Block, Neuraxial, Pain, PONV, and Delirium Cases
Key Takeaways
- Regional and neuraxial anesthesia cases require the nurse to know expected block effects, dangerous spread, local anesthetic toxicity, and procedure-specific monitoring.
- Pain treatment in PACU must balance analgesia with respiratory status, sedation, opioid tolerance, regional techniques, and non-opioid options.
- Postoperative nausea and vomiting risk is higher with volatile agents, opioids, certain surgeries, prior history, and motion sickness history.
- Emergence delirium and agitation require physiologic assessment before labeling the behavior as anxiety, noncompliance, or dementia.
- Remediation should group misses by technique-specific complications: peripheral block, neuraxial block, pain safety, PONV, or cognitive recovery.
Technique-specific thinking
A regional block is not just a pain plan. It changes assessment, safety, and complication surveillance. A dense leg block creates fall risk. An interscalene block may affect diaphragmatic movement. A neuraxial block can cause hypotension, urinary retention, high spinal symptoms, or delayed motor recovery. Local anesthetic exposure can lead to local anesthetic systemic toxicity, especially when neurologic symptoms and cardiovascular instability appear together.
When the stem mentions a block, ask three questions. What should be numb or weak? What should not be affected? What complication matches the timing? Expected numbness in the surgical limb is different from ringing in the ears, metallic taste, circumoral numbness, seizure activity, or sudden dysrhythmia after local anesthetic dosing.
Case pattern: comfort with safety limits
A patient with chronic opioid therapy arrives after shoulder repair with an interscalene catheter. Pain is 8/10, RR is 10/min, SpO2 is 93% on oxygen, and the patient is sleepy but arousable. The wrong answer is either to withhold all analgesia or to push repeated opioid doses without reassessment. CPAN reasoning supports a multimodal plan: verify catheter function and sensory distribution, use ordered non-opioid adjuncts, titrate opioids carefully, monitor ventilation, and consult anesthesia or acute pain service when pain remains severe.
PONV and delirium are assessment problems
Postoperative nausea and vomiting can delay recovery, increase aspiration risk, stress fresh wounds, and raise intraocular or intracranial pressure in vulnerable cases. Risk factors include prior PONV, motion sickness, volatile anesthesia, opioids, nonsmoking status, and some laparoscopic, gynecologic, ENT, and eye procedures. Treat with ordered antiemetics, hydration assessment, oxygenation, pain control, and trigger reduction.
Agitation after anesthesia may be pain, hypoxia, hypercarbia, bladder distention, hypoglycemia, stroke, medication effect, alcohol withdrawal, pediatric emergence, or delirium in an older adult. The nurse protects the patient, keeps lines and drains safe, reorients calmly, invites a familiar caregiver when appropriate, and escalates abnormal physiologic findings. Restraints or sedatives are not first-line when correctable causes have not been assessed.
Integrated cue table
| Cue | Concern | Priority action |
|---|---|---|
| Tinnitus, metallic taste, seizure | Local anesthetic systemic toxicity | Stop local anesthetic, call help, prepare emergency treatment |
| Numb hands, dyspnea, hypotension after spinal | High neuraxial block | Airway and circulation support, notify anesthesia |
| Severe pain plus RR 8 | Analgesia limited by ventilation | Support breathing, reassess sedation, use multimodal options |
| Repeated vomiting after eye surgery | Pressure and aspiration risk | Antiemetic, protect airway, notify if persistent |
| Pulling lines, new confusion | Delirium or physiologic problem | Safety, oxygenation, pain, glucose, bladder, neuro assessment |
Remediation grid
| Miss type | Review target | Practice task |
|---|---|---|
| Block complication missed | Anatomy and spread | Make one expected versus dangerous effect card per block |
| Gave opioid despite hypoventilation | Pain-safety balance | Pair every pain score with RR and sedation score |
| Treated PONV as minor | Complication awareness | Link vomiting risk to wound, airway, eye, and neuro cases |
| Restrained delirious patient first | Cognitive recovery | Drill physiologic causes before behavior labels |
| Ignored neuraxial level | Technique context | Review high spinal and hypotension cue clusters |
A patient with a continuous peripheral nerve block reports ringing in the ears, metallic taste, circumoral numbness, and then has a brief seizure. What is the priority nursing response?
A patient recovering from spinal anesthesia develops numbness in the hands, difficulty speaking, dyspnea, bradycardia, and hypotension. Which action is most appropriate?
An 82-year-old patient is pulling at the IV and trying to climb over the side rail after hip surgery. SpO2 is 88%, bladder scan shows 650 mL, and pain is 8/10. What is the best interpretation?