THE RESPIRATORY SYSTEM Serve as a resonating chamber in speech.

Composed of the air conducting system and Common site of infection.

the respiratory unit (lungs)
Paranasal sinuses
Major function is RESPIRATION
Named by location:
Commonly divided into UPPER
RESPIRATORY tract and LOWER Frontal
RESPIRATORY tract Ethmoidal
Ventilation and Respiration Sphenoidal
VENTILATION- movement of air from the Maxillary
atmosphere into the lungs and out of the The Pharynx
lungs
Musculo-membranous tube from behind the
EXTERNAL RESPIRATION- exchange of nasal cavity to the level of the cricoid
gases between the alveoli and the blood cartilage (C6)
INTERNAL RESPIRATION- exchange of The Pharynx
gases between the blood and the tissues
3 regions:
The Respiratory System
Nasal
Commonly divided into
is located posterior to the nose and above
UPPER RESPIRATORY tract and
the soft palate.
LOWER RESPIRATORY tract Oral
The UPPER Respiratory tract house the faucial, or palatine, tonsils.
The nose, pharynx and larynx Laryngeal
THE NOSE extend from the hyoid bone to the cricoids
Functions of the nose cartilage.

1. Hairs or vibrissae filter large particles Adenoids

2. Blood vessels warm the air also known as pharyngeal tonsils, the
adenoids and other lymphoid tissue encircle
3. Mucus serves to humidify the air. the throat.

Paranasal sinuses Epiglottis – form the entrance to the larynx.

includes four pairs of bony cavities that are The Larynx

lined with nasal mucosa and ciliated
pseudostratified columnar epithelium. Larynx
or voice box, is a cartilaginous epithelium- Bronchioles
lined structure that connects the pharynx
and the trachea. Primary bronchussecondary
bronchustertiary bronchus terminal
Vocalization bronchioles

protect the lower airway from foreign Respiratory bronchioles belong to the
substance and facilitates coughing. respiratory unit

The Larynx Respiratory unit

Epiglottis Respiratory bronchioles

a valve flap of cartilage that covers the Alveolar ducts

opening to the larynx during swallowing.
Alveolar sacs
Glottis
alveolus
the opening between the vocal cords in the
larynx. The Pleura

The LOWER respiratory tract Surrounds the lungs and provide protection

Composed of The trachea down to the 1. Parietal pleura- in the chest wall
Lungs 2. Visceral pleura- intimately attached to the
Lower airway: Trachea lungs

Called windpipe 3. Pleural space- in between the two

Made up of 15-20 C-shaped cartilage DIAPHRAGM

10-11 inches Respiratory Physiology

The Bronchial Tree Ventilation and gas exchange

RIGHT Bronchus Mechanics of breathing

Wider Gas transport

Shorter Pulmonary volumes

More vertical Respiratory control

Left bronchus Ventilation

Narrower Ventilation is the movement of air into the

lungs
Longer

More horizontal
Air (oxygen) moves by the process of Special landmarks:
diffusion from the higher concentration in
the alveoli to the pulmonary capillaries 2nd ICS for needle insertion for Tension
Pneumothorax
Mechanics of breathing
4th ICS for chest tube insertion
Gas transport
T4 for lower margin of ET on CXR
1. OXYGEN- majority is transported in the
blood loosely bound to hemoglobin- Posterior
oxyhemoglobin T7 – 8 ICS as landmark for thoracentesis.
2. CARBON DIOXIDE- majority is Techniques of Examination
transported in the blood in the RBC as
BICARBONATE Orderly fashion

Fig. 15.8 IPaPeA

Control of Respiration: Central With the patient SITTING

Respiratory center in the medulla Examine the posterior thorax & lungs

Controls the rate and depth of respiration Arms be folded across the chest, afterwhich

Increased CO2 is the most potent stimulus Ask the patient to lie down

Control of Respiration: Peripheral Techniques of Examination

1. Chemoreceptors in the carotid and aortic Orderly fashion

bodies
IPaPeA
Sensitive to changes in pH and O2
With the patient SUPINE
Decreased O2 increase respiration
Examine the anterior thorax & lungs
Decreased pH (acidosis) increase
respiration For patients who cannot sit up without aid

The Assessment Roll the patient to one side & then to the
other
HISTORY
Percuss & auscultate both lungs in each
Reason for seeking care position

Present illness INITIAL SURVEY OF RESPIRATION &

THE THORAX
Previous illness
Always inspect the patient for any signs of
Family history respiratory difficulty
Social history
Assess the patients color for cyanosis Count the number of breaths for a full
minute.
Listen to the patients breathing. Is there any
audible wheezing? Respiratory pattern

Inspect the neck. During inspiration, is there Even, coordinated & regular
contraction of the accessory muscles? Is
the trachea midline? With occasional sighs (long, deep breaths)

Also observe the shape of the chest. INSPECTION

ASSESSMENT Accessory muscle use

General appearance Observe the diaphragm & the intercostals

muscles with breathing.
State of awareness
Frequent use of accessory muscles?
LOC
Purses his lips & flares his nostrils when
Built & nutritional status breathing?

Signs of distress INSPECTION

Posture/Gait Skin, tongue, mouth, fingers & nail beds.

Motor activity Bluish tint to their Skin & MM are

considered CYANOTIC
ASSESSMENT
Long-term Hypoxia = CLUBBING of fingers
Examine the back of the chest first
INSPECTION: memory board
Observe the chest from the side.
CRAMP characteristics
The diameter of the thorax should be
greater side to side than from front to back. Chest wall assymetry

Respiratory assessment landmarks Respiratory rate & pattern (ABNORMAL)

Respiratory assessment landmarks Accessory muscle use

Posterior view Masses or Scars

INSPECTION Paradoxical movement

Inspect for chest wall symmetry. PALPATION

Note masses or scars that indicate trauma Chest wall should feel smooth, warm & dry.
or surgery
Gentle palpation shouldn‟t cause the patient
Respiratory rate pain.
Pain may be caused by costochondritis, rib Shifts the scapulae out of the way.
or vertebral fractures or sore muscles as a
result of protracted coughing. Lightly place your open palms on both sides
of the patients back, without touching his
Crepitus which feels like puffed-rice cereal back with your fingers.
crackling under the skin = air leakage from
lungs or airways Ask the patient to repeat the phrase
“NINETY-NINE”.
PALPATION
PERCUSSING THE CHEST
Palpate for tactile fremitus
CHEST PERCUSSION
Palpable vibrations caused by the
transmission of air through the Helps to establish whether the underlying
bronchopulmonary system. tissues are air-filled, fluid-filled or solid
material.
Then, evaluate chest wall symmetry &
expansion It penetrates only 5cm-7cm into the chest.

PALPATION PERCUSSION

Place your palm/palms lightly over the Key points for good technique:
thorax. Place your nondominant hand over the
Palpate for tenderness, alignment, bulging chest wall.
and retractions of the chest & intercostal
Hyperextend the middle finger of your left
spaces. hand, known as the pleximeter finger.
Assess the patient for crepitus, especially Press its distal interphalangeal joint firmly
around the drainage sites.
on the surface to be percussed.
PALPATION Avoid surface contact by any other part of
Use the pads of your fingers to palpate the the hand, because this dampens out
back & front of the thorax. vibrations.

Pass your fingers over the ribs & any scars, Note that the thumb & 2nd, 4th & 5th fingers
lumps, lesions or ulcerations. are not touching the chest.

Note the skin temperature, turgor & PERCUSSION

moisture. The middle finger should be partially flexed,
Also note tenderness or SQ crepitus relaxed and poised to strike.

The muscles should feel firm & smooth. With a quick, sharp but relaxed wrist motion,
strike the pleximeter finger with the right
Ask the patient to fold his arms across his middle finger or plexor finger.
chest.
Aim at your distal interphalangeal joint.
You are trying to transmit vibrations through Is the most important examination
the bones of this joint to the underlying technique for assessing air flow through the
chest wall. tracheobronchial tree.

PERCUSSION Involves

Strike using the tip of the plexor finger, not Listening to the sounds generated by
the finger pad. breathing

A short fingernail is recommended to avoid Listening for any adventitious (added)

self-injury. sounds

Withdraw your striking finger quickly to If abnormalities are suspected, listening to

avoid damping the vibrations you have the sounds of the patients spoken or
created. whispered voice as they are transmitted
through the chest wall
EXAMINATION OF THE ANTERIOR
CHEST EXAMINATION OF THE ANTERIOR
CHEST
PERCUSSION

In a woman, gently displace the breast with

your left hand while percussing with the Characteristics of Breath Sounds
right
The Assessment
PNM typically occurs behind the right breast
LABORATORY EXAMINATION
Percussion notes & their characteristics
1. ABG analysis

2. Sputum analysis
PERCUSSION
3. Direct visualization - bronchoscopy
Diaphragmatic excursion
4. Indirect visualization - CXR, CT and MRI
The distance the diaphragm moves
between inhalation & exhalation 5. Pulmonary function test

The diaphragm doesn‟t move as far in ABG Analysis

obese patients or patients with respiratory
Pre-test: choose site carefully, perform the
disorders. Allen‟s test, secure equipments- syringe,
EXAMINATION OF THE POSTERIOR needle, container with ice
CHEST
Intra-test: Obtain a 5 mL specimen from the
AUSCULTATION artery (brachial, femoral and radial)

Post-test: Apply firm pressure for 5 minutes,

label specimen correctly, place in the
container with ice
ABG Analysis Expiratory reserve volume(800-1200)

ABG normal values Residual volume (1000-1200)

PaO2 80-100 mmHg Pulse Oximetry

PaCO2 35-45 mmHg Non-invasive method of continuously

monitoring the oxygen saturation of
pH 7.35- 7.45 hemoglobin
HCO3 22- 26 mEq/L A sensor or probe is attached to the
O2 Sat 95-99% earlobe, forehead, fingertip or the bridge of
the nose
Sputum Analysis
Thoracentesis
This test analyzes the sample of sputum to
Pleural fluid aspiration for obtaining a
diagnose respiratory diseases, identify
organism, and identify abnormal cells specimen of pleural fluid for analysis, relief
of lung compression and biopsy specimen
Bronchoscopy collection

A direct inspection of the trachea and Respiratory treatments

bronchi through a flexible fiber-optic or a
rigid bronchoscope  CHEST PHYSIOTHERAPY (CPT)

Done to determine location of pathologic  POSTURAL DRAINAGE

lesions, to remove foreign objects, to collect  OXYGEN (O2) ADMINISTRATION
tissue specimen and remove
secretions/aspirated materials Artificial airway

Pulmonary Function Tests Tracheostomy

Volume and capacity tests aid diagnosis in Endotracheal tube

patient with suspected pulmonary
dysfunction

Evaluates ventilatory function

Determines whether obstructive or

restrictive disease

Pulmonary Function Test

Lung Volumes

Tidal volume

Inspiratory reserve volume (2100-3000ml)

Medical and Surgical Nursing Bluish discoloration of the skin

Respiratory disorders A LATE indicator of hypoxia

Common Respiratory Problems Central cyanosis

and the common interventions Peripheral cyanosis

Dyspnea Cyanosis

Breathing difficulty Interventions:

Associated with many conditions- CHF, Check for airway patency

MG, GBS, obstruction, etc…
Oxygen therapy
Dyspnea
Positioning
General nursing interventions:
Suctioning
Fowler’s position
Chest physiotherapy
An alternative position is the
ORTHOPNEIC position Check for gas poisoning

O2 usually via nasal cannula Measures to increased hemoglobin

Cough and sputum production Hemoptysis

Cough is a protective reflex Expectoration of blood from the respiratory

tract
Sputum production has many stimuli
Common causes: Pulmo infection, Lung CA,
Thick, yellow, green or rust-colored Pulmo emboli
bacterial pneumonia
Hemoptysis
Profuse, Pink, frothy pulmonary edema
Interventions:
Scant, pink-tinged, mucoid Lung tumor
Keep patent airway
Cough and sputum production
Determine the cause
General nursing Intervention
Suction and oxygen therapy
1. Provide adequate hydration
Administer Fibrin stabilizers like
2. Administer aerosolized solutions aminocaproic acid and tranexamic acid

3. Advise smoking cessation Upper Airway Infections

4. Oral hygiene Rhinitis

Cyanosis
Inflammation & irritation of the mucous Instructs to avoid or reduce exposure to
membranes of the nose allergens & irritants such as

Acute or Chronic Dusts

Non allergic or allergic Molds

Non allergic Rhinitis Animals

Environmental factors Fumes

Changes in temperature or humidity odors,

Odors, foods, infection Powders

OTC Sprays

Presence of foreign bodies Tobacco smoke

PathoPhysiology of Rhinitis Nursing Management

Lining of nasal passages becomes Patient education regarding the use of OTC
inflamed, congested & edematous medications

Swollen nasal conchae block the sinus Saline nasal spray

opening, thus the mucus is discharged from
the nostrils To achieve maximal relief

Sinusitis Instruct Px to blow the nose before applying

any medication into the nasal cavity
Inflammation & congestion with thickened
mucous secretions filling the sinus cavities Keep the head upright
& occluding the openings Spray quickly & firmly into each nostril
S&Sx of Rhinitis Wait at least 1 minute before administering
Rhinorrhea the second spray

Exessive nasal drainage or runny nose Medical Management

Nasal congestion Antihistamines

Nasal discharge Decongestants

Sneezing Low dose steroid therapy/intranasal

corticosteroids
Pruritus of the nose, roof of mouth, throat
Antibiotics if necessary
Headache if with sinusitis
Acute/Chronic Sinusitis
Nursing Management
Inflammation of the sinuses Most commonly caused by Viruses

Sinuses Adenovirus

Mucus lined cavities filled with air, normally Influenza virus

drain into the nose & are involved in many
URIs Epstein – Barr virus

Nasal congestion caused by inflammation, Herpes simplex virus

edema & transudation of fluid leads to Bacterial causes
obstruction of the sinus cavities
Group A Beta Hemolytic strep, H. influenzae
Sinusitis & Mycoplasma
Most common organisms Acute pharyngitis
S. Pneumonia
S&Sx
H. Influenzae Fiery – red pharyngeal membrane & tonsils
Moraxella catarrhalis Enlarged & tender cervical lymph nodes
S&Sx Fever, malaise & sore throat
Facial pain, nasal obstruction, purulent
Nursing Management
nasal discharge, fever, decreased sense of
smell, sore throat & cough Promote bed rest

Nursing Management Proper disposal of used tissues

Steam inhalation Warm saline gargle

Warm compress Ice collar

Stop smoking Educate about the full course of ATBs

Importance of antibiotic compliance Teach possible Cx: nephritis & RF

Co-amoxiclav Medical Management

Clarithromycin Penicillins

Cefuroxime TOC

Levofloxacin If caused by S.aureus (resistant to

Penicillins)
Acute pharyngitis
Cephalosporines
Sudden inflammation of the pharynx
Macrolides
Primary symptom is a sore throat
Clarithromycin or Azithromycin Laryngitis

Tonsilitis Inflammation of the larynx

Inflammation of palatine & lingual tonsils Caused commonly by viruses

(lymphatic tissue on each side of
oropharynx) Maybe caused also by some bacteria

Group A Beta Hemolytic strep S&Sx

Most common organism Hoarseness of voice

Tonsilitis Dry cough

S&Sx Sore throat

Sore throat Nursing Management

Fever Rest the voice

Odynophagia Maintain well-humidified environment

Foul smelling breath Increase OFI 2-3LPD

Voice impairment Importance of full course of ATB therapy

May cause otitis media Stop smoking

Nursing management Medical Management

Increased OFI Medications

Salt water gargles Antihistamines

Provide bedrest Low dose steroid therapy

Monitor VS Antibiotics

Medical Management Epistaxis (Nosebleed)

Antibiotic therapy Hemorrhage from the nose

Tonsillectomy Rupture of tiny, distended vessels in the

mucous membrane of the nose
If with repeated episodes of tonsilitis
Epistaxis
Hypertrophied tonsils that cause
obstructions Nursing management

Repeated attacks of otitis media Sit upright with head in neutral position

RF Monitor VS
Assists in the control of bleeding occur 2 days or less

Provide tissues & emesis basin normal incentive spirometry result

Assess airway & breathing Mild

Avoid forceful nose blowing & straining occur 2 days or more

Apply direct pressure for 15 minutes normal incentive spirometry result

Epistaxis Affects ADLs, use inhaler twice a week.

Medical management Moderate

Cotton pledgets soaked in a awaken up with cough, takes more than a

vasoconstricting solution (epinephrine or week, ADL is affected, lung function test is
ephedrine) abnormal

If uncontrolled bleeding Severe

Balloon-inflated catheter maybe used occur throughout each day

Antibiotic therapy ADL is limited

Antihypertensive medications Awaken up every night

ASTHMA Related factors

- is a chronic inflammatory disorder of Extrinsic

the airways
Animal dander
- Characteristics
Food additives
- recurrent episodes of
wheezing Dust or mold

- Breathlessness Feather pillows

- chest tightness exposure to noxious fumes

- Coughing Pollen

- reversible, either spontaneously or Intrinsic

with treatment anxiety
- most common chronic disease of coughing or laughing
childhood and can occur at any age
emotional stress
Classifications
genetic factors
Intermittent
ASSESSMENT MEDICAL MANAGEMENT

 Corticosteroids
A complete family, environmental, and
occupational history is essential  most potent and effective
anti-inflammatory medication
Physical examination Inhalation corticosteroids –
rinse mouth after
Measurements of lung function administration to prevent
thrush
Measurement of allergic status to identify
risk factors  Long – acting beta adrenergic
Inspection: cough, shortness of breath, agonist (LABA)
dyspnea, central cyanosis  used with anti-inflammatory
Palpation: decrease symmetrically chest medications to control
wall expansion asthma symptoms,
particularly those that occur
Percussion: reduced breath sound during the night

DIAGNOSTIC FINDINGS  Leukotriene modifiers or

antileukotrienes
Blood test: elevated levels of eosinophils,
immunoglobulin E may be elevated if allergy  A vasoconstrictors e.g.
is present montelukast, zafirlukast

ABG and pulse oximetry reveal hypoxemia.  It handles inflammation to

Respiratory alkalosis (low PaCO2) make bronchi relax.

Pulmonary function – is usually normal  Bronchodilator

between exacerbations
 Beta 2 agonist (e.g.albuterol)
Chest X-ray: helpful in excluding a
pneumothorax or pneumonia  relieve bronchospasm

Nursing diagnosis  reduce airway

obstruction
Ineffective breathing pattern related to
swelling of bronchial tubes  by allowing
increase
Ineffective airway clearance related to oxygen
bronchoconstriction, excessive mucus distribution
production throughout the
lungs
Anxiety related to hypoxia
Medical Management
Deficient knowledge related to disease
condition  Anticholinergics (e.g. ipratropium)
  decrease mucus secretion Patients are instructed to avoid causative
agents whenever possible.
 Methylxanthines (e.g. theophylline)
Knowledge about the disease conditions
 sympathomimetic response and how to take care self.
 Increases HR Complications
 Oxygen therapy Status asthmaticus - is severe and
 Antibiotic therapy persistent asthma that does not respond to
conventional therapy, the attacks can occur
 given with evidence of with little or no warning and can progress
infection rapidly to asphyxiation.

 Intravenous fluid for hydration Respiratory failure

Nursing Management Atelectasis

1. Instruct the patient to avoid allergens and Pneumonia

environmental factors
Dehydration
2. Assess the airway and patient‟s response
to treatment, cardiopulmonary status, O2 Emphysema
sat, Blood pressure and cardiac rhythm Cigarette smoking
3. Place the patient in high fowlers position Heredity, Bronchial asthma
4. Encourage purse lip and diaphragmatic Aging process
breathing, help him to relax

5. Administer medications as prescribed

6. Administer fluids if the patient is Disequilibrium between

dehydrated as prescribed
ELASTASE & ANTIELASTASE (alpha-1-
7. Administer oxygen as order antitrypsin)
8. Assist for intubation – if the patient fail to
maintain adequate oxygenation
Destruction of distal airways and alveoli
9. Monitor the patient for the first 12 to 24
hours, or until status asthmaticus is under Overdistention of ALVEOLI
control.
Hyper-inflated and pale lungs
Prevention

Patient with recurrent asthma should Air traping, decreased gas exchange and
undergo test to identify the substances that Retention of CO2
precipitate the symptoms.
 The client has difficulty exhaling carbon
dioxide.

Hypoxia Respiratory COPD Management

acidosis
Independent and Collaborative
Chronic bronchitis Management

Chronic inflammation of the bronchial air 5. O2 therapy 1 to 3 lpm (2 lpm is safest)

passageway characterized by the
presence of cough and sputum Do not give high concentration of
production for at least 3 months in each oxygen. The drive for breathing may be
2 consecutive years. depressed.

Excessive production of mucus in the COPD Management

bronchi with accompanying persistent Independent and Collaborative
cough. Management
COPD Management 6. Avoid cigarette smoking, alcohol, and
Independent and Collaborative environmental pollutants-These inhibit
Management mucociliary function.

1. Rest-To reduce oxygen demands of 7. CPT –percussion, vibration, postural

tissues drainage

2. Increase fluid intake-To liquefy mucus COPD Management

secretions Pharmacotherapy
3. Good oral care-To remove sputum and 1. Expectorants (guaiafenessin)/
prevent infection mucolytic (mucomyst/mucosolvan)
COPD Management 2. Antitussives
Independent and Collaborative Dextrometorphan
Management
Codeine
4. Diet:
Observe for drowsiness
High caloric diet provides source of
energy Avoid activities that involve mental
alertness, e.g driving, operating
High protein diet helps maintain integrity electrical machines
of alveolar walls
Cause decrease peristalsis thereby
Moderate fats constipation
Low carbohydrate diet limits carbon
COPD Management
dioxide production (natural end product).
Pharmacotherapy Types

3. Bronchodilators b. Open pneumothorax

Aminophylline (Theophylline) occurs when air accumulates between

the chest wall and the lung as the result of
Ventolin (Salbutamol) an open chest wound or other physical
Bricanyl (Terbutaline) defect.

Alupent (Metaproterenol) The larger the opening, the greater the

degree of lung collapse and difficulty of
Observe for tachycardia breathing

COPD Management Pneumothorax

Pharmacotherapy Types

4. Antihistamine c. Tension pneumothorax: air enters the

pleural space with each inspiration but
Benadryl (Diphenhydramine) cannot escape; causes increased
intrathoracic pressure and shifting of the
Observe for drowsiness
mediastinal contents to the unaffected
5. Steroids side (mediastinal shift).

Anti-inflammatory effect Pneumothorax

6. Antimicrobials Assessment findings

Pneumothorax 1. Sudden sharp pain in the chest,

dyspnea, diminished or absent breath
Partial or complete collapse of the lung sounds on affected side, tracheal shift to
due to an accumulation of air or fluid in the opposite side (tension pneumothorax
the pleural space accompanied by mediastinal shift)
Pneumothorax 2. Weak, rapid pulse; anxiety;
diaphoresis
Types
Pneumothorax
a. Spontaneous pneumothorax
Assessment findings
sudden onset of a collapsed lung
without any apparent cause, such as a 3. Diagnostic tests
traumatic injury to the chest or a known lung
disease. a. Chest x-ray reveals area and degree of
pneumothorax
A collapsed lung is caused by the collection
of air in the space around the lungs b. pCO2 elevated

Pneumothorax c. pH decreased
Pneumothorax nonbacterial infections, or iatrogenic
causes
Nursing interventions
Pathophysiology
1. Provide nursing care for the client with
an endotracheal tube. At first the pleural fluid is thin, with a low
leukocyte count
Pneumothorax
it frequently progresses to a fibropurulent
Nursing interventions stage
2. Restore/promote adequate respiratory finally, to a stage where it encloses the lung
function. within a thick exudative membrane
a. Assist with thoracentesis and provide (loculated empyema)
appropriate nursing care. Clinical Manifestations
b. Assist with insertion of a chest tube to S/S similar to those of an acute respiratory
water- seal drainage and provide infection or pneumonia (fever, night sweats,
appropriate nursing care. pleural pain, cough, dyspnea, anorexia,
Pneumothorax weight loss).

Nursing interventions Assessment and Diagnostic Findings

3. Provide relief/control of pain. decreased or absent breath sounds

over the affected area
a. Administer
narcotics/analgesics/sedatives as dullness on chest percussion
ordered and monitor effects. thoracentesis
b. Position client in high-Fowler’s fluid is drained and appropriate antibiotics,
position. in large doses, are prescribed based on the
EMPYEMA causative organism.

An empyema is an accumulation of thick, Sterilization of the empyema cavity requires

purulent fluid within the pleural space 4 to 6 weeks of antibiotics.

with fibrin development and a loculated Drainage of the pleural fluid depends on the
(walled-off) area where infection is located stage of the disease

- complications of bacterial - Needle aspiration (thoracentesis)

pneumonia or lung abscess - Tube thoracotomy

- Other causes include penetrating Nursing Management

chest trauma, hematogenous instructs in lung-expanding breathing
infection of the pleural space, exercises to restore normal respiratory
function.
provide care specific to the method of endobronchial disease (bronchogenic
drainage of the pleural fluid (eg, needle carcinoma, inflammatory structures)
aspiration, closed chest drainage, or rib
resection and drainage). Pathophysiology

instructs the patient and family on care of Obstruction of the bronchus impedes
the drainage system and drain site, passage of air to and from the alveoli that
measurement and observation of drainage. normally receives air through the bronchus.

instruct signs and symptoms of infection, Trapped alveolar air becomes absorbed into
and how and when to contact the health the bloodstream but outside air cannot
care provider. replace the absorbed air because of
obstruction

Nursing interventions Isolated portion of the lungs become airless

and shrinks in size causing remainder of the
Monitor respiratory status lung to over expand.

Identify the cause of ards Atelectasis

Administer oxygen therapy as prescribed Assessment findings

Position client in high fowler‟s position 1. Signs and symptoms may be absent
depending upon degree of collapse and
Restrict fluid intake as prescribed rapidity with which bronchial obstruction
occurs
Provide respiratory treatment as prescribed
2. Dyspnea, decreased breath sounds on
Administer diuretics, anticoagulants,
affected side, decreased respiratory
corticosteroids as prescribes
excursion, dullness to flatness upon
Promote calmness percussion over affected area

Atelectasis Atelectasis

Collapse of part or all of a lung due to Assessment findings

bronchial obstruction
3. Cyanosis, tachycardia, tachypnea,
May be caused by elevated temperature, weakness, pain
over affected area
intrabronchial obstruction
Atelectasis
tumors, bronchospasm
Assessment findings
foreign bodies
4. Diagnostic tests
extrabronchial compression (tumors,
enlarged lymph nodes); or a. Bronchoscopy: may or may not reveal
an obstruction
b. Chest x-ray shows diminished size of Exudative effusion: accumulation of
affected lung and lack of radiance over protein rich fluid
atelectatic area
Pleural Effusion
c. pO2 decreased
Assessment findings
treatment
1. Dyspnea, dullness over affected area
Vigorous coughing and CPT – to remove upon percussion, absent or decreased
obstruction breath sounds over affected area, pleural
pain, dry cough, pleural friction rub
Antibiotic therapy
2. Pallor, fatigue, fever, and night sweats
Bronchoscopy (with empyema)
PEEP and IPPB to improve lung volume Pleural Effusion
expansion
Assessment findings
Client education
3. Diagnostic tests
Prevent Aspiration
a. Chest x-ray positive if greater than 250
Encourage patient to cough and do deep cc pleural fluid
breathing
b. Pleural biopsy may reveal
Turn patient frequently to stimulate bronchogenic carcinoma
coughing
c. Thoracentesis may contain blood if
Early ambulation to mobilize and clear cause is cancer, pulmonary infarction, or
secretions tuberculosis; positive for specific
Administer medication, antibiotic, organism in empyema.
nebulization, chest physiotherapy Pleural Effusion
Pleural Effusion Nursing interventions: In general:
Defined broadly as a collection of fluid in 1. Assist with repeated thoracentesis.
the pleural space
2. Administer narcotics/sedatives as
A symptom, not a disease; may be ordered to decrease pain.
produced by numerous conditions
3. Assist with instillation of medication
Pleural Effusion into pleural space (reposition client
General Classification every 15 minutes to distribute the drug
within the pleurae).
Transudative effusion: accumulation of
protein-poor, cell-poor fluid 4. Place client in high-Fowler’s position
to promote ventilation.
Pleural Effusion RELATED FACTORS

Medical management Elderly

1. Identification and treatment of the Infants

Underlying cause
Substances abusers
2. Thoracentesis
Cigarette smokers
3. Drug therapy
Postoperative clients or those on prolonged
a. Antibiotics: either systemic or inserted bed rest
directly into pleural space
Client with chronic illnesses such as COPD
b. Fibrinolytic enzymes: trypsin,
streptokinase-. streptodornase to Clients with AIDS
decrease thickness of pus and dissolve
Other immunosuppressed clients
fibrin clots
Malnutrition
4. Closed chest drainage
Classifications
5. Surgery: open drainage
Community acquired pneumonia (CAP)
PNEUMONIA
community setting or
 inflammation of the lung
parenchyma within the first 48 hours after hospitalization

 caused by Hospital acquired pneumonia (HAP)

 Bacteria also known as nosocomial pneumonia

 Mycobacteria onset of pneumonia symptoms more than

48 hours after admission in patients with no
 Chlamydia evidence of infection at the time of
 Mycoplasma admission

 Fungi Ventilator Associated Pneumonia (VAP)

 Parasites individual connected to ventilator

 Viruses microbes can move from the endotracheal

tube directly unto the lung
 Mode of Transmission
Classifications
 air-borne
Aspiration Pneumonia
 droplets
gastric secretion, food fluid, tube feedings
into airways
Lobar Pneumonia antibodies, macrophages) loses
effectiveness
complete consolidation of whole lobe of the
lung  allow organism to penetrate
the sterile lower respiratory
Broncho Pneumonia tract where inflammation
infection can be throughout the lung develops
involving the bronchioles as well as the  There are several ways that
alveoli microorganism gain access
COMPLICATIONS but the most common is
aspiration from the
Pleural involvement with empyema and oropharynx.
pleuritis, pleural effusion, atelectasis
 Disruption of the mechanical
Lung abscess and bacteremia. defense of cough and ciliary motility
leads to colonization of microbes in
Heart failure, cardiac dysrhythmias, the alveoli or bronchi causing
pericarditis subsequent infections.
Shock and Respiratory failure  The inflammation causes the alveoli
to filled with fluid making it difficult
Pneumonia
for O2 and CO2 to exchange due to
PATHOPHYSIOLOGIC FINDINGS ARE: obstruction and lung tissues
becomes consolidated resulting to
HYPERTROPHY OF MUCOUS hypoxemia.
MEMBRANE
Pneumonia
Increased sputum production
PATHOPHYSIOLOGIC FINDINGS ARE:
Wheezing
INCREASED CAPILLARY PERMEABILITY
Dyspnea
Increased Fluid Exudation
Cough
Consolidation-tissue that solidifies as a
Rales result of collapsed alveoli
Ronchi Hypoxemia
Pathophysiology Pneumonia
Pneumonia is a an infection of the lung PATHOPHYSIOLOGIC FINDINGS ARE:
caused by microbes (bacteria, virus, fungi ).
INFLAMMATION OF THE PLEURA
 Defense mechanism of the lungs
(cilia, pseudostratified columnar Chest pain
epithelial tissues, cough reflex, Ig
Pleural effusion
Dullness Pneumonia

Decreased Breath sounds Diagnostic tests

Increased tactile fremitus Chest x-ray

Pneumonia confirm the diagnosis which will show

infiltrates
PATHOPHYSIOLOGIC FINDINGS ARE:
WBC increased
HYPOVENTILATION
PaO2 decreased
Decreased Chest expansion
Sputum examination
Respiratory acidosis
Blood culture
Depressed PROTECTIVE MECHANISM
NURSING DIAGNOSIS
Increased WBC (leukocytosis)
Ineffective airway clearance related to
Increased RR and Fever copious tracheobronchial secretions
Pneumonia Activity intolerance related to impaired
Assessment findings respiratory function

Cough with greenish to rust-colored Risk for fluid volume deficit related to fever
sputum production and rapid respiratory rate

rapid, shallow respirations with an Deficient knowledge about the treatment

expiratory grunt regimen and preventive health measures

PLANNING
nasal flaring; intercostal rib retraction;
use of accessory muscles of respiration Maintain patent airway and adequate
rales or crackles (early) progressing to oxygenation
coarse (later). Rest to conserve energy
Tactile fremitus is INCREASED! Maintenance of proper fluid volume
Pneumonia Maintenance of adequate nutrition
Assessment findings EVALUATION
Fever, chills, chest pain, weakness, Demonstrate improved airway patency, as
generalized malaise evidenced by adequate oxygenation by
Tachycardia, cyanosis pulse oximetry or arterial blood gas analysis

Rapid shallow breathing Rests and conserves energy by limiting

activities and remaining in bed.
Maintain hydration by adequate fluid intake 4. Provide adequate rest and
and urine output and normal skin turgor relief/control of pain.

Pneumonia a. Provide bed rest with limited physical

activity.
1. Facilitate adequate ventilation.
b. Limit visits and minimize
a. Administer oxygen as needed. conversations.
b. Place client in Fowler’s position. c. Maintain pleasant and restful
c. Turn and reposition frequently. environment

d. Administer analgesics as ordered. Pneumonia

e. Auscultate breath sounds every 2—4 GENERAL Nursing interventions

hours. 5. Administer antibiotics as ordered.
f. Monitor ABGs. 6. Prevent transmission
Pneumonia 7. Control fever and chills: monitor
GENERAL Nursing interventions temperature and administer

2. Facilitate removal of secretions antipyretics as ordered, maintain

increased fluid intake, provide frequent
general hydration clothing and linen changes.

deep breathing and coughing Pneumonia

Suctioning GENERAL Nursing interventions

Expectorants 8. Provide client teaching and discharge

planning concerning prevention of
aerosol treatments via nebulizer, recurrence.
humidification of inhaled air
a. Medication regimen/antibiotic therapy
chest physical therapy
b. Need for adequate rest,
Pneumonia
c. Need to continue deep breathing and
GENERAL Nursing interventions coughing
3. Observe color, characteristics of Pneumonia
sputum and report any changes;
encourage client to perform good oral GENERAL Nursing interventions
hygiene after expectoration.
8. Provide client teaching and discharge
Pneumonia planning concerning prevention of
recurrence.
GENERAL Nursing interventions
d. Availability of vaccines Restlessness (cardinal initial sign)

e. Techniques that prevent transmission Dyspnea

(use of tissues when coughing, adequate
disposal of secretions) Stabbing chest pain

f. Avoidance of persons with known Cyanosis

respiratory infections Tachycardia
g. Need to report signs and symptoms of Dilated pupils
respiratory infection
Apprehension/ fear
Medical Management
Diaphoresis
Oxygen as needed
Dysrhythmias
Antihistamines
Hypoxia
Mucolytic
Pulmonary Embolism
Expectorant
Diagnostic Tests:
PAI with Salbutamol or Ipratropium +
salbutamol Ventilation-perfusion scan

Steroid therapy if needed Pulmonary arteriography

Antibiotics/antiviral/antifungal CXR

Endotracheal intubation ECG

Pulmonary Embolism ABG

Causes Pulmonary Embolism

Fat embolism. Air embolism Nursing Interventions

Multiple trauma Oxygen therapy STAT

PVD’s Early ambulation postop

Abdominal surgery Do not massage legs

Immobility Relieve pain- analgesics

Hypercoagulability HOB elevated

Pulmonary Embolism Heparin (2 weeks) then Coumadin (3-6

months)
Assessment
PULMONARY TUBERCULOSIS
  an infectious disease that primarily 3. Granulomas are formed which are
affects the lung parenchyma clumps of live and dead bacilli
surrounded by macrophages forming
 caused by Mycobacterium a protective wall.
tuberculosis
4. Granulomas are transformed to a
 an acid fast aerobic rod that fibrous tissue mass. The central
grows slowly and is sensitive portion of the fibrous mass is called
to heat and ultraviolet light Ghon‟s tubercle.
 It may spread to any part of 5. The material becomes necrotic,
the body including meninges, forming a cheesy mass, may
kidney, bones and lymph become calcified, forming a
nodes. collagenous scar.
Mode of Transmission 6. The bacteria become dormant with
Droplet nuclei no further progression of active
disease.
Coughing
ASSESSMENT
Sneezing
Easy fatigability
Laughing
Anorexia, nausea and weight loss
singing
Low grade afternoon fevers
Exposure to TB
Night sweats
RISK FACTORS
Chronic cough
Close contact with someone who has active
TB. Dyspnea

Immune compromise status Hemoptysis

Drug abuse and alcoholism Swollen cervical glands

Immigrants from countries with higher

incidence of TB DIAGNOSTIC FINDINGS

Living in substandard conditions

Chest x ray
pathophysiology
show nodular lesions, infiltrates, cavity
1. The susceptible person inhales M. formation, scar tissue
bacilli and becomes infected.
Sputum culture
2. Body‟s immune system responds by
initiating an inflammatory reaction. show aerobic acid – fast bacilli
Quantiferon Gold Test No alcohol: s/s of liver issues like
jaundice
measures interferon-gamma by white blood
cells after incubating the blood with specific
antigens from M. Tuberculosis proteins, 24
hours‟ results will be release. I – isoniazide (INH)

Tuberculin or Purified protein derivative kills bacteria and stops its growth
(PPD) skin test – positive Decreases vitamin B6 levels
Assess for induration need to take supplement
MEDICAL MANAGEMENT
Watch for perineuropathy
Pulmonary TB is treated primarily with anti- tingling sensation of
tuberculosis agents for 6 to 12 months to extremities, tiredness
prevent relapse
Monitor liver function , neurotoxicity
Medications – acronym “PERI” or “RIPE”
Streptomycin
1. P – Pyrazinamide
stops protein synthesis & kills
. Watch the patient with DM, kidney bacteria
problems, gout- increase uric acid
Monitor hearing & watch for reports
.Monitor uric acid level of ringing in the ears
E – Ethambutol
Ototoxitiy
prevent bacteria from reproducing ASSESSMENT
Inflame optic nerve– advise regular Obtain history of exposure to TB
eye check up
Assess for symptoms of active disease
Peripheral neuropathy – damage to
nerves numbness in extremities Auscultate lungs for crackles

R – Rifampicin (rifampin) During drug therapy assess for liver function

stops RNA –polymerase (kills NURSING DIAGNOSIS

bacteria)

body fluids turns „‟örange” Ineffective breathing pattern related to

pulmonary infection and potential for long
it will stain contact lenses term scarring with decreased lung capacity.
wear hard lenses Imbalanced nutrition less than body
Sunburn easily requirement related to poor appetite, fatigue
and productive cough
Risk for spreading infection elated to nature Serious reactions to drug therapy
of disease and patient‟s symptoms (hepatotoxicity; hypersensitivity)

Non-compliance related to lack of PREVENTION

motivation and lack of treatment
Isolation
NURSING INTERVENTIONS
Ventilate the room

Encourage rest and avoidance of exertion Cover the mouth

Monitor breath sounds respiratory rates, Wear mask

sputum production and dyspnea Finish entire course of medication
Monitor vital signs and observe for Vaccinations – BCG for infant and children
temperature changes
EVALUATION
Encourage increased fluid intake
Maintains patent airway by managing
Instruct about best position to facilitate secretions with hydration, humidification and
drainage coughing.
Explain importance of eating nutritious diet Demonstrate an adequate level of
to promote healing and defense against knowledge by taking medications in a
infection correct time schedule and their side effects.
Monitor weight of the patient Adheres to treatment regimen by taking
Be aware that TB is transmitted by medications as prescribed and reporting
respiratory droplets follow-up screening.

Promote hand hygiene, wear mask and Participates in preventive measures,

proper disposal of tissue. disposes of used tissues properly.

COMPLICATIONS Exhibits no complications.

Bones. Spinal pain and joint destruction bronchiectasis

may result from TB that infects your bones Bronchi – airway
(TB spine)
Stasis – pooling or collection of secretion
Brain (meningitis)
Abnormal and permanent dilation of one or
Liver or kidneys more bronchi resulted to inflammation.
Heart (cardiac tamponade) Chronic or recurrent infection and pooling of
Pleural effusion secretions in dilated airways.

TB pneumonia Etiology
  both congenital and acquired Thick sputum that obstruct the bronchi
causes
The bronchi wall become permanently
causes dilated and distorted

Acquired Clinical manifestation

Tuberculosis Large Purulent and foul smelling sputum

production From 10-150 ml.
Pneumonia
Chronic cough with green/yellow sputum
Inhaled foreign bodies 8oz daily
Allergic bronchopulmonary aspergillosis Hemoptysis – mild to massive due to dilated
(fungi) and bronchiole tumors are the major bronchi arteries
acquired causes of bronchiectasis.
Frequent bronchial infection and
Infective causes are: staphylococcus, breathlessness are common indicators
Bordetella pertussis, the causative agent of
whooping cough. Dyspnea, wheezing

Other toxic substance: pulmonary Systemic manifestations: fever, weight loss

aspiration, alcoholism, drug abuse,
allergies, aids

Congenital causes Assessment/diagnostic findings

Immotile ciliary syndrome Assess for health history

Immunodificiency Physical examination

Williams-Campbell syndrome – known as Ct scan

broncho-malacia is a disease of the airways
Sputum culture
where cartilage in the bronchi is defective
leads to collapse of the airways. Bronchoscopy – obstruction, tumor

Marfan‟s syndrome – disorder of connective treatment

tissue, resulting in abnormally long and thin
digits. Antitubeculosis drugs

Pathophysiology Antibiotics – for pseudomonas bacteria:

quinolone, cephalosporin, piperacillin
Bronchiectasis - abnormal and permanent
dilation of bronchi. Corticosteroids

Due to etiologic factor Oxygen therapy

Inflammation of bronchial wall Chest physio-therapy

Loss of supporting structure Mucolytics

Bronchodilators ↓

Postural drainage Severe hypoxemia

summary Assessment/ Diagnostic findings

Bronchiectasis is an extreme form of Dyspnea

obstructive bronchitis, causes permanent
abnormal dilation and distortion of bronchi Tachypnea
and bronchioles. Management of Confusion
bronchiectasis is same as that for COPD.
ABG results – low PO2
Acute respiratory distress syndrome
Air hunger
severe form of acute lung injury.
Chest retractions and cyanosis
sudden and progressive pulmonary edema
Crackles
increasing bilateral infiltrates on chest x-ray
Hypoxemia
hypoxemia refractory to oxygen
supplementation Chest x-ray diffuse bilateral interstitial and

reduced lung compliance alveolar infiltrates - edema

Pathophysiology .Decrease lung compliance

Release of cellular and chemical mediators Medical management

due to inflammatory response.
1. Supplemental oxygen
↓
2. Intubation and mechanical
Alveoli collapse ventilation

↓ 3. Hypovolemia – IV therapy with

careful monitoring pulmonary status
Small airways narrowed
4. Hypotension – inotropic or
↓ vasopressor agents
Decreased lung compliance 5. Pulmonary artery pressure catheters
↓ are used to monitor the patients fluid
status and pulmonary hypertension
Shunting of non-ventilated blood in the
lungs 6. Frequent assessment of the
patient‟s status is necessary to
↓ evaluate the effectiveness of
treatment.
Severe ventilation-perfusion mismatching
occurs
7. The nurse turns the patient frequently to Brain injury, sedatives, metabolic disorders
improve ventilation and perfusion in the  impair the normal response of the brain
lungs and enhance secretion drainage to normal respiratory stimulation

8. The nurse explains all procedures and Acute Respiratory Failure

provides care in a calm, reassuring manner
PATHOPHYSIOLOGY
9. Rest is essential to limit oxygen
consumption Dysfunction of the chest wall

10. Administer Corticosteroids, antibiotics Dystrophy, MS disorders, peripheral nerve

disorders disrupt the impulse
Acute Respiratory Failure transmission from the nerve to the
diaphragm abnormal ventilation
Sudden and life-threatening deterioration of
the gas-exchange function of the lungs Acute Respiratory Failure

Occurs when the lungs no longer meet the PATHOPHYSIOLOGY

body‟s metabolic needs
Dysfunction of the Lung Parenchyma
Acute Respiratory Failure
Pleural effusion, hemothorax,
Defined clinically as: pneumothorax, obstruction interfere
ventilation prevent lung expansion
1. PaO2 of less than 50 mmHg
Acute Respiratory Failure
2. PaCO2 of greater than 5o mmHg
ASSESSMENT FINDINGS
3. Arterial pH of less than 7.35
Restlessness
Acute Respiratory Failure
dyspnea
CAUSES
Cyanosis
CNS depression- head trauma, sedatives
Altered respiration
CVS diseases- MI, CHF, pulmonary emboli
Altered mentation
Airway irritants- smoke, fumes
Tachycardia
Endocrine and metabolic disorders-
myxedema, metabolic alkalosis Cardiac arrhythmias

Thoracic abnormalities- chest trauma, Respiratory arrest

pneumothorax
Acute Respiratory Failure
Acute Respiratory Failure
DIAGNOSTIC FINDINGS
PATHOPHYSIOLOGY
Pulmonary function test- pH below 7.35
Decreased Respiratory Drive
CXR- pulmonary infiltrates

ECG- arrhythmias

Acute Respiratory Failure

MEDICAL TREATMENT

Intubation

Mechanical ventilation

Antibiotics

Steroids

Bronchodilators

Acute Respiratory Failure

NURSING INTERVENTIONS

1. Maintain patent airway

2. Administer O2 to maintain Pa02 at more

than 50 mmHg

3. Suction airways as required

4. Monitor serum electrolyte levels

5. Administer care of patient on mechanical

ventilation
Medical-Surgical Nursing: Body fluids normally shift between two
major compartments or spaces to
FLUID, ELECTROLYTE, & maintain equilibrium.
ACID-BASE BALANCE Third spacing – loss of ECF into a space
Distribution of Body Fluids: that does not contribute equilibrium
between ICF and ECF. Ex: ascites, burns,
Approximately 60 % of typical adult's peritonitis and bowel obstruction.
weight consist of fluids (water and
electrolytes) Signs of third spacing:

Factors that influence the amount of Decrease urine output

body fluids: Increase heart rate
a) Age – younger people have a higher Decrease BP
body fluids than older people
Decrease CVP
b) Gender – Men have more body fluids
than women Edema

c) Fats – Obese people have less fluids Increase body weight

than thin people, because fat cells have
less water Intake and Output imbalances

Body fluids is located in two fluid ELECTROLYTES – active chemicals

compartments: (cations-carries positively charges and
anions which carries negatively
Intracellular space (fluid in the cell) – two charges).
thirds of body fluid is located primarily in
skeletal muscle mass. Major Cations in body fluids:

Extracellular space (fluid outside the a. Sodium

cell) b. Potassium
a) Intravascular space – fluids within the c. Calcium
blood vessels which contains plasma (3
liters out 6 liters of blood) d. Magnesium

b) Interstitial space – contains fluids that e. Hydrogen ions

surrounds the cell and has a total of 8
liters in adult. Example lymph (fluids Major Anions:
present in the vessels in the lymphatic
a. Chloride
system)
b. Bicarbonate
c) Transcellular space – smallest
division of ECF and contains 1 liter of c. Phospate
fluids. Ex: CSF, synovial, pleural, sweats
and digestive secretions d. Sulfate
e. Proteinate ions It is involved in many of the physical and
physiological process of the body.
IV Solutions:
Fluctuations in the amount of water in the
HYPERTONIC SOLUTION – a solution body (EDEMA & DEHYDRATION) can
with an osmolality higher than that of have harmful and even fatal consequences.
serum. Ex. 3% or 5% sodium chloride
Fluid & Electrolyte Balance
HYPOTONIC SOLUTION - a solution with
an osmolality lower than that of serum. Human life is suspended in a saline solution
Ex. 0.45% NaCl and 0.3% Nacl having a salt concentration of 0.9%.

ISOTONIC SOLUTION – a solution with For life to continue and cells to properly
the same osmolality as serum and other function, body fluids must remain fairly
body fluids. Ex. PLR and 0.9 NaCl constant with regard to amount of water and
specific electrolytes of which they are
Homeostasis composed.
The maintenance of the body‟s internal Body Fluids/Compartments
environment within a narrow range of
normal values. Intracellular fluid (All of the water and ions
inside the cells).
It is an ongoing process, with changes
constantly occurring in the body. Extracellular fluid (fluid outside the cells).

Maintaining homeostasis is essential to life. Substance Movement

Chemical Organization Substances must be able to both enter and

leave cells.
Basic chemical and physical principles,
shown below, are necessary to understand The ability of a membrane to permit
the higher levels of organization. substances to pass through it is called
permeability.
Elements.
Substances move by passive or active
Atoms. transport.
Molecules and Compounds. Types of Passive Transport
Ions. Diffusion.
Gases Osmosis.
Two important gases in the body are Filtration.
oxygen and carbon dioxide.
Diffusion
Water
The tendency of molecules to move from a
Water constitutes approximately 60% of the region of higher molecular concentration to
total body weight of an adult.
a region of lower molecular concentration tissues become swollen. This condition is
until an equilibrium is reached. called edema.

Osmosis Dehydration/Fluid Volume Deficit

The diffusion of water through a semi- When more water is lost from the body than
permeable membrane from a region of is replaced.
lower water concentration to a region of
higher water concentration. Caused by water deprivation, excessive
urine production, profuse sweating,
Filtration diarrhea, and extended periods of vomiting.

Fluids and the substances dissolved in them Sources of Fluid Loss

are forced through cell membranes by
hydrostatic pressure. Skin (loss of 300 to 400ml. per day by
diffusion and perspiration).
Hydrostatic pressure is the pressure that the
fluid exerts against the membrane. Lungs (300 to 400ml. per day with expired
air, saturated with water vapor).
Active Transport
Gastrointestinal Tract (200ml. per day in
Accomplished by means of carrier feces).
molecules, which can latch onto specific
molecules and transport them in or out of Kidneys (1,200 to 1,500ml. per day).
the cell. Disturbances in Electrolyte Balance
Examples of important ions transported by Sodium.
this process are calcium, sodium,
potassium, and magnesium. Potassium.

Starling‟s Law of the Capillary Calcium.

Fluids leave (filtration) or enter (re- Magnesium.

absorption) the capillaries depending on
how the pressure in the capillary and Phosphate.
interstitial spaces relate to one another
Chloride.
Volume re-absorbed is similar to volume
Sodium
filtered: “A net equilibrium”
135-145 mEq/L
Regulates relative volumes of blood &
Hyponatremia (subnormal serum sodium
interstitial fluid
value). Causes – SIADH, Enemas,
Edema/Fluid Volume Excess Hypergylcemia

When the amount of interstitial fluid (fluid in Hypernatremia (above normal serum
tissue spaces around each cell) returned to sodium value). Causes – hypertonic enteral
the circulatory system lessens and the fluid feeding, near drowning, malfunction of
accumulates in the tissue spaces, the hemodialysis
Sodium Deficit (Hyponatremia) – refers 1. Monitor I & O
to a serum sodium level that is below
normal (less than 135 mEq/L). 2. Monitor daily wt.

Clinical Manifestations: 3. Observe for GI manifestations

(anorexia, nausea, vomiting and
Depends on the cause, magnitude, and abdominal cramping
speed with which the deficit occurs
4. Monitor/Assess CNS changes
Poor skin turgor
a. Lethargy
Dry mucusa
b. confusion
Decrease saliva production
c. muscle twitching
orthostatic fall in blood pressure
d. seizures
nausea
5. Monitor sodium level and specific
abdominal cramping gravity

When the serum sodium level drops Sodium Excess (Hypernatremia):

below 115 Meq/L, signs of intracranial Is a higher than normal serum sodium
pressure may occur: level (exceeding 145mEq/L)

Lethargy Clinical Manifestations:

Confusion The clinical manifestations of

hypernatremia are primarily neurologic
Muscle twitching because of cellular dehydration.
Hemiparesis Moderate hypernatremia:Restlessness
Papilledema (optic disc swelling) and Weakness

Seizures Severe hypernatremia:

disorientation, delusions and
Medical Management: hallucinations

Sodium Replacement: Medical Management:

Careful administration of sodium by

mouth, nasogastric tube, or parenteral
means. 1. Hypotonic solution (0.3% Nacl) or an
isotonic nonsaline solution (destrose 5%
Lactated Ringer’s solution or isotonic in water D5W).
saline (0.9% sodium chloride) solution
may be prescribed.

Nursing Management: 2. Reduce the serum sodium level not

more than 2mEq/L/H. to allow
readjustment through diffusion across Causes:
fluid compartments.

3. Diuretics
1. GI loss – most common cause of
Nursing Management: potassium depletion

2. Vomiting

1. Assess for abnormal loss of water or 3. Gastric suctioning

low intake of water and large gains of
sodium. 4. Loss in kidneys

2. Avoid OTC medications 5. Diarrhea

3. Obtain medication history 6. Prolonged intestinal suctioning

(ileostomy and villous adenoma)
4. Note the patient’s thirst and elevated
temperature 7. Drugs (potassium-losing diuretics) Ex.
Thiazides
5. Monitor changes in behavior,
restlessness, disorientation and Clinical Manifestations:
lethargy. 1. Fatigue
Significance of Potassium: 2. Anorexia

3. Nausea
Potassium is the major intracellular
4. Vomiting
electrolyte
5. Muscle weakness
98% of body’s potassium is inside the
cell. The remaining 2% is in the ECF. 6. Leg cramps

Potassium influences both skeletal and 7. Decrease bowel motility

cardiac muscle activity.
8. paresthesias (numbness and tingling)
The normal potassium concentration
ranges from 3.5 to 5.5 mEq/L. 9. Dysrhythmias

Potassium 10. Death due to cardiac and respiratory

3.5-5.5 mEq/L arrest

Hypokalemia (subnormal serum potassium Medical Management:

value).

Hyperkalemia (above normal serum

1. Oral or IV replacement therapy.
potassium value).

Potassium Deficit (hypokalemia)

2. Administration of 40-80 mEq/day of Emergency Pharmocologic Management:
potassium
1. Administer IV calcium gluconate –
3. Diet containing potassium for antagonizes cardiac conduction
hypokalemia. 50-100 mEq/day average abnormalities.
adult.
2. Administration of sodium bicarbonate
4. Foods high in potassium include fruits to antagonized the cardiac/respiratory
(raisins, bananas, apricots and oranges) effects of potassium

Nursing Management: Nursing Management:

1. Monitor: fatigue, anorexia, muscle 1. Monitor/assess patients suffering from

weakness, dysrhythmias and renal failure.
paresthesias)
2. Observe signs of muscle weakness
2. Observe/ read ECG or cardiac monitor and dysrhythmias

3. Observe signs for digitalis toxicity 3. Observe for GI symptoms (nausea and
vomiting)
4. Monitor I & O
4. Monitor/measure serum potassium
Potassium Excess (Hyperkalemia) level
Major cause of hyperkalemia is renal 5. Avoid prolonged use of tourniquet in
excretion of potassium: drawing blood sample.
Clinical Manifestation: Chloride 96-106 mEq/L
1. Skeletal muscle weakness Hypochloremia (subnormal serum chloride
2. Flaccid quadriplegia value).

3. Paralysis of respiratory muscle Hyperchloremia (above normal serum

chloride value).
4. nausea
Chloride Deficit (hypochloremia)
5. diarrhea
low level of serum chloride, salt
Medical Management: restricted diets, GI tube drainage and
severe vomiting and diarrhea.
1. Immediate ECG to detect changes
Clinical Manifestations:
2. Diet restriction
1. Hyperexcitability of muscles
3. Oral potassium restriction
2. Tetany
4. Hemodialysis and peritoneal
3. Hyperactive deep tendon reflexes
4. Weakness 1. Tachypnea

5. Twitching 2. Weakness

6. Muscle cramps 3. Lethargy

Medical Management: 4. Deep, rapid respirations

5. Diminished cognitive ability

1. IV administration of normal saline 6. Hypertension

(0.9% and 0.45% NaCl)
Medical Management:
2. Reevaluate patients receiving loop
diuretics 1. Restoring Fluid and Electrolyte
balance
3. Prescribe foods high in chloride
(tomato juice, salty broth, canned 2. Lactated Ringer’s solution to increase
vegetables, processed meats and fruits) bicarbonate level and correct acidosis

4. Avoid water free electrolytes (bottled 3. Sodium bicarbonate IV may be

water) to prevent chloride loss administered

5. Ammonium chloride to prevent 4. Diuretics may be administered to

metabolic alkalosis eliminate chloride

Nursing Management: 5. Na, Fluids and chloride is restricted

Nursing Management:

1. Monitor I & O

2. ABG values 1. Monitor V/S

3. Serum electrolytes level 2. ABG

4. Level of consciousness, muscle 3. Intake and output

strength and movement 4. Assessment findings re: respiratory,
5. V/S neurologic and cardiac

6. Encourage intake of foods high in 5. Instruct patients about dietary intake

chloride
Assessment and Fluid Balance
Chloride Excess (hyperchloremia) – exist
Health History/Causes of Deficits and
when serum chloride level exceeds 106 Excesses
mEq/L
Diagnostic and Laboratory Data.
Clinical Manifestations:
Physical Examination
Daily Weight, Vital Signs, Intake and Fluid volume deficit, risk for.
Output, Thirst, Skin, Buccal (Oral) Cavity,
Eyes, Jugular and Hand Veins, Gas exchange, impaired.
Neuromuscular System. Cardiac output, decreased.
Assessments include: Knowledge deficit.
Respirations (increase/decrease) Breathing pattern, ineffective.
Heart rate (increase/decrease) Anxiety.
Central venous pressure (increase or Thought processes, altered.
decrease)
Injury, risk for.
Weight (gains/losses)
Oral mucous membrane, altered.
Skin turgor (poor/good)
Fluid Balance & Implementation
Mucous membranes (dry or normal)
Monitoring daily weight.
Urine volume (high/low)
Measuring vital signs.
Specific gravity of urine (increase/decrease)
Measuring intake and output.
Hematocrit (increase/decrease)
Monitor hematocrit and electrolyte values.
Level of consciousness
(confused/disoriented, altered) Providing oral hygiene.

Diagnostic and Laboratory Data Initiating oral fluid therapy.

Hemoglobin and Hematocrit Indices. Maintaining tube feeding.

Urine pH. Monitoring intravenous therapy.

Serum Albumin. IV Therapy

Osmolality (a measurement of the total Intravenous therapy is the administration of

concentration of dissolved particles per fluids, electrolytes, nutrients, or medications
kilogram of water). by the venous route.

Serum Osmolality. Clients receiving IV therapy require constant

monitoring for complications.
Urine Osmolality.
Acids, Bases, and pH
Fluid Balance & Nursing Diagnosis
Acids, bases, and Ph are important for life.
Fluid volume excess.
When blood pH falls below 7.35, acidosis
Fluid volume deficit. occurs.
When blood pH increases about 7.45, Remove pressure from the ulnar artery and
alkalosis occurs. assess the color of the extremity distal to
the pressure point.
Acid-Base Balance
Acid-Base Imbalances
Buffer systems.
Acid-Base Imbalances
Respiratory Regulation of Acid-Base
Balance. Respiratory Acidosis

Renal Control of Hydrogen Ion Maintain patent airway

Concentration.
Improve ventilation
Buffers
Monitor for signs of respiratory distress
Substances that attempt to maintain pH
range or H+ ion concentration, in the Administer O2
presence of added acids or bases. Place in a semi-Fowler‟s position
Buffer Systems Encourage and assist the client DBE
Bicarbonate buffer system (works to Prepare to administer chest physiotherapy
regulate pH in both intracellular and
extracellular fluids). Encourage hydration

Phosphate buffer system (works to regulate Suction client as necessary

the pH of intracellular fluid and fluid in
kidney tubules). Monitor electrolyte values

Protein buffer system (works to regulate pH Avoid the use of tranquilizers, narcotics and
inside cells, especially red blood cells). hypnotics

Diagnostic and Laboratory Data Administer antibiotics for infection

The biochemical indicators of acid-base Respiratory Alkalosis

balance are assessed by measuring the
Maintain a patent airway
arterial blood gases (ABGs).
Provide emotional support and reassurance
Allen‟s test
to the client
Ask client to make a tight fist.
Encourage appropriate breathing patterns
Apply direct pressure over the client‟s ulnar
Assist with breathing techniques (breath
and radial arteries.
holding, use of rebreathing bag)
While pressure is applied, ask the client to
Provide cautious care with ventilator clients
open the hand.
Monitor electrolyte values
Administer medications as prescribed Prepare to administer acidifying solutions

Prepare to administer calcium gluconate for

tetany as prescribed Medical–Surgical NURSING
NCM 112
Metabolic Acidosis
1.4 PERIOPERATIVE NURSCING CARE
Determine the cause of the acidosis
1.4 PERIOPERATIVE NURSING CARE
Maintain a patent airway
PERIOD OF TIME THAT CONSTITUTE
Assess LOC for CNS depression THE SURGICAL EXPERIENCE; INCLUDE
Monitor electrolyte values THE PREOPERATIVE, INTRAOPERATIVE
,POSTOPERATIVE PHASE OF NURSING
Maintain intake and output (I&O) and assist CARE.
with fluid and electrolyte replacement as
COMMUNICATION, TEAMWORK , AND
prescribed
PATIENT ASSESSMENT ARE CRUCIAL
Initiate safety precautions for convulsions TO ENSURE GOOD PATIENT OUTCOME.
and coma
PROFESSIONAL PERIOPERATIVE AND
Prepare to administer IV solutions as PERIANESTHESIA NURSING STANDARD
prescribed ENCOMPASS THE DOMAIN OF
BEHAVIORAL RESPONSE,
Monitor the potassium level closely when PHYSIOLOGIC RESPONSE AND PATIENT
acidosis is being treated SAFETY ARE GUIDES, TOWARD
DEVELOPMENT OF NURSING
Metabolic Alkalosis
DIAGNOSIS, INTERVENTION, AND
Maintain a patent airway PLANS.

Monitor vital signs 3 Phases of perioperative nursing

Monitor input and output Preoperative phase

Monitor electrolyte values Intraoperative Phase

Monitor for muscle weakness Post operative phase

Initiate safety precautions for tetany and 1.4.1 surgical classifications;

convulsions
Diagnosis - a diagnostic procedure such as
Prepare to replace potassium and chloride biopsy, exploratory, laparotomy,
as prescribed laparoscopy

Prepare to administer medications as Cure - excision of a tumor, or an

prescribed to promote kidney‟s excretion of inflamedappendix
bicarbonate
Repair -multiple wound repair
Reconstructive or Cosmetic - mamoplasty  Increase technical and
or a facelift mechanical problems related
to surgery
Palliative - to relieve pain or correct .
removal of a dysfunctional gallbladder  Increase the risk of
hypoventilation and post
Rehabilitative - total joint replacement pulmonary complication
surgery to correct crippling pain or
progression  obesity tends to have shallow
respiration when supine
of generative osteo arthritis
 Physical characteristic found in
Surgery can also classified based in the obese patient which impede
degree of Urgency involved emergent, intubation
urgent, and
 short thick neck
optional,
 large tongues
1.4.2 Special consideration during the
perioperative period  redundant pharyngeal tissue

Preventing surgical complication  increased oxygen

demand
thromboembolism [VTE]
 decreased pulmonary
Surgical site infection reserves
Gerontologic Consideration  presence of
Respiratory and cardiac complication obstructive sleep
apnea.
Bariatrics patients
Bariatric considerations
treatment and managing patients who are
obese More weight = extra pressure

Bariatric Positioning concerns

obesity - increase the risk and severity of
complication associated with surgery Might need to raise the head and upper
Wound infection common in patient that are chest for difficult induction/intubation
obese Additional weight compresses diaphragm

Prone bariatric

Not well tolerated due to pressure on the

 Dehiscence (wound separation) aorta and diaphragm

Patient undergoing Ambulatory Surgery

Outpatients, same day, or short stay individual who is not autonomous and
surgery cannot give or withhold consent

not required to admit for an overnight stay in cognitively impaired, mentally ill, or
the hospital. neurologically incapacitated

Patient undergoing Emergency Surgery Informed Subject

Emergency surgeries are unplanned shoud be in writing

usually due to trauma it contain explanation of procedure and it's

risk, description of benefits and alternative
unconscious patient informed consent are
need to be obtained from family member. Patient able to comprehend

INFORMED CONSENT to provide consent (written and verbal) in a

language that is
 consent is a legal mandate, but also understandable to the client.
helps the patient to prepare
psychologically

 helps to ensure that the patient PREOPERATIVE PHASE

understand the surgery to be
performed Preadmission Testing

 the NURSE may ask the patient to 1. Initiate initial preoperative assessment
sign the consent form and witness 2. Initiates education appropriate to patient's
the signature needs
 the SURGEON'S responsibility to 3. Involves family in interview
provide a clear and simple
explanation of what the 4. Verifies completion of preoperative
surgery will entail diagnostic-testing

 In an emergency, the surgeon to 5. Verifies understanding of surgeon

operate as life saving measure specific preoperative orders
without the patient informed
consent. (e.g. bowel preparation, preoperative
shower)
Refusing to undergo a surgical
procedure is a person's legal right and 6. Discusses and reviews advance directive
privilege document

a valid informed consent 7. Begins discharge planning by assessing

patent's need for post operative
Voluntary Consent -at least 18 years old of transportation and care.
age
Admission to Surgical Center
Incompetent Patient
1. Complete preoperational assessment To assess and address risk factors that
contribute to post operative complication
2. Assesses for risk for postoperative and delay recovery.
complication
Before surgical treatment is initiated:
3. Reports unexpected findings or any
deviation from normal -Health history is obtained

4. Verifies that operative consent has been -Physical examination is performed

signed
-Ask about allergies, Genetic
5. Coordinates patient education and plan of consideration during assessment to prevent
care with nursing staff and other health complication with
team members.
anesthesia.
6. Reinforces previous education
-Known allergies to drugs, food and
7. Answers patient's and family's questions latex could avert an anaphylactic response.

In the holding area LATEX ALLERGY -- can manifest as

a rash, asthma or anaphylactic shock.
1. Identifies patient
-Ask patient about use of prescription
2. Asses patient's status, baseline pain, and and over the counter (OTC) medications
nutritional status including herbal and other supplements.
3. Reviews medical record -Activity and functional level should be
4. Verifies surgical site and that it has been determine.
marked per institutional policy -Laboratory test and other diagnostic
5. Establish IV line test are prescribed.

6. Administrates medication if prescribed

7. Takes measures to ensure patient's preparation for surgery

comfort Nutritional and Fluid Status
8. Provide psychological support Identify factors that can affect the patient
surgical course; obesity , weight loss,
9. Communicates patient's emotional status
to other appropriate members of the health malnutrition
care team. deficiencies in specific nutrients, metabolic
abnormalities and the effect of medication
preoperative assessment
on nutrition
The goal is for the patient to be as healthy
as possible. Assessment of a patient hydration status is
essential
Dehydration, Hypovolemia and Electrolyte  surgery contraindicated if
imbalances can lead to significant problems patient has: acute nephritis;
in patient, acute renal insufficiency with
oliguria or anuria, or other
Dentition acute renal problems
Dental caries , dentures significant to the Endocrine Function
anesthesiologist
Diabetic patient who is undergoing surgery
decayed teeth or dental prostheses may is at risk for both hypoglycemia and
become dislodge during intubation and hyperglycemia
occlude the airway
Hypoglycemia
any bodily infections like the mouth can be
source of post operative infection. maybe develop during anesthesia or
postoperatively from inadequate
Drug or Alcohol use carbohydrates or excessive administration
even moderate amount of alcohol prior to of insulin
surgery can weaken patient immune system Hyperglycemia
and increase developing post op
complication. which increase the risk of surgical wound
infection.
use illicit drugs and alcohol may impede the
effectiveness of some medication strict glycemic control 80 to 110 mg/dl

Respiratory Status frequent monitoring of blood glucose level

before, during and after surgery
Educate patient about breathing exercise
and the use of an incentive spirometer the patient who received corticosteroid are
at risk for adrenal insufficiency close
patient with underlying respiratory disease monitored
e.g asthma, COPD are assess carefully for
current threats to their pulmonary status. the patient with uncontrolled thyroid
disorders are at risk for thyrotoxicosis
Cardiovascular Status
(hyperthyroid disorder).
uncontrolled HPN surgery maybe
postponed until the blood pressure is under Immune Function

control to determine the presence of infection or

allergies
Hepatic and Renal Function
Routine laboratory tests to detect infection
The liver , lungs , and kidneys are the include the white blood count (WBC) and
routers for eliminations of drugs and toxins. the urinalysis
 Liver is involved in excreting in the presence of infection surgery may
anesthetic medication postponed
Identify and document any sensitivity to - to educate proper deep breathing,
medication and past adverse reactions , coughing and use incentive Spirometry
previous

allergic reactions; medication; blood

transfusion; contrast agents, latex and food 2. Mobility and Active body movement
products. - To improve circulation - Prevent
mildest symptoms or slightest temp venous stasis - Promote optimal respiratory
elevation must be investigated. function

Previous Medication Use Patients should be taught: >

frequent ambulation
Any medication the patient using or has
used in the past are documented, including > frequent
position changes turn from side to side
OTC preparation and herbal agents
> to assume
ASPIRIN the lateral position without causing pain or
disrupting intravenous lines
 should be discontinue 7 to 10 days
before surgery > Exercise of
the extremities
 otherwise the patient risk for
bleeding *
Adduction or elevation
HERBAL MEDICATION- discontinue the
use at least 2 weeks before surgery. *
Extension and flexion of the knee
Psychosocial Factors
* Hip
The nurse anticipate that most patient have joints
emotional reactions prior to surgery
3. Pain Management
Fear maybe related to the unknown
- pain assesment should include
Spiritual and Cultural Beliefs differentiation between acute and chronic
showing respect for a patients cultural disease
values and beliefs facilitates rapport and - pain intensity scale should be
trust. introduced and explained to the patient to
preoperative nursing interventions promote more effective postoperative
pain management
Provide Patient Education
0 - relaxed, comfotable
1. Promote optimal lung expansion and
resulting blood oxygenation after anesthesia 1to 3 - mild discomfort

4 to 6 - moderate pain
 7 to 10 - severe discomfort or  (15-20 mins) medicines
pain ready to administer as soon
as a call received from OR

 Maintaining the Preoperative

- Medication are given to relieve pain and checklist, verification forms, surgical
maintain comfort without suppressing consent
repiration function
 Transporting the patient to the
4. Cognitive coping strategies Presurgical area
- Useful for relieving tension,  30-60 minutes before the
overcoming anxiety, decreasing fear and anesthetic is to be given
achieving relaxation
 Attending to family needs
1. Imaginary - concentrates
on a pleasant experience / restful scenes  ambulatory surgery - have
waiting area where family
2. Distraction - thinks of an members can stay
enjoyable
 Expected patient outcomes
3.Optimistic- self - recitation
thoughts ( I know all will go well)  Evidence when the patient
shows decrease anxiety and
4. Music fear
Immediate preoperative Nursing  show relief in anxiety when
Intervention Patient verbalizes an
understanding of the
 Patient changes into hospital gown
preanesthetic medication
 Patient with long hair may braid,
remove hairpins cover the head with  appears relaxed when visited
disposable paper cap by health care team
members
 Mouth inspected, dentures or plates
are removed  Discusses fears with health
care professionals or a
 Jewerly not worn to the OR spiritual adviser or both

 Wedding rings  Verbalizes an understanding

of any expected bodily
 Body Piercing changes
 Administrating Preanesthetic Intraoperative phase / care
Medication
 Principles of Surgical Asepsis

 Surgical Asepsis - absence

of microorganism in the
 surgical environment reduce Sterilized equipment are inspected regularly
the risk of infection to ensure optimal operation and
performance
 prevents the
contamination of Unnecessary personnel and physical
surgical wounds movement may be restricted to minimize
bacteria in the air
All surgical supplies, instrument, needles,
sutures, dressings, gloves, covers and Basic Principles of aseptic technique:
solutions that may come in contact with the
surgical wound or exposed tissues must be All materials in contact with the surgical
sterilized before use. wound or used within the sterile field must
be sterilized.
The surgeon, surgical assistants, and
nurses prepares themselves by scrubbing Gowns of the surgical team are considered
their hands and arms with antiseptic soap sterile in front from the chest to the level of
and water. the sterile field. The sleeves are also
considered sterile from 2 in above the elbow
Surgical team members to the stockinette cuff.

wear long-sleeved Sterile drapes are used to create sterile

field. Only the top surface of a draped is
sterile gowns and gloves considered sterile. During draping of a table
Head and hair are covered with a cap or patient, the sterile drape is held well
above the surfaces to be covered and is
mask is worn over the nose and mouth to positioned from front to back
minimize the possibility that bacteria from
the upper respiratory tract will enter the Items are dispensed to a sterile fluid by
wounds methods that preserves the sterility of the
items and the integrity of the sterile field.
During Surgery After a sterile packaged is opened the
edges are considered unsterilized. Sterile
only personnel who have scrubbed, gloved supplies, including solutions are delivered to
and gowned can touch sterilized objects a sterile field or handed to a scrubbed
person in such a way that the sterility of the
Nonscrubbed personnel refrain from
object or fluid remains intact.
touching or contaminating any sterile
The movements of the surgical team are
Environmental controls
from sterile to sterile areas and from
surgical asepsis requires meticulous unsterile to unsterile areas. Scrubbed
cleaning and maintenance of the OR people and sterile items contact only sterile
environment areas; circulating nurses and unsterile items
contact only unsterile areas.
Floor and horizontal surfaces are cleaned
between cases with detergent, soap, and Movement around a sterile field must not
water or a detergent germicide cause contamination of the field. Sterile
areas must be kept in view during
movement around the area. At least a feet - Licensed practical nurse or
distance from the sterile field must be Surgical technologist (assistant)
maintained to prevent inadvertent
contamination. - performing hand hygiene

Whenever a sterile barriers is breached, the 3. The Surgeon

area must be considered contaminated. A - Performs the surgical procedure.
tear or punctured of the drape permitting the
access to an unsterile surface underneath - Heads the surgical team, and a
renders the area unsterile. A drape must be license physician who is specially trained
replaced. and qualified.

Every sterile field is constantly monitored 4. The Registered Nurse First Assistant
and maintains items of doubtful sterility are (RNFA)
considered unsterile. Sterile fields are
prepared as close on possible to the time of - The RNFA practices under the
use. direct supervision of the surgeon

The routine administration of hyperoxia - Responsibilities may include

(high levels of oxygen) is not recommended handling tissue, providing exposure at the
to reduce surgical site infection. operative field, suturing, and maintaining
hemostasis.
The SURGICAL TEAM are consist of:
5. Anesthesiologist
1. Patient
5. The anesthesiolohist - A physician specifically trained in
the art and science of anesthesiology.
2. Certified registered nurse anesthetist
(CRNA) 6. Surgeon - Assesses the patient before
surgery.
3. Nurses
7.Surgical Technicians - Selects the anesthesia, administers
it.
4. Registered Nurse first asstance (RFNA's)
8.Certified Surgical Technologist - Intubates the patient if necessary

- Manages the technical problem

(assistant)
related to the administration of the
ROLES OF THE SURGICAL TEAM anesthetic agent.

1. Circulating Nurse (Circulator) - Supervises the patients condition

throughout the surgical procedure
- Manages the OR and protect's
patient's safety and health by monitoring the
activities of the surgical team.

2. Scrub Role
TYPES OF ANESTHESIA AND SEDATION
THE MAIN TYPES OF ANESTHESIA - Pupils dilate, but they constrict if
exposed to light, the pulse rate is rapid and
1. General Anesthesia (Inhalation, IV) respirations may be irregular because of
2. Regional Anesthesia (--, spinal, and local uncontrolled movements of the patients.
coduction blocks) - Anesthesiologist always be
3. Moderate Sedation (Monitored assisted by someone ready to help restrain
anesthesia care / MAC) the patient or to apply cricoid pressure in
the case of vomiting to prevent aspiration.
4. Local anesthesia
Stage III: Surgical Anesthesia
ANESTHESIA - a state of narcosis or
severe central nervous system depression - Reached by administration of
produce by pharmacologic agents. anesthetic vapor or gas and supported by IV
agents.
analgesia, relaxation and
reflex loss. - The patient is unconscious and lies
quietly on the table.
General anesthesia consists of four stages:
- The pupils are small but constrict
Stage I: Beginning anesthesia when exposed to light, respiration are
regular, the pulse rate and volume are
- Dizziness and a feeling of normal and the skin is pink or slightly
detachment flushed.
- Patient may have a ringing, Stage IV: --- Depression
roaring, or buzzing in the ear although still
unconscious - Reached if too much anesthesia,.
Respiration become shallow, the pulse is
- Sense an inability to move the weak and thready and the pupils become
extremities easily. widely dilated and no longer constrict when
exposed to light.
- Noises are exaggerated; low
voices or minor sounds seem loud and Cyanosis develop and without
unreal. prompt interventions death rapidly follows. If
this stage develop .anesthetic agent is
unnecessary noises and
discontinued immediately and respiratory
motions are avoided when anesthesia
and circulatory support is initiated to prevent
begins.
death.
Stage II: Excitement
The responses of the pupils
- Characterized by struggling,
Blood pressure
shouting, talking, singing, laughing or
crying, is often avoided if IV anesthetic Respiratory
agent are given smoothly and quickly.
Cardiac rate
A. Inhalation B. Intravenous Administration

- Inhaled anesthetic agents include: General anesthesia - can be

Volatile liquid , agents, and gases produced by the IV administration of various
anesthetic and analgesic agents, such as
- Some common used inhalation barbiturates,benzodiazepines,
agents nonbarbiturates hypnotics, dissociative
* Combination with oxygen agents and opiod agent .
and nitrous oxide Advantage:
- When inhaled, the anesthetic agent - the onset of anesthesia is pleasant.
enter the blood through the pulmonary There is none of the buzzing, roaring, or
capellaries and act on cerebral centers to dizziness.
produce loss of consciousness and
sensation. When discontinued, the vapor or - The duration of action is brief and
gas is eliminated through the lungs. patient awakens with little nausea or
vomiting.
The vapor from inhalation anesthetic
agents can be given to the patients by - non-expensive, requires little
several methods: equipment

a. (LMA) - Laryngeal Mask Airway - Easy to administer

a flexible tube with an - The method useful in eye surgery

inflatable silicon ring and cuff that can be
inserted into the larynx. - The low incidence of
postoperation nausea and vomiting

increases intraocular pressure and

endanger vision in the operated eye

b. Intranasal Intubation - inserted through - Useful for short procedure but is

the nose c. oral intubation - inserted used less often for the longer procedure of
through the abdominal surgery.
mouth

Endotracheal technique - for administering

anesthetic medication consists of
introducing a soft or rubber or plastic ETT
into the trachea, usually by means of a Disadvantage:
laryngoscope
- It is not indicated for those
- when in place, the who require intubation because of their
tube seals off the lungs from the susceptibility to respiratory obstruction.
esophagus. So if patient vomits, stomach
content do not enter the lungs - The combination of IV and
inhaled anesthetic agents produces an
effective and smooth experiences for the - receiving regional anesthesia is
patient. awake and aware of their surroundings
unless medications are given to produce
- IV neuromuscular mild sedation or relieve anxiety.
blockers(muscle relaxant) block the
transmission of nerve impulses at the - avoid careless conversation,
neuromuscular function of skeletal muscle. unnecessary noise, and unpleasant odors
these may be noticed by the patient.
Muscle relaxants
B. Epidural Anesthesia
- are use to relax the muscle in abdominal
and thoracic surgery. - achieved by injecting a local
anesthetic agent into the epidural space that
- relax eye muscle in certain types of eye surrounds the dura matter of the spinal cord
surgery
- the given medication diffuses
- facilitate endotracheal intubation across the layers of the spinal cord to
- treat laryngospasm provide anesthesia and pain relief.

- assist in mechanical ventilation - blocks sensory, motor, and

autonomic functions
A. Regional Anesthesia
Advantage: is the absence of headache
- an anesthetic agent is injected
around nerves so that the region supplied disadvantage: is the greater technical
challenge of introducing the anesthetic
by the nerve is anethetized
agent into the epidural space rather than
- the effect depends on the type of subarachnoid space.
nerve involved
: if inadvertent puncture of the
* Motor fiber - the largest dura occurs during epidural anesthesia and
fiber and have the thickest myelin sheath. the anesthetic agent travels toward the
head high spinal anesthesia this can
* Sympathetic fiber - the produce severe hypotension and respiratory
smallest and have minimal covering depression and arrest.
* Sensory fiber - are Treatment of these complication inludes
intermediate airway support, IV fluids and the use of
vasopressors
- a local anesthetic agent blocks
motor nerves least readily and sympathetic C. Spinal Anesthesia
nerve most readily
- is an extensive conduction nerve
- an anesthetic agent is not block that is produced when a local
considered metabolized until all anesthetic agent is introduced into the
three(motor, sensory, and autonomic) are subarachoid space at the lumbar level
no longer affected usually between L4 and L5
 - it produces anesthesia of the lower Moderate Sedation
extremities, perineum, and lower abdomen.
- referred to a conscious sedation
- for the lumbar puncture procedure,
the patients usually lies on the side in the - IV administration of sedatives or
level - chest position anallgesic medications to reduce patients
anxiety and control pain.
- sterile technique is used as a
spinal punctured is made and the - being used to specific short term
medication is injected thru the needles. surgical procedure

- a few minutes after induction of a - the patient receiving moderate

spinal anesthetic agents, anesthesia and sedationis never left alone and is closely
paralysis affect the toes and perineum and monitored by a physican or nurse who is
then gradually the legs and abdomen. knowledgeable and skilled in detecting
dysrhythmias, administering oxygen, and
- nausea and vommiting and pain performing resuscitation.
my occur during surgery
- the continual asessment of the
- headache an after affect of patient: vital signs, level of conciousness
anesthesia and cardiac and repiratory function.

- factors are related to the incidence

of headache:
Monitored Anesthesia Care (MAC)
*The size of the spinal
needles used - referred to as monitored sedation

*The leakage of fluid from the - used for healthy patients undergo
subarachnoid space through the puncture minor surgical procedure and some critically
site. ill patient who unable to tolerate anesthesia.

*Patient hydration status Local Anesthesia

D. Local Conduction Blocks - the injection of a solution

containing the anesthetic agent into the
includes: tissue a the planned incision site.

1. Brachial plexus block - which - it is combined with a local regional

produce anesthesia of the arm block by injecting around the nerves
immediately supplying the area
2. Paravertebral anesthesia - which
produce anesthesia of the nerves supplying advantages: it is simple, economical, and
the chest, abdominal wall and extremities. nonexpensive

3. Transsacral (caudal) block - which : equipment needed is minimal

produce anesthesia of the perineum and
occasionaly, the lower abdomen. : post operative recovery is brief
 : undesirable effects of general lowered and basin is provided to collect the
anesthesia are avoided vomitus.

: it is deal for short and minor Suction is used to remove saliva and
surgical procedures vomited gastric contents.

- local anesthesia is often given in C. Anaphylaxis

combination with Epinephrine. Epinephrine
constricts blood vessels, which prevents - Anytime the patient comes into
rapid absorption of the anesthetic agent and contact with a foreign substance, there is
prolongs its local action and prevents potential for an Anaphylactic Reaction
seizures. occur in response to many medication, latex
or other substance.
Contraindiction:
- The reaction maybe immediate or
> high preoperative levels of anxiety delayed

> for some surgical procedures, D. Hypoxia and other Respiratory

local anesthesia is impractical because of Complication
the number of infections and the amount of
anesthetic medication that would required. - Inadequate ventilation

e.g. breast reconstruction, - Occulusion of the airways

tooth extration,

potential intraoperative complication - Inadvertent intubation of the

esophagus
A. Anesthetic awareness
- Hypoxia
- Sensation of pushing and pulling
tissues may still be recognized and they In addition of these dangers:
may hear conversations among the - Asphyxia caused by foreign bodies
operative team. in the mouth
- In many cases, patients may be - Spasm of the vocal cord
able to respond to question and involve
themselves in the discussion. - Relaxation of the tongue

- Indication of the occurence include - Aspiration of the vomitus, saliva or

blood pressure, rapid heart rate and blood
patients movement.
Brain damahge from hypoxia - occurs with
minutes monitoring of the patient
oxygenation status is a primary function
B. Nausea and Vommiting or
Regurgitation(intraoperative period) - Peripheral perfusion - checked
frequently and pulse oximetry values
- If gagging occurs, the patient is
turned to the side, the head of the table is
E. Hypothermia - Monitoring of -- temperature,
urinary output, ECG, blood pressure, arterial
- during anesthesia, the patient's blood gas levels and serum electrolyte level.
temperature may fall
F. Malignant Hyperthermia
- Glucose Metabolism is reduced
and as a result, metabolic acidosis develop - is a rare inherited muscle disorders
that is chemically induce by anesthetic
- 36.6 ℃ - 98 ℉ or less - a core body agents
temperature
- this disorders can be triggered by
- may occur as a result of a low myopathies, emotional stress, heatdtroke,
temperature in the OR infusion of cold fluid, neuroleptic malignant syndrome, strenuous
inhalation of cold gases, open body wounds exercises exertion and trauma.
or cavities, adnvanced age, or the
pharmaceutical agents Pathophysiology of malignant hyperthemia

e.g. vasodilators, During anesthesia --- agents such as:

phenothiazines, general anesthetic
medications. > inhalation anesthetic agents (e.g.
halothane, enflurane, isoflurnae)
- Hypothermia can depress neuronal
activity and ↓ cellular oxygen requirements > muscle relaxants (succinylcholine)
below the minimum levels normally required Stress and some medication such as:
for continued cell viability.
> sympathominetics (epinophrine)
goal: safe return to normal body
temperature > Theophylline, Aminophylline,
anticholinergic (atrophine)
- Enviromental temperature can be
temporarily set at 25 ℃ to 26.6 ℃ (78℉to > Cardiac glycosides(digitalis)
80℉)
* The Physiology of
- IV and irrigating fluid are warm to Malignant Hyperthemia
37 ℃(98 ℉)
related
- Wet gowns and drapes are to
removed promptly and replaced with dry
materials

- Warm air blankets and thermal Hypermetabolic condition that involves

blankets altered mechanism of

- warming must be accomplished calcium function in skeletal muscle cells

gradually not rapidly This disruption of calcium causes clinical
symptoms of hypermetabolism
Which in turn increases muscle contraction > Provide oxygen and nutrtion tissue
(rigidity)
> Correct electrolyte imbalance
Causes hyperthemia and
* Malignant hyperthemia usually manifest
subsequent damage to the CNS about 10-20 minutes after induction of
anesthesia or during the first 24 hours after
Clinical Manifestation: surgery
Initial symptoms of Malignant Nursing Process: The patient during
Hyperthemia are cardiovascular, respiratory surgery intraoperative, focus on Nursing--
and abnormal musculoskletal activity. Diagnosis, interventions and outcomes that
> Tachycardia (heart rate surgical patients and their families
greater than 15 bpm) experience.

> Sympathetic nervous Priorities include collaborative problems and

stimulation leads to ventricular dysrhythmia expected goals:
hypotension Assesment:
> Decreased cardiarc output Nursing assesment obtain data from
oliguria and cardiac arrest. the patient and the patient's medical record.
> Hypercapnia, increase in include:
carbon dioxide(CO2) early respiratory sign
> Physiologic status (anxiety level,
> Abnormal transport of verbal communication problems, coping
Calcium, Rigidity or Tetanus like movement, mechanism)
often in the jaw - muscle rigidity early
sign. > Psychological status (surgical site,
skin condition, and effectiveness of
> Late sign develops rapidly preparation, mobility of joints)
the rise of body temperature can increase
1℃ to 2℃(2℉ to 4℉) every minutes and > Ethnical concerns
core body temperature can exceed
42℃(107℉) Diagnosis:

Medical Management: Nursing diagnosis may include:

Goals of treatment > Anxiety related to surgical or

enviromental concerns
> Low metabolism
> Risk of latex -
> Reverse metabolic and respiratory
acidosis Planning / Goals

> Correct dysrythmias Reduced anxiety, absence of latex

exposure, absence of positioning injuries,
> Decrease in Body Temperature
freedom from injury maintanance of the of surgery and anesthesia should they
patient dignity and absence of complication. occur.

Nursing Interaction

Reducing anxiety Postoperative nursing care

Reducing latex exposure Postoperative period - extends from the

time the patient leaves the operating room
Preventing perioperative positioning (OR) until the last follow up visit with the
injury surgeon
Protecting the patient Nursing Care focus on:
Type of position during surgery 1. Reestablishing the patient's
1. Dorsal Recumbment Nursing physiologic equilibrium

2. Trendeleburg position 2. Allevating pain

3. The Lithotomy position 3. Preventing Complications

4.The sims or lateral position 4. Educating the patient about the

self care

Care of the patient in the Post Anesthesia

Evaluation: Care Unit (PACU)

Expected patient outcomes may include: - formly reffered to as the recovery

room or the Post anesthesia recovery room
1. Exhibits low level of anxiety while
awake during the intraoperative phase of - patient may remain for as long 4-6
care. hours

2. Has no symptoms of latex surgery - transporting the patient involves

special consideration of the incision site,
3. Remains free of perioperative potential vascular change and exposure
positioning injury
- Orthostatic hypotension - patient is
4. Experience no unexpected threats moved too quickly from one position to
to safety another
5. Has dignity preserved throughout - side risk to raised to prevent falls
OR experience
Nursing management pacu
6. Is free of complications (e.g.,
nausea and vomiting, anaphylaxis,hypoxia, Objectives:
hyperhemia, malignant hyperthemia, or
deep vein thrombosis) or experiences
successful management of adverse effects
 -to provide care until the patient has * Administration of postoperative
recovered from the effects of anesthesia analgesic medications is a top priority in
(until resumption of motor and sensory ---) order to provide pain relief

- oriented, stable vital sign, show no * Facilitate early ambulation

evidence of hemorrhage or other
complications 2. Maintaining a patent airway

1. Assesing the patient Objectives:

* Skilled assesments of the patient's 1. To maintain ventilation

airway, respiratory function, cardiovascular 2. Prevent Hypoxemia (reduced
function, skin, color, level of conciousness oxygen in the blood)
and ability to response to a command.
3. Prevent Hypercapnia (excess
* Vital Signs are observed and carbon dioxide in the blood)
recorded, as well as level of conciousness
Hypoxemia
* The nurse performs and
documents abaseline asessment Hypercapnia

* Checked the surgical site for * Administering supplement oxygen

drainage or hemorrhage as prescribed

* Make sure that all drainage, tubes * Asses respiratory rate and depth, --
and monitoring lines are connected and - of respiration, oxygen saturation and
functioning. breath sounds

* Check IV fluids with the goal of * The movement of the thorax and
maintaining a euvolumic state the diapraghm does not necessarily indicate
that the patient is breathing, the nurse
* Medications currently infusing are needs to place the palm of the hand at the
checked, verfying that they are infusing at patient's nose and mouth to feel the exhaled
the correct dosage and rate.
breath.
* Assesed and document every 15 Hypophary-- obstruction - obstruction of
minutes air passage. e.g. prolonged anesthesia
* The nurse must be aware of patient are unconcious with all muscle
pertinent information from the patient relaxed. The relaxation extends to the
history. muscle of the pharynx when patient lies on
their back, the lower jaw and the tongue fall
e.g. deaf or difficulty in backward and airpassage become
hearing, history of seizures, has diabetes, obstructed.
allergic to certain medication or to latex
Signs of occlusion: choking, noisy and
irregular respiration decrease oxygen
saturation scores, and within minugte a - Neurogenic - Anaphylctic
blue, ducky color cyanosis
- Septic
3. Maintaining Cardiovascular Stability
Classic signs of Hypovolemic's Shock (the
- To monitor cardiovascular stability most common shock)
the nurse asseses the patient's level of
conciousness: vital signs, cardiac rythm, Signs are pallor, cool, moist skin,
skin temperature, , color and moisture, and rapid breathing, cyanosis of the lips, gums
urine output. and tongue, rapid, weak, thready pulse,
narrowing pulse pressure, low blood
- Asses the patency of all IV lines pressure, and concentrated urine.

Primary cardiovascular complication seen in Can be avoided: timely

the PACU administration of IV fluid, blood, blood
products and medication that elevates blood
- Hypotension and shock, pressure.
hemorrhage, hypertension and dysrythmia
Primary Intervention for hypovolemic
- Additional monitoring these shock
include: (CVP) Central Venous Pressure,
pulmonary artery wedge pressure, and A. Volume replacement
cardiac output.
1. infusion of lactated
ringers solution

4. Hypotension and shock 2. 0.9 Sodium

chloride solution
- Can result from blood loss,
hypoventilation, position changes, pooling of 3. Colloids or blood
blood in the extremities, or side effects of component therapy
medication and anesthetic
B. Oxygen given by nasal
- The most common cause is loss of cannula, face mask, or mechanical
circulatory volume through blood and ventilation
plasma loss. The amount of blood loss
exceed 500 ml. - replacement usually 5. Hemorrhage
indicated - Uncommon but serious
Shock - one of the most serious complication that result in hypovolemic
postoperative complication shock and death

- can result from hypovolemia Signs:

and decreased intravascular volume - Rapid, thready pulse,
Types of shock: disorientation, restlessness, oliguria and
cold pale skin.
- Hypovolemic - Cardiogenic
 - Early signs of shock will manifest in - Opiods analgesic medications are
feeling of apprehension, decreased cardiac given mostly IV in PACU. Opiods provide
output, vascular assistance immediate pain relief and are short acting

- Breathing becomes labored and 8. Controlling Nausea and vommiting

“air hunger” , the patient will feel cold
(hypothermia) cord experience tinnitus. - should intervene at the patient first
report of nausea to control the problem
- Laboratory values show a sharp rather wait for it to progress to vommiting
drop in hemoglobin and hematocrit level.
- Postoperative nausea and vomiting
- Transfering blood or blood (PONV) - a variety of alternative technique
products and determining the cause of have been suggested to control PONV,
hemorrhagethe initial therapeutic measure including deep breathing and
aromatheraphy
- Surgical site and incision should be
input for bleeding. If bleeding evident, a - risk of PONV 10%-30% within 24
sterile gauge pad and a pressure dressing hours postoperative care risk include:
are applied and site of bleeding is elevated general anesthesia, female gender, non
to heart level if possible. smoker, history of PONV and history of
motion sickness
- Patient place in shock position (Flat
on back, legs elevated at a 20 degrees - surgical risk: Increase in intra
angle knees kept straight) abdominal pressure, elevated central
venous pressure, the potential for
6. Hypertension and Dysrhythmias aspiration.
Hypertension - Postoperative period Gerontologic considerations:
secondary t sympathetic nervous system
stimulation form pain, hypnoxia, or bladder Post operative Nursing care:
distention
> Keep patient warm, older adults
Dysrhythmias - are associated with are more susceptible to hypothermia
electrolyte imbalance, altered respiratory
function, pain hypothermia, stress and > Position is changed frequently to
anesthetic agent stimulate respiration; promote circulation
and comfort
hypertension + Dysrhytmias
- are managed by treating the underlying > Careful monitor it is possible to
cause. detect cardio pulmonary deficits before
signs and symptoms are apparent
7. Relieving pain and anxiety
> Changes associated with the
- monitors the patient physiologic aging process, the prevalence of chronic
status, manages pain and provides disease,
physchological support in an effort to relieve
the patient's fears and concerns. - alternation in fluid and
nutrtion status
 - the increased use of to the other or ambulating without
medication result in the need for discomfort
postoperative vigilant
Determinating for Postanesthesia Care
- older adults may have Unit Discharge
slower recovery from anesthesia due to
prolonged time to eliminate sedative Aldrete score is use to determine the
and anesthetic agent patient's general condition. The patient is
assesed at regular intervals, and total score
> Post operative confusion and in calculated and recorded on the
delirium may occur in up to half of older assesment record. Baseline score between
adult 7 and 10. Before discharge from PACU less
than 7 must remain in the PACU until
condition improve or this are transferred to
an ICU.
> Post operative confusion and
delirium may occur in up to half of older Thank you…
adult

* Acute confusion may

caused by pain

* Hypoxia can present as

confusion and restlessness due to blood
loss and electrolytes
imbalance

* Confusion must precede

the assumption that confusion is related to
age, circumstances and
medications.

> Dehydration, Constipation, and

Malnutrition may occur post-operatively.

> Sensory limitation such as

impaired vision or hearing and reduced
tactile sensitivity, frequent interact with the
unfamiliar post-operative enviroment so
Falls are prevented.

> Maintaining safe enviroment

requires alertness and planning

> Arthritis a common condition

among older adult patients, and it affects
mobility, creatingn difficulty turning one side