongation
 Etomidate: myoclonic and tonic movements
 Ketamine: hallucinations, dreams, psychotic episodes (can
cross blood–brain barrier)
 Propofol: local burning on injection sites, bradycardia, hypotension,
pulmonary edema
 Fospropofol: sensation of perianal burning, stinging, tingling, rash (do
not usually require intervention and will usually pass)

Interactions

The following are drug-drug interactions involved in the use of nonbarbiturate

anesthetics:

 Ketamine and halothane can cause severe cardiac depression

with hypotension and bradycardia.
 NMJ Blockers. Potentiated muscular blocking of NMJ if paired with
ketamine
 Inhaled anesthetics, other CNS depressants, narcotics,
propofol, thiopental. Increased toxicity and length of recovery with
use of midazolam.

Anesthetic Gases

Description

 Anesthetic gases enter the bronchi and alveoli, pass the capillary
system and is transported to the heart to be pumped throughout the
boyd. It has high affinity for fatty tissue (including the lipid membrane
of the nerves in the CNS), and is lipophilic.
 Passes quickly to the brain and causes CNS depression.
  Very flammable and associated with toxic adverse effects.

Therapeutic Action

The desired and beneficial actions of anesthetic gases are as follows:

 Moves quickly in and out of the body that it can accumulate in closed
body compartments (e.g. sinuses) and cause pressure there.
 Very potent analgesic.
 Do not cause muscle relaxation.

Indications

Anesthetic gases are indicated for the following medical conditions:

 Nitrous oxide is usually used for dental surgery. It is also combined

with other agents for anesthetic use.
 Only one anesthetic gas, nitrous oxide (blue cylinder), is still used.

Here are some important aspects to remember for indication of anesthetic gases
in different age groups:

Children

 At greater risk for complications after anesthesia (e.g. Laryngospasm,

bronchospasm, aspiration, etc.)
 Nursing care should include support and reassurance; assessment of
child for any skin breakdown related to immobility; and safety
precautions.
 Children need to be cautioned not to bite themselves when receiving
dental anesthesia.

Adults
  They should receive education about what will happen during
administration of anesthesia. Expected body reactions should also be
explained.
 Continuously reassure adult patients during the time that they are
aware of their surroundings but they are unable to speak.
 Most general anesthetics are not recommended during pregnancy
because of potential adverse effects to the fetus.
 A period of 4-6 hours after receiving anesthetic is required for lactating
women before they can start nursing.

Older adults

 They are more susceptible to adverse effects (e.g. CNS, CV, and
dermatological effects).
 At risk for developing toxicity because of possible hepatic and renal
impairment.
 Safety measures should be instituted (e.g. side rails, call light,
ambulation assistance, and skin care).
 Longer monitoring and regular orienting and reassuring is essential.
 After general anesthesia, it is important for nurses to promote vigorous
pulmonary toilet to decrease the risk of pneumonia.

Pharmacokinetics

Here are the characteristic interactions of anesthetic gases and the body in
terms of absorption, distribution, metabolism, and excretion:

Route Onset Peak Duration

IV 1-2 min N/A 20 min

T1/2: minutes
Metabolism: not metabolized
Excretion: lungs
Contraindications and Cautions

The following are contraindications and cautions for the use of anesthetic gases:

 Conditions which are at risk for hypoxia. Oxygen is always given

with nitrous oxide because the drug can block the reuptake of oxygen
after surgery. Susceptible patients should be monitored for signs of
hypoxia, chest pain, and stroke.
 Pregnancy. Potential adverse effects to the fetus.
 Lactation. Should wait 4 hours after administration of nitrous oxide
before nursing a baby.

Adverse Effects

Use of anesthetic gases may result to these adverse effects:

 Respiratory: pneumothorax
 GI: bowel obstruction
 EENT: acute sinus pain, middle ear pain
 Inactivates Vitamin B12.

Interactions

The following are drug-drug interactions involved in the use of anesthetic gases:

 Ketamine and halothane can cause severe cardiac depression

with hypotension and bradycardia.

Volatile Liquids

Description
  Volatile liquids are also inhaled anesthetics because they are
unstable at room temperature and release gases.
 Most volatile liquids are halogenated hydrocarbons.

Therapeutic Action

The desired and beneficial actions of volatile liquids are as follows:

 Depresses the CNS, causing anesthesia. It also relaxes muscles.

 It sensitizes the myocardium to the effects
of norepinephrine and epinephrine.

Indications

Volatile liquids are indicated for the following medical conditions:

 Halothane, the prototype drug, is used for maintenance of anesthesia

and can be effective as an induction agent.
 Desflurane is widely used to in outpatient surgery because of its rapid
onset and quick recovery time.
 Isoflurane is widely used to maintain anesthesia after inductions. It
can cause muscle relaxation.

Here are some important aspects to remember for indication of volatile liquids
in different age groups:

Children

 At greater risk for complications after anesthesia (e.g. Laryngospasm,

bronchospasm, aspiration, etc.)
 Nursing care should include support and reassurance; assessment of
child for any skin breakdown related to immobility, and safety
precautions.
  Halothane is widely used for children, especially those with
respiratory dysfunction because it tends to produce bronchial dilation.
However, it is contraindicated for those with increased intracranial
pressure (ICP).

Adults

 They should receive education about what will happen during

administration of anesthesia. Expected body reactions should also be
explained.
 Continuously reassure adult patients during the time that they are
aware of their surroundings but they are unable to speak.
 Most general anesthetics are not recommended during pregnancy
because of potential adverse effects to the fetus.
 A period of 4-6 hours after receiving anesthetic is required for lactating
women before they can start breastfeeding.

Older adults

 They are more susceptible to adverse effects (e.g. CNS, CV, and
dermatological effects).
 At risk for developing toxicity because of possible hepatic and renal
impairment.
 Safety measures should be instituted (e.g. side rails, call light,
ambulation assistance, and skin care).
 Longer monitoring and regular orienting and reassuring is essential.
 After general anesthesia, it is important for nurses to promote vigorous
pulmonary toilet to decrease the risk of pneumonia.

Pharmacokinetics

Here are the characteristic interactions of volatile liquids and the body in terms
of absorption, distribution, metabolism, and excretion:
Route Onset Peak Duration

Inhaled Rapid Rapid End of inhalation

T1/2: Unknown
Metabolism: liver
Excretion: kidney (urine)

Contraindications and Cautions

The following are contraindications and cautions for the use of volatile liquids:

 Hepatic impairment. Can contribute to hepatic toxicity.

 Cardiovascular disease. Associated with bradycardia and
hypotension
 Respiratory depression and increased sensitivity. Has tendency
to cause respiratory depression and it is an irritant to the airways.
 Pregnancy, lactation. Potential adverse effects to the fetus and the
baby.
 All of these drugs have the potential to
trigger malignant hyperthermia. In such cases, dantrolene is the
preferred treatment and should be readiily available.

Adverse Effects

Use of volatile liquids may result to these adverse effects:

 Halothane’s recovery syndrome: fever, anorexia, nausea,

vomiting, hepatitis (can progress to fatal hepatic necrosis). It is not
used for more than 3 weeks to reduce the patient risk.
 Desflurane is associated with a collection of respiratory
reactions: cough, increased secretions, laryngospasm.

Interactions
The following are drug-drug interactions involved in the use of volatile liquids:

 Caution should be used when any of these drugs is combined with

other CNS suppressants.

Nursing Considerations

Here are important nursing considerations when administering this drug:

Nursing Assessment

These are the important things the nurse should include in conducting
assessment, history taking, and examination:

 Assess for the mentioned cautions and contraindications (e.g. drug

allergies, hepatic and renal impairment, etc.) to prevent any untoward
complications.
 Perform a thorough physical assessment (e.g. weight, neurological
status, vital signs, heart sounds, skin color and lesions, bowel sounds,
etc.) to establish baseline data before drug therapy begins, to
determine effectiveness of therapy, and to evaluate for occurrence of
any adverse effects associated with drug therapy.
 Monitor laboratory test results (e.g. liver and renal function tests) to
determine possible need for a reduction in dose and evaluate for
toxicity.

Nursing Diagnoses

Here are some of the nursing diagnoses that can be formulated in the use of
this drug for therapy:

 Impaired gas exchange related to respiratory depression

  Impaired skin integrity related to immobility secondary to effects
of positioning during anesthesia and immobility
 Risk for injury related to CNS depressive drug effects

Implementation with Rationale

These are vital nursing interventions done in patients who are taking general
anesthetics:

 Prepare emergency equipment to maintain airway and

provide mechanical ventilationwhen patient is not able to maintain
respiration because of CNS depression.
 Monitor temperature for prompt detection and treatment of
malignant hyperthermia. Maintain dantrolene on standby.
 Monitor vital signs and ECG readings to assess systemic response to
CNS depression and provide appropriate support as needed.
 Provide safety measures (e.g. adequate lighting, raised side rails, etc.)
to prevent injuries.
 Educate client on drug therapy to promote understanding and
compliance.
 Provide comfort measures (e.g. pain relief, skin care, etc.) to help
patient tolerate drug effects.

Evaluation

Here are aspects of care that should be evaluated to determine effectiveness of

drug therapy:

 Monitor patient response to therapy (analgesia, loss of consciousness).

 Monitor for adverse effects (e.g. respiratory depression, hypotension,
bronchospasm, skin breakdown, etc).
 Evaluate patient understanding on drug therapy by asking patient to
name the drug, its indication, and adverse effects to watch for.
  Monitor patient compliance to drug therapy.

Local Anesthetic Agents

Description

 Local anesthetic agents are used primarily to prevent the patient

from feeling pain for varying periods of time after the agents have
been administered in the peripheral nervous system.
 They can cause loss of the following sensations in this sequence:
temperature, touch, proprioception, and skeletal muscle tone.
 They are very powerful nerve blockers and should not be absorbed
systemically. Systemic absorption can lead to toxic effects on
the nervous system and the heart.
 Local anesthetics can either be esters or amides. Pramoxine is a
local anesthetic agent that does not fit into either of these classes.

Therapeutic Action

The desired and beneficial actions of local anesthetics are as follows:

 Local anesthetics work by causing a temporary interruption in the

production and conduction of nerve impulses. They affect the
permeability of nerve membranes to sodium ions. By preventing
the sodium ions from entering the nerve, they stop the nerve from
depolarizing.
 Reduce the height and rate of rise of the action potential and increase
the excitation threshold. Conduction velocity is slowed too.
 Ester local anesthetics are broken down immediately in
the plasma by enzymes calledplasma esterses.

Indications
Local anesthetics are indicated for the following:

 Infiltration anesthesia, peripheral and sympathetic nerve blocks,

central nerve blocks, spinal and caudal anesthesia, topical anesthetic
for skin or mucous membrane disorders.

Here are some important aspects to remember for indication of local anesthetics
in different age groups:

Children

 Nursing care should include support and reassurance; assessment of

child for any skin breakdown related to immobility; and safety
precautions.
 Local anesthetics are used in children in much the same way as they
are used in adults.
 Infants are at particular risk for systemic absorption and toxicity from
topically-applied local anesthetics. Tight diapers and occlusive
dressings can increase systemic absorption.

Adults

 They should receive education about what will happen during

administration of anesthesia. Expected body reactions should also be
explained.
 Regional or local anesthetics are preferred if surgery is needed during
pregnancy.

Older adults

 They are more susceptible to adverse effects (e.g. CNS, CV, and
dermatological effects).
 At risk for developing toxicity because of possible hepatic and renal
impairment.
  Safety measures should be instituted (e.g. side rails, call light,
ambulation assistance, and skin care).
 Longer monitoring and regular orienting and reassuring is essential.

Pharmacokinetics

Here are the characteristic interactions of local anesthetics and the body in
terms of absorption, distribution, metabolism, and excretion:

Route Onset Peak Duration

IM 5-10 min 5-15 min 2h

Not generally absorbed

Topical
systemically

T1/2: 10 min, then 1.5-3 h

Metabolism: liver
Excretion: kidney (urine)

Contraindications and Cautions

The following are contraindications and cautions for the use of local anesthetics:

 Allergy to anesthetics and parabens. To avoid hypersensitivity

reactions.
 Heart block. Could be exacerbated with systemic absorption
 Shock. Can alter the local delivery and absorption of these drugs
 Decreased plasma esterase. Can result in toxic levels of ester-type
local anesthetics
 Pregnancy, lactation. Potential adverse effects to fetus and baby.

Adverse Effects

Use of local anesthetics may result to these adverse effects:

  CNS: headache (especially with epidural and spinal anesthesia),
restlessness, anxiety, dizziness, tremors, blurred vision, backache
 CV: peripheral vasodilation, myocardial depression,
arrhythmias, blood pressure changes
 Respiratory: respiratory arrest
 GI: nausea, vomiting
 Loss of skin integrity, especially in patients who are unable to move.

Interactions

The following are drug-drug interactions involved in the use of local anesthetics:

 Succinylcholine: increased and prolonged neuromuscular blockade

 Epinephrine: less risk of systemic absorption and increased local
effects of local anesthetics

Nursing Considerations

Here are important nursing considerations when administering this drug:

Nursing Assessment

These are the important things the nurse should include in conducting
assessment, history taking, and examination:

 Assess for the mentioned cautions and contraindications (e.g. drug

allergies, hepatic and renal impairment, etc.) to prevent any untoward
complications.
 Perform a thorough physical assessment (e.g. weight, neurological
status, vital signs, heart sounds, skin color and lesions, bowel sounds,
etc.) to establish baseline data before drug therapy begins, to
determine effectiveness of therapy, and to evaluate for occurrence of
any adverse effects associated with drug therapy.
  Inspect site for local anesthetic application to ensure integrity of the
skin and to prevent inadvertent systemic absorption of the drug.
 Monitor laboratory test results (e.g. liver and renal function tests,
plasma esterases) to determine possible need for a reduction in dose
and evaluate for toxicity.

Nursing Diagnoses

Here are some of the nursing diagnoses that can be formulated in the use of
this drug for therapy:

 Disturbed sensory perception related to local anesthetic effect

 Impaired skin integrity related to immobility caused by action of drugs
 Risk for injury related to loss of sensation and mobility

Implementation with Rationale

These are vital nursing interventions done in patients who are taking local
anesthetics:

 Prepare emergency equipment to maintain airway and

provide mechanical ventilation if needed.
 Ensure that patients receiving spinal anesthesia or epidural anesthesia
are well hydrated and remain lying down for up to 12 hours after the
anesthesia to minimize headache.
 Provide skin care to site of administration to reduce risk of skin
breakdown.
 Provide comfort measures to help patient tolerate drug effects.
 Provide safety measures (e.g. adequate lighting, raised side rails, etc.)
to prevent injuries.
 Educate client on drug therapy to promote understanding and
compliance.

Evaluation
Here are aspects of care that should be evaluated to determine effectiveness of
drug therapy:

 Monitor patient response to therapy (loss of feeling in designated

area).
 Monitor for adverse effects (e.g. respiratory depression, blood
pressure changes, arrhythmias, GI upset, skin breakdown, injury, CNS
alterations, etc).
 Evaluate patient understanding on drug therapy by asking patient to
name the drug, its indication, and adverse effects to watch for.
 Monitor patient compliance to drug therapy.
 . The only anesthetic gas used currently in medical and dental
procedures.
 A. Nitrous oxide (pink)
B. Nitrous oxide (blue)
C. Nitrous oxide (green)
D. Nitrous oxide (yellow)
 2. The depth of anesthesia where surgery can be safely
performed?
 A. Excitement Stage
B. Climax Stage
C. Surgical Anesthesia Stage
D. Stable Surgery Stage
 3. The most dangerous stage in the induction of anesthesia?
 A. Recovery period
B. Excitement phase
C. Medullary paralysis
D. Analgesic phase
 4. Method of local anesthesia which involves injecting the
anesthetic directly into the tissues to be treated.
 A. Nerve block
B. Field block
 C. Topical
D. Infiltration
 5. Tooth extraction often use what method of local anesthesia?
 A. Field block
B. Peripheral nerve block
C. Infiltration
D. Central nerve block
 6. Methohexital was used as an anesthetic agent for a patient.
After the procedure, which is an appropriate nursing intervention
to facilitate comfort?
 A. Discuss with the doctor the need for a prescription of analgesic.
B. Keep the patient on side-lying position.
C. Perform range of motion exercises on extremities.
D. Reassure patient that everything will be fine now that surgery is done.
 7. Which non-barbiturate anesthetics is ideal for short
procedures?
 A. Droperidol
B. Ketamine
C. Propofol
D. Midazolam
 8. Which anesthetic agent is usually used for children
undergoing surgerybut at the same time have respiratory
dysfunction?
 A. Desflurane
B. Halothane
C. Ketamine
D. Isoflurane
 Answers and Rationale

 1. Answer: B. Nitrous oxide (blue).
 Nitrous oxide is usually used for dental surgery. It is also combined with
other agents for anesthetic use. Only one anesthetic gas, nitrous oxide
(blue cylinder), is still used.
 2. Answer: C. Surgical Anesthesia Stage.
 The depth of anesthesia is divided into four (4) phases: analgesic,
excitement, surgical anesthesia, and medullary paralysis phase. Phase 3
is where surgery can be safely performed because it is where patient has
muscle relaxation and the respiration is regular.
 3. Answer: B. Excitement Phase.
 Induction is a phase in the administration of anesthesia which
encompasses stage 1 (analgesic) to 3 (surgical anesthesia). It is in stage
2 (excitement phase) of the induction process that most complications
can occur because most systemic effects occur here.
 4. Answer: D. Infiltration.
 It involves injecting the anesthetic directly into the tissues to be treated.
It brings the anesthetic into contact with the nerve endings in the area
and prevents them from transmitting nerve impulses to the brain.
 5. Answer: A. Field block.
 It involves injecting the anesthetic all around the area that will be
affected by the surgery. Anesthesia comes in contact with all of the nerve
endings surrounding the area. It is often used for tooth extraction.
 6. Answer: A. Discuss with the doctor the need for a prescription
of analgesic.
 Methohexital do not have analgesic properties so patients would require
analgesic postoperative.
 7. Answer: C. Propofol.
 It is used for short procedures because it has a very rapid clearance and
produces much less of a hangover effect and allows for quick recovery.
 8. Answer: B. Halothane.
 It is widely used for children, especially those with respiratory dysfunction
because it tends to produce bronchial dilation. However, it is
contraindicated for those with increased intracranial pressure (ICP).

 . During surgery, there is an increased potential for arrhythmias

when catecholamines are given with:
 A. halothane (Fluothane)
B. digoxin (Lanoxin)
C. bupivacaine (Marcaine)
D. lidocaine (Xylocaine)

 2. General anesthetics potentiate the effects of which of the

following drugs?

 A. Depolarizing agents
B. Skeletal muscle relaxants
C. Volatile liquids
D. Inhalation anesthetics

 3. The most dangerous metabolic side effect of general anesthesia

that can occur during surgery is:

 A. Hyperglycemia
B. Hyperthermia
C. Hypoglycemia
D. Hypothermia

 4. Mr. Baltazar will be undergoing surgery with general

anesthesia. The client should be given which of the following
instructions preoperatively?

 A. Eat big breakfast

B. Expect to be incontinent of urine postoperatively
C. Double your medication doses
D. Expect nausea, vomiting, shivering, and pain postoperatively.

 5. Geneva is reviewing for her upcoming quiz in Pharmacology.

She should be aware that local and regional anesthesia act by:
 A. Inhibiting depolarization.
B. Increasing depolarization.
C. Producing a semiconscious state.
D. Inhibiting motor movement.

 6. Which of the following statements about shivering is correct?

 A. Shivering is a response controlled by the brainstem.

B. Shivering can occur in the absence of hypothermia.
C. Shivering is effectively treated with small doses of naloxone.
D. Shivering is an uncomfortable, though harmless, effect of anesthesia.

 7. Early signs and symptoms of local anesthetic toxicity include

ALL BUT ONE of the following. Indicate the exception:

 A. Tinnitus
B. Perioral numbness
C. Dizziness
D. Hypertension

 8. A preoperative patient receives atropine before induction of

anesthesia. The nurse caring for this patient understands that this
agent is used to prevent:

 A. anxiety.
B. bradycardia.
C. dry mouth.
D. hypertension.

 9. The nurse teaching a client who will

receive thiopental (Pentothal) as an anesthetic explains that what
common adverse effects might occur?
 A. Headache
B. Emergence delirium
C. Nausea and vomiting
D. Paralysis

 10. A client received lidocaine viscous before a gastroscopy was

performed. Following the procedure, the nurse places priority on
what assessment?

 A. Return of the gag reflex

B. Ability to urinate
C. Abdominal pain
D. Ability to stand

 11. The nurse observes a co-worker preparing to administer a

solution of lidocaine and epinephrine to a client with multiple
premature ventricular contractions. The appropriate action by the
nurse is to:

 A. Offer to monitor the client’s heart rhythm.

B. Notify the supervisor of the error.
C. Do nothing; the drug choice is correct.
D. Prevent the administration, and give a plain lidocaine solution.

 12. During induction of anesthesia, the nurse notes the client

becomes hyperactive and physically resists the treatment. The
nurse concludes what interventions are needed?

 A. Anesthesia must be discontinued.

B. An intravenous drug will be given to calm the client.
C. Anesthesia must be discontinued.
D. The surgery will need to be rescheduled.
 13. The nurse receives the client in the postanesthesia care unit
(PACU) following a procedure requiring general anesthesia. The
most important assessment made by the nurse relates to the
client’s:

 A. Level of consciousness.
B. Pain.
C. Vital signs.
D. Respiratory status.

 14. Nurse Gretchen is discussing the use of cocaine as a local

anesthetic with a nursing student. Which statement by the
student indicates understanding of this agent?

 A. “Anesthetic effects develop slowly and persist for several hours.”

B. “Cocaine is a local anesthetic administered by injection.”
C. “Vasoconstrictors should not be used as adjunct agents with this drug.”
D. “When abused, cocaine causes physical dependence.”

 15. The client asks the nurse to explain the action of infiltration
anesthesia. The nurse’s response is based on the knowledge that
infiltration anesthesia:

 A. Is applied only to mucous membranes to provide local anesthesia.

B. Blocks a specific group of nerves in tissues close to the operative area.
C. Blocks sensation to an entire limb, or a large area of the face.
D. Produces numbing to large, regional areas such as the lower abdomen
and legs.

 16. All narcotics, regardless of their origin, reduce pain by:

 A. Stimulating opiate receptors

B. Promoting the release of excitatory transmitters
 C. Releasing large quantities of endorphin
D. Blocking the mu receptors

 17. In addition to analgesia, narcotic effects include:

 A. Euphoria, diarrhea, increased respirations

B. Euphoria, miosis, nausea and vomiting
C. Respiratory depression, increased blood pressure
D. Dependence, seizures, muscle spasms

 18. The half-life of morphine is:

 A. 4 to 6 hours
B. 2 to 4 hours
C. 6 to 8 hours
D. 30 minutes to 1 hour

 19. Which of the following statements about morphine is correct?

 A. Morphine is contraindicated in pain relief caused by head injury.

B. Morphine‘s withdrawal symptoms cannot be relieved by methadone.
C. Morphine is most effective by parenteral administration.
D. Morphine quickly enters all body tissues.

 20. When administering codeine, the nurse should be aware that:

 A. Codeine produces more sedation than other opiates.

B. Codeine causes diarrhea, so the client must take an additional drug to
prevent this.
C. Codeine is very constipating.
D. Codeine is an antitussive in high doses.

 Answers and Rationale

 Here are the answers for this exam. Gauge your performance by counter
checking your answers to those below. If you have any disputes or
clarifications, please direct them to the comments section.

 1. Answer: A. halothane (Fluothane)

 Arrhythmias are a result of an interaction that can occur

with halothane and catecholamines. Other choices do not interact
with halothane to cause arrhythmias.

 2. Answer: B. Skeletal muscle relaxants

 The effects of skeletal muscle relaxants are potentiated with the use of
the general anesthetics. Depolarizing agents do not interact with general
anesthetics. C and D are general anesthetics.

 3. Answer: B. Hyperthermia

 Malignant hyperthermia is the most dangerous metabolic side effect of

general anesthesia.

 4. Answer: D. Expect nausea, vomiting, shivering, and pain

postoperatively.

 These responses should be expected, and the client should be prepared

for them. Food is contraindicated before surgery. Urinary retention,
not incontinence is likely. Medication is more likely to be held on the day
of surgery.

 5. Answer: A. Inhibiting depolarization.

 When local anesthesia is used, sensation is removed and the area
anesthetized by inhibition of depolarization. Choice B is incorrect because
the opposite is true. Choices C and D do not occur with local anesthesia.

 6. Answer: B. Shivering can occur in the absence of hypothermia.

 Shivering can also appear after surgery. This is known as postanesthetic

shivering.

 7. Answer: D. Hypertension

 Manifestations of local anesthetic toxicity typically appear 1-5 minutes

after the injection, but onset may range from 30 seconds to as long as 60
minutes. Initial manifestations may also vary widely. Classically, patients
experience symptoms of central nervous system (CNS) excitement such
as the following: Circumoral and/or tongue numbness, metallic taste,
lightheadedness, dizziness, visual and auditory disturbances (difficulty
focusing and tinnitus), disorientation and drowsiness.

 8. Answer: B. bradycardia.

 Atropine, an anticholinergic drug, is used as an adjunct to anesthesia to

counter the effects of vagal stimulation, which is caused by surgical
manipulations that trigger parasympathetic reflexes, resulting in
bradycardia. Atropine is not an anxiolytic. Atropine causes dry mouth and
sometimes is used to minimize bronchial secretions.

 9. Answer: B. Emergence delirium

 Emergence delirium could occur postoperatively, and is characterized by

hallucinations, confusion, and excitability.

 10. Answer: A. Return of the gag reflex

 Because the throat is anesthetized, monitor the client for return of
the gag reflexbefore drinking or eating.

 11. Answer: D. Prevent the administration, and give a

plain lidocainesolution.

 Solutions of lidocaine containing preservatives or epinephrine are

intended for local anesthesia only, and must never be given IV for
dysrhythmias.

 12. Answer: B. An intravenous drug will be given to calm the

client.

 Stage 2 is the stage of excitement and hyperactivity. Medications may be

given IV to calm the client.

 13. Answer: D. Respiratory status.

 General anesthesia causes relaxation of all muscles, including respiratory

muscles, requiring mechanical ventilation. The client’s respiratory status
must be monitored closely following general anesthesia.

 14. Answer: C. “Vasoconstrictors should not be used as adjunct

agents with this drug.”

 Cocaine should not be combined with epinephrine or other

vasoconstrictors, because it causes vasoconstriction itself, and the
combination could precipitate severe hypertension. Cocaine has a rapid
onset of effects, which last about 1 hour. It is used only topically for
anesthesia. Although subject to widespread abuse with profound
psychological dependence, it does not cause substantial physical
dependence.
 15. Answer: B. Blocks a specific group of nerves in tissues close to
the operative area.

 Infiltration anesthesia blocks a specific group of nerves close to the

operative area by diffusion of a drug into the tissues. It is used to
anesthetize small areas. Topical anesthetics are applied to mucous
membranes. Nerve blocks provide anesthesia to a large surface area.
Spinal anesthesia affects large, regional areas.

 16. Answer: A. Stimulating opiate receptors

 It is the stimulation of cerebral opiate receptors that reduces pain.

Excitatory transmitters are not released during administration
of morphine. Endorphin release is not associated with narcotic pain relief.
The mu receptors mediate analgesia and are not blocked during narcotic
administration.

 17. Answer: B. Euphoria, miosis, nausea and vomiting

 These are the effects that often occur with administration

of narcotics. Constipation(not diarrhea) and decreased respirations (not
increased) are noted during administration of narcotics.
Decreased blood pressure results from narcotic
administration. Narcotics do not cause the effects in choice D at all.

 18. Answer: B. 2 to 4 hours

 The half-life of morphine is 2 to 4 hours. Other choices are incorrect

because they are either longer or shorter than the true half-life
of morphine.

 19. Answer: D. Morphine quickly enters all body tissues.

 Morphine quickly enters all body tissues. Morphine is not contraindicated
for head-injured clients, and withdrawal symptoms can be relieved
by methadone. Morphine is equally effective by all routes when the proper
dose is prescribed.

 20. Answer: C. Codeine is very constipating

 Codeine is very constipating, so the client’s diet should include foods that
fight constipation, such as water, fruits, and vegetables.