MEDSURG REVIEWER ● Limited opportunity to observe for lare post op

complications
PERIOPERATIVE NURSING
Procedures: [C.E.S.T.T.L.V.N]
Surgery 1. circumcision
● Any procedure performed on the human body 2. excision of breast mass
that uses instruments to alter tissue or organ 3. tooth extraction
integrity. 4. tubal ligation
5. laparoscopic procedures (x in the PH)
3 Phases: 6. vasectomy
1. Preoperative Phase 7. nasal pack removal
2. Intraoperative Phase
3. Postoperative Phase Informed Consent
● Patient’s autonomous decision about whether to
3 Classification of Surgery undergo a surgical procedure.
1. Based on Urgency ● Necessary before non-emergent surgery can be
a. Em-ergent (w/o delay) performed in order to protect the patient from
b. Urgent / Imperative (24-30 hours) unsanctioned surgery and protect the surgeon
c. Required (plan within weeks - months) from claims of an unauthoriZed operation
d. Elective (scheduled)
e. Optional (personal preference) Validation Criteria:
2. Based on Degree of Risk 1. Specific - it should only cover the procedure to
a. Major be done and should not include any other
i. High risk alternative communicated to the patient
ii. Prolonged OR time 2. Voluntary - should not be taken by force or
iii. Extensive pressure. Nurse has duty to emphasize that
iv. Increased blood loss freewill can be exercised and ultimately, the
v. Vital organ involved patient makes the decision
b. Minor 3. Informed - the explanation should be completely
i. Less risk understood and questions answered
ii. Fewer complications
iii. Shorter surgery time Surgeon
3. According to Purpose ● responsible for obtaining signed consent before
a. Diagnostic - to confirm diagnosis, establish sedation is given and surgery is performed.
the presence of a disease or illness (e.g. Anesthesiologist
biopsy) ● Obtains the consent for anesthesia and explains
b. Exploratory - to determine the extent of risks and benefits
disease condition (ExLap) Nurse
c. Curative - to treat the disease condition or ● clarify facts presented by the physician and
remove a diseased part. dispel myths that the client or family may have
i. Ablative - removal of an organ (ectomy) about surgery.
ii. constructive - repair of congenitally Patient
defective organ (plasty, orrhaphy, pexy) ● Provides the decision without external force
iii. Reconstructive - to restore function to
traumatized malfunctioning tissue / Guidelines:
damaged organ ● Nature and intention of the surgery
d. Palliative - to give relief or reduce intensity ● Name and qualifications of the person
of illness (not cure) performing the surgery
i. Transplantation - replace organs ● Risk/complications including tissue damage,
ii. Cosmetic - for aesthetic disfigurement, or even death
● Possible alternative measures (time frame and
4 Major Types of Pathologic recovery, consequences of refusal)
● Obstruction - impairment to the flow of vital fluids ● Chances of success
● Perforation - rupture of an organ ● Right of the client to refuse consent or later
● Erosion - wearing off of a surface withdraw consent
● Tumors - abnormal new growth
Special Considerations
Surgical Settings ● In emergency cases when the patient is at
● Surgical suites imminent risk of physical injury. Physician can
● Ambulatory care setting perform any procedure as good practice of
● CLinics medicine dictates without such consent
● Physician offices ● When the patient is either a minor, or legally
● Community setting incompetent, in which case. a third party
● Homes consent Is required
● When disclosure of material information to
Outpatient setting / Ambulatory Surgery patient will jeopardize the success of treatment,
in which case, third party disclosure and consent
Advantages: shall be in order
● shorter length of hospital stay = low cost ● When the patient waives his right in writing
● low risk of infection
● minimal disruptions from ADL
● less time lost from work and family life

Disadvantages:
● Less time for rapport
● Less time to assess, evaluation, teach
● Risk of potential complication post D/C
 Risk factors that may lead to postoperative
PREOPERATIVE NURSING complications and hinder recovery:
MANAGEMENT 1. age
2. poor nutrition and fluid & electrolyte imbalance
The preoperative phase begins when the decision to 3. dentition
proceed with surgical intervention is made and ends with 4. drug or alcohol use
the transfer of the patient onto the operating room (OR) 5. respiratory status
table. 6. cardiovascular status
7. hepatic and renal function
Pwedeng nasa bahay pa, ward, etc. 8. endocrine function
9. immune function
Ambulatory Surgery 10. medications
11. other factors
● short stay and does not require overnight stay but a. nature
may entail admission for less than 24 hours. b. location
● brief time so nurses must act quickly and c. magnitude or urgency of the surgery
comprehensively assess. d. mental attitude of the patient
● Anticipate patient's needs at the same time begin e. surgeon factor/ surgical team
planning for discharge and follow-up & home care.
● Documentation Diagnostic Examinations
Move quickly and comprehensively assess, during Laboratory Test
admission start planning (health teachings + discharge
planning) ● CBC
● Blood typing & cross matching
Minor Surgeries ONLY! Because of the limitations of ● Electrolytes
equipment. ● Clotting test (PT, APTT)
○ Partial thromboplastin time
Major surgeries are possible but there are qualifiers. ○ Activated Partial Thromboplastin Time
○ Important to know if kaya magclot ng
Emergency Surgery blood = increased risk of bleeding >
shock
● unplanned and very little time for preparation for
patients and nurses. Imaging
● unpredictable nature poses a unique challenge but it
is important to be calm and communicate effectively ● Chest x-ray
in these situations. ● ECG
● Informed consent issues ● MRI
● essential info such as pertinent past medical history, ● CT-scan
allergies to be obtained from family members/
guardians if avail. Physical Needs
● clinical eye important in assessment
● Speech
Done in a Major OR! Emergency Cases are not just for ● VS
ER Nurses! ● LOC
● Weight and height
Preoperative Assessment ● Blood circulation status
● MObility and exercise
Patient Interview is the primary responsibility of the ● Prosthesis
Nurse!
Health history
● health history is obtained (drug and food allergies)
● physical examination, blood test, x-ray, CT, MRI ● History of present illness, chief complaint
● baseline vital signs ● Past medical history
● genetic considerations ● Medical conditions
● Signs of abuse ● Previous hospitalization/surgery
● Allergies
● Drug maintenance
● Substance abuse
Overall goal is to identify risk factors and plan care to
ensure patient safety throughout surgical experience. Psychological Aspect

● Establish baseline data for comparison in the ● Feelings towards surgery

intraop and postop. ● Understanding of the procedure, risks involved
● Determine the client’s psychological status. ● Fears may be related to fear of the unknown or
● Determine the physiologic factors directly or of death, anesthesia, complications
indirectly related to the surgical procedure. ● Body image disturbance
● Participate in the identification and ● Past experiences
documentation of the surgical site. ● Preop and postop instructions
● Identify prescription drugs, OTC drugs, and ● Coping strategies
herbs. ● Support system
● Review the results of all preoperative diagnostic
studies in the patient’s chart. HOPE is the strongest method of coping.
● Identify cultural and ethnic factors.
Nursing interventions: ● People who abuse drugs or alcohol frequently
deny or attempt to hide it.
● Provide support ● Nurse obtaining the health history needs to ask
● Be a good listener, be emphatic, and provide direct questions with patience, care, and a non
information that helps alleviate concerns judgemental attitude.
● Give opportunities to ask questions and be ● If emergency surgery is required, local, spinal, or
acquainted with those who might be providing regional block anesthesia is used for minor
care during and after surgery surgery. To prevent vomiting and potential
● Acknowledge concerns or worries about aspiration, an NGT is inserted before GA is
impending surgery by listening and administered.
communicating therapeutically
● Explore any fears with client and arrange for the Respiratory Status
assistance of other health professionals if
needed. ● The goal for surgical patients is optimal
respiratory function.
Spiritual & Cultural Needs ● Surgery postponed if the patient has a
respiratory infection.
● Preferred language ● Patients with underlying respiratory disease are
● Therapeutic use of touch (OR NOT) assessed carefully for current threats to their
● Regardless of the patient’s religious affiliation, pulmonary status.
spiritual beliefs can be as therapeutic as ● Patients who smoke are urged to stop 4 to 8
medication. weeks before surgery to significantly reduce
● Respecting individual beliefs and preferences. pulmonary and wound healing complications
● Provision of time for prayer.
● Arrange for a visit from spiritual adviser/ Cardiovascular Status
clergyman as desired.
● Take into consideration religious beliefs in the ● The goal is to ensure a well-functioning
operative care (BT and removal of body parts) cardiovascular system to meet the oxygen, fluid,
● One’s culture may require that the family be and nutritional needs of the perioperative period.
included in decision-making. ● Uncontrolled hypertension may cause
postponement of surgery until the blood
Medication Use pressure is under control.
● At times, surgical treatment can be modified to
● Pre Op medications (antiemetics, meet the cardiac tolerance of the patient
anticholinergics, sedatives, and antibiotics)
● Post Op pain control Hepatic and Renal Function
● Drug interactions with anesthetic agents can
cause serious problems, such as arterial ● The goal is optimal function of the liver and
hypotension and circulatory collapse urinary systems so that medications, anesthetic
● Certain drugs may interfere with wound healing agents, body wastes, and toxins are adequately
(e.g. anticoagulants) metabolized and removed from the body.
● Document present and past medication ● The liver is important in the biotransformation of
including otc preparations, including herbal anesthetic compounds. Therefore, any disorder
agents and frequency used of the liver has an effect on how anesthetic
agents are metabolized.
Pre Op Teachings
Endocrine Function
1. Deep breathing & coughing exercises
2. Incentive spirometry, moving and positioning ● A diabetic who is undergoing surgery is at risk
3. Feet and leg exercises for hypoglycemia and hyperglycemia.
4. NGT and other contraptions ● Hypoglycemia may develop during anesthesia or
5. Wound dressings (JP drain, penrose drain, etc) postop from inadequate carbohydrates or
excessive administration of insulin.
Nutritional and Fluid Status ● Hyperglycemia can increase the risk for surgical
wound infection as a result from the stress of
● Include overnutrition and undernutrition surgery can trigger increased levels of
● Nutritional problems impair the ability to recover catecholamine. Other risks are acidosis and
from surgery glucosuria.
● Obese or very thin can be protein & vitamin ● Patients who have received corticosteroids are
deficiency (Vit A, C, B complex). These at risk for adrenal insufficiency. Use of
important substances are essential for wound corticosteroids for any purpose during the
healing preceding year must be reported. Monitor for
● The older adult is often at risk for malnutrition signs of adrenal insufficiency.
and fluid volume deficits ● Uncontrolled thyroid disorders are at risk for
● Dehydration, hypovolemia and electrolyte thyrotoxicosis (with hyperthyroid disorders) or
imbalances can lead to significant problems in respiratory failure (with hypothyroid disorders).
patients with comorbids Therefore, the patient is assessed for a history
of these disorders.
Dentition
Immune Function
● Dental caries, dentures and partial plates are
particularly significant to the anesthesiologist ● Important to identify and document any
because decayed teeth or dental prostheses sensitivity to medications and past adverse
may become dislodged during intubation and reactions and allergies.
occlude the airway ● Immunosuppressed patients are highly
susceptible to infection. Great care is taken to
Drug or Alcohol Use ensure strict asepsis.
General Preoperative Nursing Interventions

1. Patient Teaching
a. Deep Breathing, Coughing & Incentive
Spirometry
b. Mobility And Active Body Movement
c. Pain Management
d. Cognitive & Coping Strategies
2. Psychosocial Interventions
a. Reducing Anxiety, Decreasing Fear
b. Cultural, Spiritual And Religious Beliefs
3. Maintaining Safety
4. Managing Nutrition & Fluids
5. Skin And Bowel Preparation

Expected Outcomes

● Relief of anxiety
● Decreased fear
● Understanding of the surgical interventions
● Minimal to no evidence of preoperative
complications

Preparation on the day of the surgery

● Morning bath and mouth care.

● Provide a clean gown
● Remove hair pins, braid long hair and cover hair
with cap
● Remove dentures, foreign materials, colored nail
polish, hearing aids, glasses and contact lens.
● Take baseline vital signs before pre-op meds
● Check the ID band.
● Check for special orders: enema, gastric tube,
IV line.
● Have the client void before preoperative
medications.
● Continue to support emotionally.
● Accomplish the pre op checklist

Checklist

● Informed consent
● Multidisciplinary conference
● Laboratory tests
● Skin preparation
● Bowel preparation
● IV fluids
● Preoperative meds
● Removal of dentures, nail polish & jewelries
● NPO status
 INTRAOPERATIVE NURSING
OR Attire
MANAGEMENT
Proper Attire must be strictly observed in the OR
Intraoperative Nursing
● Scrub suit/dress (dark to light)
The period the client is admitted to the OR and
● Head cover (disposable)
transferred to the OR room table, the administration of
● Shoes
anesthesia until the surgical procedure is done and the
● Mask (surgical/ n95)
patient is brought to the recovery room or PACU. The
● Sterile gown (provided by the hospital)
care during and after surgery.
● Sterile gloves (size mo!!)
Nursing priorities
What is Asepsis?
● Reduce anxiety and emotional trauma
Principles of Surgical Asepsis
● Provide physical safety
● Prevent complications
● Asepsis is the absence of microorganisms
● Safeguard from injuries
● Remove or kill microorganisms from hands and
● Provide info about disease process/surgical
objects
procedure, prognosis, and treatment needs
● The ideal approach but not absolute
● Skin cannot be sterilized
Nursing Diagnosis
● Some areas cannot be scrubbed
● Infected areas are grossly contaminated
● Risk for positioning injury ● Air is contaminated by dust and droplets
● Risk fro infection
● Risk for altered body temperature
What is Surgical Conscience?
● Risk for injury from mechanical/ thermal sources
● The basis upon which the OR nurse’s skill and
Goals of Care
techniques are built. The OR nurse and all other
team members should never be reluctant to
● The patient is free from signs and symptoms of admit a possible break in technique, even if
injury caused by extraneous objects there is doubt about it.
● The patient is free from s/s of injury related to
positioning
WHEN IN DOUBT, DISCARD!
● Safe administration of anesthesia, right patient,
right procedure, correct site
Sources of Infection
● The patient Is free from s/s of infection
● The patient’s fluid, electrolyte and acid base
● The sources of infection should be efficiently
balances are consistent with or improved from
managed in order to control infection
baseline levels established preoperatively
● Air, water, food, man-made objects, skin,
mucous membranes, throat, and soil are
THE OPERATING ROOM
potential carriers of bacteria
● In any OR facility, there are particular possible
Hot and Humid Environment = Bacteria
sources of contamination, which are a threat to
an open incision. The following are the possible
OR should be situated in the center!! MDMRC is an sources of infection.
exception because MDMRC is not originally a hospital. ○ The entire surgical team
○ The surgical patient
Laminar flow/ Hepa Filters – nasa ceiling, may positive ○ All items used in the wound and on the
pressure, yung air palabas. sterile setup
○ Dust in the air
Physical Environment ○ Other OR personnel and visitors
May red line sa floor = red zone! Principles of Aseptic Technique
Department Layout: Three distinct zone

1. Unrestricted zone – people in street clothes interact

with those in scrub attire (entrance, reception desk)

2. Semi-restricted zone – surrounding support areas

and corridors (holding area, PACU)

3. Restricted zone – the red zone

Environmental Control
 Sterile – below your shoulders up to waist Interns/ Clerks

Intraoperative Complications ● Usually, the extra pair of hands to help for a

smooth surgery
● Hypoventilation ● Must show initiative to gain knowledge and learn
● Hypotension new skills from the surgeons
● Cardiac dysrhythmia ● · Surgeons help them in making important
● Hypothermia decisions like what field to pursue in the future
● Peripheral Nerve Damage
● Malignant Hyperthermia Scrub Nurse
● Hemorrhage
● TABLE DEATH ● Serve the gowns and gloves and assists the
surgical team
Potential Liabilities ● Serves the instruments and anticipates the
needs of the tam throughout the surgery
● Loss of sponges, Falling, Burns, Wrong site, ● Ensures that the operative field is in good order
Wrong person, Wrong surgery
● Tissue specimens, right to privacy, Personal Circulating Nurse
Property Defective Equipment
● Overall responsible for the overall running of the
Health Hazards OR before, during and after the surgery
● Ensures that all paper works are properly filled
● Faulty equipment exposure to toxic substances up and documentation is done
as well as infectious waste, cuts, needlestick ● Cares for the patient immediately after surgery
injuries and lasers. Internal monitoring of the OR and clean up the OR after
includes the
● Regardless of the size or location of an incision, Position
unintentional retention of an object (sponge,
instrument) , laser risk, inhalation of the laser ● Supine
plume, fire and electrical hazards. ● Trendelenburg
● Exposure to blood and body fluids ● Reverse Trendelenburg’s
● Lithotomy
The Surgical Team (roles and responsibilities) ● Prone
● Lateral
Two teams: Sterile and Unsterile ● Fowler’s
● Jack knife
Surgeon
Regions
● The captain of the ship
● The leader of the surgical team and has the
ultimate responsibility of performing the surgery
safely and correctly
● Dependent upon other members of the team
from the patient’s emotional well-being and
physiologic monitoring
● Make certain that all team members are aware
of what is needed, and all equipment are
available
● Responsible for obtaining informed consent,
postoperative management

Anesthesiologist Common Incisions

● Monitors the overall condition of the patient
● Administers the anesthetic to the patient
● Monitors cardiac and respiratory status, VS, and
urine output throughout the procedure
● Gives the STOP and GO or PAUSE signal to the
team

Assist to the Surgeon

● Can be another physician

● Primary responsibility is to help the surgeon in
any way requested like holding retractors, Services in OR
draping, and placement of equipment and
supplies ● ENT/ORL
● Helps in hemostasis suturing and placement of ● General Surgery
dressings ● Plastic & Reconstructive Surgery
● Goal is to make everything easier for the ● Neurosurgery
surgeon ● Urology
● May perform some portions of the surgery under ● Pediatric Surgery
direct supervision ● Orthopedics
● Obstetrics & Gynecology
● Minimally Invasive Surgery

ORL – Otorhinolaryngology
 The Surgical Experience ● RR shallow, pulse weak, thready
● Pupils widely dilated and nonreactive
Anesthesia ● Cyanosis develop, very deep CNS depression
with loss of respiration and vasomotor center
● Greek word – anesthesia, an (without) aesthesis stimuli, in which death can occur rapidly
(sensation) ● Marked by hypotension or circulatory failure
● Induced state of partial or total loss of sensation, ● Considered critical period because anesthesia
occurring with or without loss of consciousness has become too intense (comatose/death)
● Used to block nerve impulse transmission, ● Nursing Resp: if arrest occurs, respond
suppress reflexes, promote muscle relaxation, immediately to assist in establishing the airway.
and in some instances, achieve a controlled Provide cardiac arrest tray, drugs, syringes, long
level of unconsciousness needle. Assist surgeons with closed or open
cardiac massage.
Types of Anesthesia

1. General – whole body

● Reversible loss of consciousness and sensation
induced by inhibiting neuronal impulses in
several areas of the CNS
● Achieved by a single agent or a combination of
agents
● CNS in depressed, resulting in analgesia,
amnesia, and unconsciousness, with loss of
muscle tone and reflexes

4 stages:

induction Common Complications

● Characterized by loss of pain sensation. Patient ● Direct trauma to the mouth

still conscious and able to communicate. ● Slow recovery from anesthesia due to drug
● Warmth, Dizziness, Detachment may be interactions or inappropriate choice of drug
experienced dosage
● Ringing, roaring, or buzzing in the ears, still ● Hypothermia due to long operation with
conscious but with inability to move extremities extensive fluid replacement/ cold blood
● Noises are exaggerated, limit noises and transfusion
motions ● Allergic reaction to anesthetic agent
● Nursing Resp: close door, avoid unnecessary ○ Minor Effect: post-op N/V, vomiting,
noise or motions nausea
○ Major Effect: CVS collapse, respiratory
Excitement depression

● Period of excitement and often combative

behavior with many signs of sympathetic
stimulation 2. Regional Anesthesia
● Struggling, shouting, talking, singing, laughing, ● Loss of sensation in an area of the body but
crying (but often voided if anesthetic agent is remain conscious. Patient awake and aware of
administered smoothly) his or her surroundings unless medications are
● Pupils dilate but constrict in light, PR rapid, RR given to produce mild sedation or to relieve
irregular anxiety
● REM stage; from loss of consciousness to loss ● Anesthetic agents are injected around nerves so
of lid reflex that the region supplied by these nerves is
● Nursing Resp: assist anesthesiologist in anesthetized
restraining patients to ensure safety. Touch the ● OR TEAM must avoid careless conversation, or
patient only for purpose restraint. anything that may contribute to the patient’s
negative response to surgical experience
Surgical anesthesia
Types of Regional Anesthesia:
● Continued administration of the anesthetic vapor
or gas, patient unconscious and lies quietly on EPIDURAL - by injecting a local anesthetic
the table agent into the epidural space that surrounds the
● Pupils small but reactive dura mater of the spinal cord. blocks sensory,
● RR is irregular, PR normal motor, and autonomic functions.
● Involves muscle relaxation
● Loss of lid reflex to loss of most reflex SPINAL - an extensive conduction nerve block
● It is the stage in which operation is safely that is produced when a local anesthetic agent is
performed introduced into the subarachnoid space at the
● Nursing Resp: Begin preparation for surgery lumbar level usually between L4 and L5.
only when anesthetist indicated stage 3 has
been reached & client is breathing well with a LOCAL BLOCK - brachial plexus block,
stable VS paravertebral anesthesia, trans sacral (caudal)
● Not everyone is ok for GA block

Medullary depression (OVERDOSE) Small number = small size

● Reached if too much anesthesia has been

administered
 3. Moderate Sedation
● IV administration of sedatives or analgesics
medications to reduce patient anxiety and
control pain during diagnostic or therapeutic
procedures
● The goal is to depress a patient’s level of
consciousness to a moderate level to enable
surgical, diagnostic, or therapeutic procedures to
be performed while ensuring the patient’s
comfort during and cooperation with the
procedures
● Respond purposefully to verbal commands/light
touch/ painful stimuli

4. Monitored Anesthesia Care (MAC)

● Minor surgical procedures and for some critically

ill patients who may be unable to tolerate
anesthesia without extensive invasive
monitoring and pharmacologic support
● Moderate sedation administered by anes or
anesthetist who must be prepared and qualified
to convert to GA

Local Anesthesia
 POSTOPERATIVE NURSING ● Language barrier
● Location of patient’s family
MANAGEMENT
PHASES OF POSTANESTHESIA CARE UNIT (PACU
PROGRESSION)
POST OPERATIVE PHASE
Phase I PACU
● Begins at the time the surgeon completes the
work of the surgery up to the follow-up check up
● Immediate recovery phase, intensive care
● OR Nurse & anesthesiologist endorses patient
provided
to the PACU Nurse
● Patient may also be transferred to the ICU
Phase II PACU
(CCU, SICU, NICU, MICU, PICU, ETC)
● Patient is prepared for self-care or care in the
POST ANESTHESIA CARE UNIT
hospital, or an extended care setting
● Located adjacent to the OR suite
Phase III PACU
● Patients still under anesthesia or recovering
from anesthesia are placed in this unit for easy
● Preparation for discharge
access to experienced, highly skilled nurse,
anesthesiologists or anesthetists, surgeons,
advanced hemodynamic and pulmonary Total Patient Care = all problems from admission
monitoring
FACTORS INFLUENCING POST-OP OBSERVATION
GOALS OF PACU CARE
● Patient’s condition
● Maintain client safety during recovery from ● Need for physiologic support
anesthesia ● Complexity of surgical procedure
● Maintain adequate body system functions ● Type of anesthesia
● Alleviate pain and discomfort ● Need for pain management
● Prevent post op complication ● Prescribed period for monitoring physiologic
● Identify actual and potential problems that may status
occur
● Ensure adequate discharge planning and EVERY 15 MINUTES ANG MONITORING VS!
teaching-
ASSESSING THE PATIENT
ROLES OF THE NURSE
Cornerstones of Nursing Care
● Supporting ventilation and perfusion
● Maintaining fluid and electrolyte balance ● Airway-Breathing-Circulation
● Promoting comfort ● Skin Color
● Reducing infection ● Level of Consciousness
● Promoting safely ● Ability to respond

PATIENT ADMISSION Next to Check

● Anesthesiologist at the head of the stretcher and ● Baseline VS

nurse at the opposite end ● Surgical site
● Transport involves special consideration of the ● Tubes & IV lines
incision site, potential vascular changes, and ● IV fluids & medication
exposure
● Surgical incision is considered every time patient MAINTAINING A PATENT AIRWAY
is moved too quickly form one position to
another ● Maintain ventilation
● Orthostatic hypotension may occur when a ● Prevent hypoxemia (low oxygen in blood)
patient is moved too quickly from one position to ● Prevent hypercapnia
another ● Administer oxygen
● Soiled gown, replaced with a dry gown, patient ● RR, O2 sat, breath sounds
covered with lightweight blankets and warmed
● Side rails raised to prevent falls WHAT ARE THE FLAG SIGNS OF AN OCCLUDED
● PACU nurse reviews essential information with AIRWAY?
the anesthesiologist and the OR nurse
● Monitoring equipment Is attached, and oxygen ● Choking
applied, and immediate physiologic assessment ● Noisy & irregular respirations
is conducted ● Decreased O2 saturation
● Cyanosis
ENDORSEMENT

● Patient name, gender, age

● Surgical procedure
● Anesthetic agents used
● Estimated blood loss/ fluid loss
● Fluid/ blood replacement
● Vital signs– significant problems
● Complications encountered (anesthetic or
surgical)
● Preoperative medical diagnosis
● Considerations for immediate post op period
SIGNS OF INADEQUATE OXYGENATION According to Onset

● Delayed capillary refill ● Primary – during operation

● Weak peripheral pulses ● Intermediary – first few hours after surgery
● Decreased O2 saturation ● Secondary – occurs some time after surgery,
● Restlessness, agitation, confusion ligature or ties slips from blood vessels
● Flushed cool or moist skin, cyanosis
● Urine output <0.5ml/kg/hr RELIEVING PAIN AND ANXIETY
● Increased to absent respiratory effort
● Abnormal breath sounds IV opioids provide immediate pain relief and are
● Use of accessory muscles short-acting, thus minimizing the potential for drug
interactions or prolonged respiratory depression while
anesthetics are still active in the patient’ s system.

HIGH RISK INDIVIDUALS

● Received GA
● Older than 55 years of age
● History of tobacco use
● Lung disease and sleep disorder breathing
● Obese
● With comorbidities
● Undergone airway, thoracic or abdominal
surgery
CONTROLLING NAUSEA & VOMITING
MAINTAINING CARDIOVASCULAR STABILITY
Nausea and vomiting are common issues in the PACU.
● patient’ s mental status The nurse should intervene at the patient’ s first report of
● vital signs nausea to control the problem rather than wait for it to
● cardiac rhythm progress vomiting.
● skin temp., color, and moisture
● urine output DETERMINING READINESS FOR DISCHARGE FROM
THE PACU
THE PRIMARY CARDIOVASCULAR COMPLICATIONS
● Easily aroused
● hypotension and shock ● full orientation
● hemorrhage ● ability to maintain and protect airway
● hypertension ● stable VS for at least 15-30 mins
● dysrhythmias ● ability to call for help if necessary
● no obvious surgical complications
TYPE OF SHOCK ● a score of 9 or 10 of ALDRETE SCORE
● hypovolemic (caused by too little blood volume)
● cardiogenic (due to heart problems)
● neurogenic (caused by damage to the nervous
system)
● anaphylactic (caused by allergic reactions)
● septic shock (due to infection)

Signs:

● pallor
● cool, moist skin
● rapid breathing
● cyanosis of the lips, gums, and tongue
● rapid, weak, thready pulse
● narrowing pulse pressure low blood pressure
concentrated urine. ADMISSION TO WARD

PRIMARY INTERVENTION: Volume Replacement of ● Room readied by assembling the necessary

LR, PNSS, or COLLOIDS equipment & supplies: IV pole, drainage
receptacle holder, suction equipment, oxygen,
HEMORRHAGE emesis basin, tissues, disposable pads,
blankets, and documentation forms.
According to Source ● Any additional items are communicated.
● PACU nurse reports relevant data about the
● Capillary – oozing blood patient to the receiving nurse
● Venous – dark colored bleeding ● Usually, the surgeon speaks to the family after
● Arterial – bright red & high-pressure bleeding surgery and relates the general condition of the
patient.
● Nurse reviews the post op orders, admits the
According to location
patient to the unit, performs initial assessment
and attends to the patient’ s immediate needs.
● Evident – bleeding site is readily visible
● Concealed – bleeding cannot be seen, internal
NURSING INTERVENTIONS Potential Nursing Diagnosis

● Assess breathing and administer supplemental ● Risk for ineffective airway clearance related to
oxygen, if prescribed. depressed respiratory function, pain, and bed
● Monitor vital signs and note skin warmth, rest
moisture, and color. ● Acute pain related to surgical incision
● Assess the surgical site and wound drainage ● Decreased cardiac output related to shock or
systems. Connect all drainage tubes to gravity hemorrhage
or suction as indicated and monitor closed ● Risk for activity intolerance related to
drainage systems. generalized weakness secondary to surgery
● Assess level of consciousness, orientation, and ● Impaired skin integrity related to surgical incision
ability to move extremities. and drains
● Assess pain level, pain characteristics (location, ● Ineffective thermoregulation related to surgical
quality) and timing, type, and route of environment and anesthetic agents
administration of last dose of analgesic. ● Risk for imbalanced nutrition, less than body
● Administer analgesics as prescribed and requirements related to decreased intake and
assess their effectiveness in relieving pain increased need for nutrients secondary to
● Place the call light, emesis basin, ice chips (if surgery
allowed), and bedpan or urinal within reach. ● Risk for constipation related to effects of
● Position the patient to enhance comfort, safety, medications, surgery, dietary change, and
and lung expansion. immobility
● Assess IV sites for patency and infusions for ● Risk for urinary retention related to anesthetic
correct rate and solution. agents
● Assess urine output in closed drainage system ● Risk for injury related to surgical
or the patient’ s urge to void and bladder procedure/positioning or anesthetic agents
distention. ● Anxiety related to surgical procedure
● Reinforce the need to begin deep breathing and ● Risk for ineffective management of therapeutic
leg exercises. regimen related to wound care, dietary
● Provide information to the patient and family restrictions, activity recommendations,
medications, follow-up care, or signs and
symptoms of complications

NURSING MANAGEMENT AFTER SURGERY Discharge from Ambulatory Surgery

● During the first 24 h after surgery, nursing care Must be stable,mobile alert and able to provide
involves continuing to help the patient recover degree of self care
from the effects of anesthesia. MUST NOT drive
● Assessing physiologic status, complications,
Accompanied by adult at the time of discharge
manage pain, encourage ambulation
● In the initial hours after admission to the ward, Assess the readiness for d/c and home care
adequate ventilation, hemodynamic stability, needs
incisional pain, surgical site integrity, n&v, Determine:
neurologic status, and spontaneous voiding are ● Availability of caregivers
primary concerns. ● Access to pharmacy
● PR, BP, and RR Q15 mins for the first hour and ● Access to phone
every 30 mins for the next 2h. ● Access to follow-up care
● Temp monitored Q4 for the first 24h Follow-up phone call to evaluate status
● Patients usually begin to return to their usual
state of health several hours after surgery or
after awaking the next morning. Although pain Discharge Instruction
may still be intense, many patients feel more
alert, less nauseous, and less anxious. ● Symptoms to report
● Breathing and leg exercises as appropriate, ● When and how to take prescribed drugs and
dangling of legs over the edge of the bed, stood, possible side effects
or assisted out of bed to the chair at least once. ● Care of incision and any dressing
● Many will have tolerated a light meal and had IV ● Bathing recommendation
fluids discontinued. The focus of care shifts from ● Activities, prohibition when various activities can
intense physiologic management and be resumed safely
symptomatic relief of the adverse effects of ● Dietary restriction and modifications
anesthesia to regaining independence with ● Where and when to return for follow-up
self-care and preparing for discharge. appointment
● Answer to any questions or concerns

POTENTIAL COMPLICATIONS

● Malignant hyperthermia
● Pulmonary infection/hypoxia
● Deep vein thrombosis (DVT)
● Hematoma or hemorrhage
● Infection
● Pulmonary embolism
● Surgical site infection
● Wound dehiscence or evisceration
 Oxygenation
Defenses of the Airways & Lungs
Concepts of Oxygenation ● Nose
● Is part of the vascular system that carries blood ● Mucocilliary blanket- 2-10 mm
from the left ventricle to organs and tissues of ● Pulmonary alveolar macrophage activity
the body ● Mucociliary escalator system
● Is the process of delivering O2 from the alveoli
to the tissue sin order to maintain cellular activity
● Is part of the gas exchange process, wherein
oxygenation occurs simultaneously with the
elimination of carbon dioxide from the
bloodstream to the lungs

Systems Involved In Oxygenation

● Respiratory System
● Cardiovascular System
● Circulatory System

Measuring Oxygen, Carbon Dioxide, And Acid-Base

Levels
● Pulse oximetry – (SpO2) Normal: 95>
● Arterial blood gasses – (PaO2) Normal: 80 to
100

REVIEW ON ANATOMY AND PHYSIOLOGY

Respiratory System
● Conducting zone - structures serve as conduit to
and from the respiratory zone
● Respiratory zone - only site of gas exchange

Functions:
● Oxygen transport Reflexes of the Airways
● Sneeze Reflex
● Cough Reflex
● Reflex-bronchoconstriction
● Hering-Breuer Reflex

Substance important in Alveolar Expansion

● Surfactants
○ Lines the alveoli
○ Fatty protein provides surface stability

Respiratory Centers

● Respiration

● Ventilation

Terms:
● Diffusion
● Perfusion
● Distribution

Ventilation/ Perfusion Ratio

● V determines the quantity of oxygen mass
reaching the alveoli per minute (g/min)
● Q expresses the flow of blood in the lungs
(l/min)
Other functions: acid-base balance, phonation,
pulmonary defense
 ELECTROPHYSIOLOGY OF THE HEART
● consist of electrical cells and mechanical cells.

Mechanical properties of the heart

● Automaticity
● Excitability
● conductivity
● Contractility
● Extensibility

The conduction System

● The electrical impulses from the heart muscle
cause the heart to contract. This electrical signal
Extreme Alterations of V/Q begins in the sinoatrial (SA) node
● Shunt
● Dead space

Mechanics of Breathing: Physical Factors

● Air pressure variance
● Airway resistance
● Compliance

Cardiovascular System
Heart

Blood Flow to the Heart

4 Chambers of the Heart

Systemic Circulation
● the part of the vascular system that carries blood
from the left ventricle to organs and tissues of
the body

Valves of the Heart

Layers of the Heart Wall

Blood Supply
● Left Coronary Artery
● Right Coronary Artery
 UPPER RESPIRATORY TRACT
Rhinosinusitis
INFECTION
● formerly called sinusitis, an inflammation of the
Rhinitis paranasal sinuses and nasal cavity. It can be
caused by a bacterial or viral infection
● a group of disorders characterized by
inflammation and irritation of the mucous Classification:
membranes of the nose due to viruses, bacteria,
or irritants
1. Acute rhinosinusitis (less than 4 weeks)
2. Subacute rhinosinusitis (4 to 12 weeks)
Types: 3. Chronic rhinosinusitis (more than 12 weeks)
1. Allergic Complications:
a. Seasonal
b. Perennial
● Osteomyelitis
2. Nonallergic
● Mucocele
a. Drug-induced rhinitis
● Cavernous sinus thrombosis
● Meningitis
Etiologic Factors ● Brain abscess
● Ischemic brain infarction
● Plant Pollens Molds Dust Mites Animal Bites ● Severe orbital cellulitis
Chemicals Foods Medicines Insect venom
● Certain infections CLinical Manifestations
● Certain medications
● Eating and drinking
● Purulent nasal drainage
● Weather or temperature changes
● Postnasal drip
● Aging
● Nasal discharge or stuffy nose
● Hormonal changes or pregnancy
● Facial pain pressure
● Consumption of alcohol, especially red wine
● Localized or diffuse headache
● Inflammation or irritation in the nose unrelated to
● Pain in your teeth or ears
allergy
● Halitosis
● Nasal symptoms of other medical conditions
● Cough
● Fatigue
Clinical Manifestations ● Fever
● Rhinorrhea (excessive nasal drainage, runny Diagnostic Examinations
nose)
● Nasal congestion Nasal discharge (purulent with
● Medical history
bacterial rhinitis)
● Physical examination
● Sneezing
● Diagnostic imaging (X-ray, CT scan, MRI)
● Pruritus of the nose, roof of the mouth, throat,
● Flexible endoscopic culture and swabbing
eyes, and ears.
Medical Management
Diagnostic Examinations
● Oral antibiotics (ARBS)
● Intranasal saline lavage
● Decongestants
Medical Management ● Antihistamines
● Intranasal corticosteroids
● Desensitizing immunizations
● Pharmacologic therapy Nursing Management
○ Corticosteroids
○ Antihistamines
● Promote drainage of the sinuses.
○ Decongestant agent
● Instruct the use of warm compresses to relieve
○ Intranasal ipratropium
pressure.
● Educate the patient about symptoms of
Nursing Management complications requiring immediate follow-up.
● Advise the patient to avoid swimming, diving,
● Instruct to avoid or reduce exposure to allergens and air travel during the acute infection.
and irritants. ● Instruct the patient to immediately stop smoking
● Instruct about controlling the environment at or using any form of tobacco.
home and work. ● Instruct the patient about the correct use of
● Saline nasal or aerosol spray may be helpful in prescribed nasal sprays.
soothing mucous membrane and softening ● Educate the patient about the side effects of
crusted secretions. prescribed and OTC nasal sprays and about
● Instruct proper technique for administration of rebound congestion.
nasal medication. ● Administer prescribed analgesics
● Emphasize hand hygiene
● In elderly, emphasize the value of receiving
vaccination
● Increase oral fluid intake
● Encourage rest.
 ● Dispose nasal discharges appropriately.
● Examine skin once or twice daily for possible
Pharyngitis rash.
● Warm saline gargles or irrigations.
● Is the inflammation of the mucous membranes ● Ice collar for severe sore throats.
of the oropharynx, also known as sore throat ● Oral care
● Instruct patient on preventive measures
Types

1. Hypertonic
a. characterized by general thickening and Tonsillitis
congestion of the pharyngeal mucous
membrane. ● Inflammation of the tonsils
2. Atrophic Pharyngitis
a. probably a late stage of the first type Etiologic Factors
(the membrane is thin, whitish,
glistening and at times wrinkled. ● Epstein–Barr virus
3. Chronic granular pharyngitis ● Adenovirus, rhinovirus, influenza
a. “clergyman’ s sore throat” ● Group A β-hemolytic streptococcus (GABHS)
4. characterized by numerous swollen lymph ● Less common bacterial causes: staphylococcus
follicles on the pharyngeal wall aureus, streptococcus pneumoniae

Etiologic Factors CLinical Manifestations

● Adenovirus, influenza virus, Epstein–Barr virus, ● Red, swollen tonsils

and herpes simplex virus ● White or yellow coating or patches on the tonsils
● Group A streptococcus (GAS) ● Sore throat
● Allergy ● Dysphagia/Odynophagia
● Trauma ● Fever
● Toxins ● Lymphadenopathy
● Neoplasia ● Mouth breathing
● Earache; draining ears
CLinical Manifestations ● Acute mastoiditis
● Foul-smelling breath
● Fiery-red pharyngeal membrane and tonsils ● Voice impairment
● Pharyngeal and tonsillar erythema ● Noisy respiration
● Tonsillar hypertrophy with or without exudates
● White-purple exudate Diagnostic Examinations
● Anterior cervical lymphadenopathy
● Palatal petechiae ● Medical history
● Odynophagia ● Physical examination
● Dysphagia ● Rapid strep test
● Fever (with or without chills) ● Throat culture
● Body malaise ● Audiometric assessment (suppurative otitis
● Vomiting media)
● Anorexia
Medical Management
Diagnostic Examinations
● Antimicrobial therapy – GABHS
● Rapid antigen detection testing (RADT) ● Macrolide such as erythromycin for patients
● Throat culture (criterion standard for diagnosis of allergic to penicillin
GAS infection) ● Analgesic
● Peripheral smear ● Tonsillectomy (chronic)
● Gonococcal culture if indicated by the history ● Adenoidectomy
● Excisional biopsy to rule out lymphoma
Medical Management
Nursing Management
● Secure airway if necessary
● Pharmacological therapy ● Promote supportive measures:
○ Bacterial pharyngitis – Penicillin (DOC) ○ Increased fluid intake.
○ Cephalosporins and macrolides ○ Analgesic as ordered.
○ Analgesics ○ Salt-water gargles.
● Nutritional therapy ○ Provide rest.
○ Cool beverages, warm liquids, and ● Post operative management:
flavored frozen desserts ○ Position: prone with head turned to the
○ Increase oral fluid intake side
○ Monitor vital signs.
Nursing Management ○ Do not remove the oral airway until gag
and swallowing reflexes have returned.
● Instruct the patient to avoid alcohol, smoking, ○ Apply an ice collar to the neck.
and secondhand smoke. ○ Provide basin and tissues
● Prompt initiation and correct administration of ○ Monitor for postoperative complications
prescribed antibiotic therapy. ● Promote nutritional therapy:
● Instruct the patient about signs and symptoms of ● Liquid or semi liquid diet for the 1st few days.
complications. ● Avoid hot, spicy, acidic foods.
● Instruct the patient to stay in bed during the ● Avoid milk & milk products.
febrile stage. ● Avoid vigorous brushing and gargling
Laryngitis ● Determine any history of allergy or the existence
of a concomitant illness
● an inflammation of the larynx, occurs as a result ● Physical Examination
of voice abuse or exposure to dust, chemicals, ○ Inspection
smoke, and other pollutants or as part of a URI. ■ Swelling
It is also associated with gastroesophageal ■ Lesions
reflux (reflux laryngitis). ■ Asymmetry of the nose as well
as bleeding or discharge
Etiologic Factors ■ Increased redness, swelling,
exudate of the nasal mucosa.
● Viral/bacterial infections ■ Swollen nasal turbinate
● Straining the vocal cords ■ Redness, ulceration, or
● Frequent exposure to harmful chemicals or enlargement of the tonsil
allergens ○ Palpation
● Acid reflux ■ tender frontal and maxillary
● Recurrent sinus infections sinuses
● Smoking or being around smokers ■ lymph nodes for enlargement
● Low-grade yeast infections caused by frequent and tenderness
use of an asthma inhaler
Nursing Diagnoses:
Clinical Manifestations
● Ineffective airway clearance related to excessive
● Hoarseness or aphonia mucus production secondary to retained
● Severe cough secretions and inflammation.
● Dry, sore throat ● Acute pain related to upper airway irritation
● Difficulty swallowing secondary to an infection.
● Sensation of laryngeal swelling ● Impaired verbal communication related to
● Fever physiologic changes and upper airway irritation
● Coughing out blood secondary to infection or swelling.
● Difficulty breathing (mostly in children) ● Deficient fluid volume related to decreased fluid
● Difficulty eating intake and increased fluid loss secondary to
● Increased production of saliva diaphoresis associated with a fever.
● Deficient knowledge regarding prevention of
Diagnostic Examinations URIs, treatment regimen, surgical procedure, or
postoperative self-care
Medical Management
Planning and Goals
● Resting the voice.
● Avoiding irritants and inhaling cool steam or an ● Maintenance of a patent airway.
aerosol. ● Relief of pain.
● Resting the voice. ● Maintenance of effective means of
● Avoiding smoking and secondhand smoke. communication.
● Antibiotics for chronic laryngitis. ● Knowledge of how to prevent upper airway
● Corticosteroids (Beclomethasone) infections.
● Proton pump inhibitors/Histamine-2 receptor ● Absence of complications.
blockers
Nursing Interventions:
Nursing Management
● Maintaining a patent airway.
● Instruct the patient to rest the voice. ● Promoting comfort.
● Maintain a well humidified environment. ● Promoting communication.
● Encourage daily fluid intake of 2 to 3 L. ● Encouraging fluid intake.
● Instruct the patient about the importance of ● Monitoring and managing potential
taking prescribed medications. Instruct the complications
patient about signs and symptoms of
complications. Evaluation
● Position: semi-fowler’s position while sleeping
● Maintains a patent airway by managing
secretions.
● Reports relief of pain and discomfort using pain
NURSING PROCESS: UPPER AIRWAY INFECTION intensity scale.
(ADPIE) ● Demonstrates ability to communicate needs,
wants, level of comfort.
Assessment ● Maintains adequate fluid and nutrition intake.
● Utilizes strategies to prevent upper airway
● Health history: infections and dallergic reaction.
○ Headache ● Demonstrates an adequate level of knowledge
○ sore throat and performs self-care adequately.
○ pain around the eyes and on either side ● Becomes free of signs and symptoms of
of the nose infection
○ difficulty in swallowing ● Absence of complications
○ Cough Hoarseness
○ Fever
○ Stuffiness
○ Generalized discomfort and fatigue
● Precipitating/aggravating factors
Chronic Obstructive Pulmonary DIsease Results to impaired gas exchange.
[COPD] Dead space = no gas exchange
● Obstructed Pulmonary System
Decreased alveolar surface dead space and impaired
● Obstruction can be caused by inflammation
oxygen diffusion
● Chronic = recurrent ng inflammation
Oxygen diffusion (higher to lower concentration)
Chronic Obstructive Pulmonary Disease
Later stage: Respiratory acidosis
● Slowly progressive respiratory disease of airflow
obstruction involving the airways, pulmonary
May retention ng carbon dioxide, decrease excretion
parenchyma, or both.
(hypercapnia)
○ Parenchyma = lung tissues (bronchi,
blood vessels, alveoli)
Decrease oxygen in blood - hypoxemia
● Include diseases that cause airflow obstruction
(emphysema, chronic bronchitis)
Complications:
Cystic Fibrosis – affects the mucus secreting gland
● Pulmonary hypertension (destruction of alveoli >
decrease size of pulmonary capillary bed >
COPD IS SYMPTOMATIC
increase ang resistance sa blood flow
(compensatory mechanism > increase pressure
High risk of developing heart disease, lung cancer and a
/ heart (RV) will pump more)
variety of other conditions.
● Cor pulmonale (pulmonary heart failure)
As the person ages, lung function decreases.
There’s over distention of alveoli > destruction of
Inflammatory response:
Types:
● proximal and peripheral airways (inflammation
1. Panlobar (Panacinar) – destruction of the
on trachea or bronchi)
bronchiole, alveolar duct, and alveolus (enlarged
● lung parenchyma
spaces)
● pulmonary vasculature
2. Centrilobular – center of the secondary lobule,
preserving portions of the acinus (pathologic
PATHOPHYSIOLOGY
change, derangement of v/q ratio > hypoxemia
or excretion of co2)
● Body won’t release response unless there are
foreign particles inside. Since may foreign
Ventilation – oxygen going into the pulmonary bed
particles, magkakaroon ng inflammation
response.
Perfusion – amount of blood
● There will be scar formation if inflammation
response is recurrent.
Polycythemia – increased RBCs affecting the
● Scar is fibrous (matigas) will lead to narrowing of
circulation making it flaggish
airway. Size is < 2 mm in diameter, which affects
the oxygen delivery
● This could irritate the goblet cells and glands. Low oxygen, body will produce more RBCs to
● If the goblet cells are irritated, mucus compensate
production is increased.
● Narrow airway + increased mucus = COPD RBC hemoglobin – oxygen carrying

Deoxy blood will be delivered leading to hypoxemia and Etiologic Factors

hypoxia.
1. Exposure to tobacco smoke (80% to 90%)
Elastic recoil facilitates gas exchange. 2. Increased age
3. Occupational exposure—dust, fumes, chemicals
Chronic Bronchitis 4. Indoor and outdoor air pollution
5. Alpha1-antitrypsin deficiency
6. Lower socioeconomic status
The presence of cough and sputum production for at
least 3 months in each of 2 consecutive years.
Smoking – depresses the activity of macrophages and
ciliary mechanism
Causes: smoke or other environmental pollutants
Carbon Monoxide (Vehicles/ Appliances) – it combines
Constant irritation causes:
with hemoglobin > carboxyhemoglobin, less efficient and
oxygen carrying ability
● increased mucus production (decrease ang
function ng cilia na taga sweep)
Increase age, decrease lung function (tidal volume)
● thickening of the bronchial walls
● narrowing of the bronchial lumen
● altered function of the alveolar macrophages Occupational exposure – dust, fumes, chemicals
(engulf foreign materials), makes the patient at
risk for infection Alpha 1 – enzyme inhibits/ protects lung tissue from
injury, lungs will be exposed if there is deficiency
Emphysema

An abnormal distention of the airspaces beyond the

terminal bronchioles and destruction of the walls of
the alveoli.
CLINICAL MANIFESTATION b. Lung Volume Reduction Surgery
c. Lung Transplantation
● Chronic cough d. Pulmonary Rehabilitation
● Sputum production
● Dyspnea (progressive) Nursing Management
● Weight loss
● Use of accessory muscles 1. Assess the patient’s vital signs/ oxygen
● Barrel chest (emphysema) (malaki ang chest, saturation
hindi maexcrete ang air) 2. Administer medications as ordered
● Cyanosis (Central – around the lips, Peripheral 3. Eliminate all pulmonary irritants
– nail bed) 4. Instruct the patient to perform directed or
● Wheezing (narrowing of airway) and crackles controlled coughing
(mucus in airway) 5. Perform chest physiotherapy with postural
● Peripheral edema (pulmonary hypertension, liliit drainage
ang pulmonary capillary bed > increase ang 6. Encourage to increase fluid intake
resistance and pressure within the bed > RV will 7. Patient education
increase BP > hindi na maayos ang circulation)
● Pursed lip breathing (controls the respiration) High caloric diet – coughing requires energy
● Tripod position
● Depression Bullae – enlarged air spac
● Tachypnea & Tachycardia

Diagnostic Examinations

● Pulmonary function test (tidal volume, vital

capacity, residual volume, total lung volume
capacity)
● Spirometry (ipablow yung ball dapat nakafloat
lang)
● Arterial blood gas (measure oxygen and co2 in
blood)
● Chest x-ray (comorbidities)
● Computed tomography (to differential diagnosis)
● Screening for Alpha 1 antitrypsin deficiency
(younger than 45 years old)

COPD Complications

● Respiratory insufficiency and failure (decrease

gas exchange)
● Pneumonia
● Chronic atelectasis
● Pneumothorax (leak of air to pleural cavity)
● Pulmonary arterial hypertension (Cor pulmonale)

Medical Management

1. Risk Reduction (smoking cessation)

2. Pharmacologic Therapy
a. Bronchodilators
b. Corticosteroid (depress immune system)
c. alpha1-antitrypsin augmentation therapy
d. antitussive agents/mucolytic
e. vasodilators
f. Nicotine replacement
g. Antidepressants
h. Nicotinic acetylcholine receptor partial
agonist
3. Management of exacerbations
a. a. Identify the cause
b. Administer the specific treatment
c. Optimization of bronchodilator
medications
4. Oxygen Inhalation (low flow)
5. Surgical Management
a. Bullectomy
 Lower Respiratory Tract Infection ● Nebulization
● Bronchoscopy (obstruction)
ATELECTASIS ● Endotracheal intubation and mechanical
ventilation
● refers to closure or collapse of alveoli ● Thoracentesis
● described in relation to chest x-ray findings ● Chest tube insertion
and/or clinical signs and symptoms.
ICOUGH Program
Types:
● Incentive spirometry
● Acute atelectasis ● Coughing and deep breathing
● Chronic atelectasis ● Oral care (brushing teeth and using mouthwash
twice a day)
Subtypes: ● Understanding (patient and staff education)
● Getting out of bed at least three times daily
● Head-of-bed elevation
● Micro atelectasis
● Macro atelectasis
● Obstructive atelectasis NURSING MANAGEMENT
● Non-obstructive atelectasis
1. Change patient’ s position frequently.
Etiologic Factors 2. Encourage early mobilization from bed to chair
followed by early ambulation.
3. Encourage appropriate deep breathing and
● Foreign body
coughing.
● Tumor or growth in an airway
4. Educate/reinforce appropriate technique for
● Altered breathing patterns
incentive spirometry.
● Retained secretions
5. Administer prescribed opioids and sedatives
● Pain
judiciously.
● Alterations in small airway function
6. Perform postural drainage and chest percussion,
● Prolonged supine positioning
if indicated.
● Increased abdominal pressure
7. Institute suctioning, if indicated
● Reduced lung volumes due to musculoskeletal
or neurologic disorders
● Restrictive defects
● Specific surgical procedures
BRONCHIECTASIS
CLINICAL MANIFESTATIONS
● a chronic condition where the walls of the
● Dyspnea bronchi are thickened from inflammation and
● Cough infection. (American Lung Association,2021)
● Sputum production ● most often secondary to an infectious process,
● Crackles that results in the abnormal and permanent
● Tachycardia distortion of one or more of the conducting
● Tachypnea bronchi or airways.
● Pleural pain ● about 40%are idiopathic bronchiectasis
● Central cyanosis
● Difficulty breathing in the supine position CAUSES
● Anxious
● Decreased breath sounds ● Cystic fibrosis
● Autoimmune disease
Quality and Safety Nursing Alert! ● Immunodeficiency disorders
● Chronic obstructive pulmonary disease (COPD)
● Tachypnea, dyspnea, and mild-to-moderate ● Diseases that affect the cilia
hypoxemia are hallmarks of the severity of ● Inflammatory bowel disease (Crohn ’ s and
atelectasis. ulcerative colitis)
● Allergic bronchopulmonary aspergillosis(ABPA)
● Chronic pulmonary aspiration
DIAGNOSTIC FINDINGS
CLINICAL MANIFESTATIONS
Chest x-ray
● Primary symptoms: Coughing and daily
● may suggest a diagnosis of atelectasis
production of mucus
● patchy infiltrates or consolidated areas.
● Coughing up yellow or green mucus daily
● Shortness of breath
Pulse oximetry
● Fatigue
● Fevers and/or chills
● low saturation of hemoglobin with oxygen
● Wheezing
● lower-than normal partial pressure of arterial
● Hemoptysis
oxygen
● Chest pain from
● Clubbing of the nail
MEDICAL MANAGEMENT
DIAGNOSTIC TEST
Goal: to improve ventilation and remove secretions
● Sputum analysis
● Frequent turning. ● Chest radiography
● Early ambulation ● High-resolution computed tomography (HRCT)
● Lung volume expansion maneuvers ● Quantitative immunoglobulin levels
● Coughing
● Chest physiotherapy
 ● Quantitative serum alpha1- antitrypsin (AAT) - Multiple drug resistance – causative
levels pathogens.
● Aspergillus precipitins and serum total Ig E - Initial antibiotic treatment must not be
levels delayed
● Autoimmune screening tests 3. Hospital-acquired pneumonia(HAP)
● Pneumonia occurring ≥48 hours after
MEDICAL MANAGEMENT hospital admission that did not appear to
be incubating at the time of admission
● Antibiotics and chest physiotherapy (mainstay) ● Predisposing factors:
● Bronchodilators - Impaired host defenses
● Corticosteroid therapy - Comorbid conditions
● Dietary supplementation - Supine positioning
● Oxygen inhalation - Aspiration
● Hospitalization for severe exacerbations - Prolonged hospitalization
● Surgical therapies - Metabolic disorders
4. Ventilator-associated pneumonia(VAP)
NURSING MANAGEMENT ● A type of HAP that develops ≥48 hours
after endotracheal tube intubation.
● Administer antibiotics as ordered. ● Incidence of VAP increases with the
● Provide chest physiotherapy (postural drainage) duration of mechanical ventilation.
● Administer bronchodilators and aerosolized
treatments. Community-Acquired Pneumonia Microbial Causes
● Initiate/monitor oxygen therapy. by Site of Care
● Prepare client for surgery (severe hemoptysis)
occurs.
● Encourage bedrest.
● Provide high protein diet with increased fluid
intake
● Provide frequent mouth care.
● Smoking cessation

Lung Disorders Across Lifespan

Pneumonia
STREPTOCOCCUS PNEUMONIA
● an inflammation of the lung parenchyma caused
by various microorganisms, including bacteria, ● Most common cause of CAP.
mycobacteria, fungi, and viruses. ● Caused by a gram-positive organism that
● Commonly spread by respiratory droplets resides naturally in the respiratory tract. (S.
pneumoniae)
Pneumonitis ● Often affects just one part, or lobe, of a lung

● a more general term that describes an HAEMOPHILUS INFLUENZA

inflammatory process in the lung tissue that may
predispose or place the patient at risk for ● Caused by H. influenzae.
microbial invasion ● Causes a type of CAP that frequently affects
older adults and those with comorbid illnesses.
Pneumonia: CLASSIFICATIONS ● Presentation is indistinguishable from that of
other forms of bacterial CAP.
1. Community-acquired pneumonia(CAP ● May be subacute, with cough or low-grade fever
- Pneumonia occurring in the community for weeks before diagnosis.
or ≤48 hours after hospital admission or
institutionalization of patients who do not MYCOPLASMA PNEUMONIA
meet the criteria for health
care–associated pneumonia. ● Caused by M. pneumoniae.
- Occurs either in the community setting ● spread by infected respiratory droplets through
or within the first 48 hours after person-to person contact.
hospitalization or institutionalization. ● Presence of mycoplasma antibodies.
- The rate of CAP increases with age ● Inflammatory infiltrate is interstitial rather than
alveolar.
● Impaired ventilation and diffusion may occur.
● Earache and bullous myringitis are common
2. Health care–associated pneumonia(HCAP)
● Pneumonia occurring in a non-hospitalized VIRAL PNEUMONIA
patient with extensive health care contact with
one or more of the following: Common pathogens:
- Hospitalization for ≥2 days in an acute
care facility within 90 days of infection ● Influenza virus (adults)
- Residence in a nursing home or ● Cytomegalovirus (Immunocompromised)
long-term care facility ● Herpes simplex virus
- Antibiotic therapy, chemotherapy ● Adenovirus
- Hemodialysis treatment at a hospital or ● Respiratory syncytial virus (young children)
clinic ● the inflammatory process extends into the
- Home infusion therapy or home wound alveolar area, resulting in edema and exudation
care
- Family member with infection due to
multidrug-resistant bacteria
FUNGAL PNEUMONIA

most common in people with: 1. Consolidation Stage

● Occurs in the first 24 hours.
● chronic health problems ● Cellular exudates containing
● weakened immune systems neutrophils, lymphocytes and fibrin
● people who are exposed to large doses of replaces the alveolar air.
certain fungi from contaminated soil or bird ● Capillaries in the surrounding alveolar
droppings. walls become congested.
● The infection spreads to the hilum and
Pneumocystis pneumonia pleura rapidly - pleurisy
● Marked by coughing and rapid, deep
● Pneumocystis jirovecii breathing.
● occurs in people with weak immune systems
due to HIV/AIDS or the long-term use of CLINICAL MANIFESTATIONS
medicines that suppress their immune system
● Sudden onset of chills
ETIOLOGIC FACTORS ● High fever Pleuritic chest pain
● Tachypnea
● Smoking; COPD ● Shortness of breath
● Immunocompromised patients ● Bradycardia – viral pneumonia
● Prolong immobility and shallow breathing pattern ● Mucopurulent sputum; rusty, blood-tinged
● Antibiotic therapy – very ill patients sputum – streptococcal, staphylococcal, and
● Alcohol intoxication Klebsiella pneumonia
● Advanced age ● Orthopnea
● Poor appetite
STAGES ● Increased tactile fremitus
● Crackles Whispered pectoriloquy
1 .Consolidation Stage
COMPLICATIONS
● Occurs in the first 24 hours.
● Cellular exudates containing neutrophils, ● Septic shock
lymphocytes and fibrin replaces the alveolar air. ● Respiratory failure
● Capillaries in the surrounding alveolar walls ● Pleural Effusion
become congested. ● Empyema
● The infection spreads to the hilum and pleura ● Meningitis
rapidly - pleurisy
● Marked by coughing and rapid, deep breathing. MEDICAL MANAGEMENT

2. Red Hepatization

● Occurs in the 2-3 days after consolidation.

● The consistency of the lungs resembles that of
the liver.
● The lungs become hyperaemic. Alveolar
capillaries are engorged with blood.
● Fibrinous exudates fill the alveoli.
● This stage is "characterized by the presence of
many erythrocytes, neutrophils, desquamated
epithelial cells, and fibrin within the alveoli.
POSSIBLE NURSING DIAGNOSIS
2.Red Hepatization: Clinical manifestations
1. Ineffective airway clearance related to copious
● Increasingly productive cough tracheobronchial secretions.
● Shortness of breath 2. Fatigue and activity intolerance related to
● Muscle aches impaired respiratory function.
● Headache 3. Risk for deficient fluid volume related to fever
● Extreme fatigue and a rapid respiratory rate.
● Fever and Chills 4. Imbalanced nutrition: less than body
● Sweating requirements.
● Cyanosis 5. Deficient knowledge about the treatment
regimen and preventive measures.
4. Resolution
PLANNING AND GOALS
● Characterized by the resorption and restoration
of the pulmonary architecture. 1. improved airway patency.
● A large number of macrophages enter the 2. Increased activity.
alveolar spaces. 3. Maintenance of proper fluid volume.
● Phagocytosis of the bacteria-laden leucocytes 4. Maintenance of adequate nutrition.
occurs. 5. An understanding of the treatment protocol and
● Consolidation tissue re-aerates and the fluid preventive measures.
infiltrates causes sputum. ü 6. Absence of complications
● Fibrinous inflammation may extend to and
across the pleural space, causing a rub heard by NURSING MANAGEMENT
auscultation, and it may lead to resolution or to
organization and pleural adhesions 1. Encourage coughing and deep breathing,
splinting the chest as necessary.
2. Chest physiotherapy.
3. Drink warm beverages, take steamy baths.
4. Encourage to increase oral fluid intake unless
contraindicated.
5. Promote bed rest.
6. Encourage the patient to assume a comfortable
position and to should change positions
frequently.
7. Observe the amount and characteristics of
sputum.
8. Collect sputum specimen for culture and
sensitivity tests in sterile containers.
9. Encourage full compliance to the prescribed
antibiotic therapy
 Pulmonary Complications
CHRONIC OBSTRUCTIVE PULMONARY DISEASE

● Slowly progressive respiratory disease of airflow

obstruction involving the airways, pulmonary
parenchyma, or both.
● Airflow limitation progressive and associated
with the lungs’ abnormal inflammatory response
to noxious particles or gasses.
● Include diseases that cause airflow obstruction ● The presence of cough and sputum production
(emphysema; chronic bronchitis) or any for at least 3 months in each of 2 consecutive
combination of these disorders. years.
● Causes: smoke or other environmental
pollutants
● Constant irritation causes:
- increased mucus production
- thickening of the bronchial walls
- narrowing of the bronchial lumen
- altered function of the alveolar
macrophages

Chronic ObstructivePulmonary Disease:

Emphysema

● High risk of developing heart disease, lung

cancer and a variety of other conditions.
● Inflammatory response:
- proximal and peripheral airways
- lung parenchyma
- pulmonary vasculature

● An abnormal distention of the airspaces beyond

the terminal bronchioles and destruction of the
walls of the alveoli.
● Results to impaired gas exchange.
● Decreased alveolar surface dead space and
impaired oxygen diffusion
● Later stage: Respiratory acidosis
● Complications:
- Pulmonary hypertension
- Cor pulmonale

Types TYPES OF EMPHYSEMA:

1. Allergic/ Extrinsic
- destruction of the respiratory bronchiole,
alveolar duct, and alveolus.
2. Centrilobular (centroacinar)
- pathologic changes take place mainly in
the center of the secondary lobule,
preserving the peripheral portions of the
acinus..

EtiologicFactors

1. Exposure to tobacco smoke (80% to 90%)

2. Increased age
3. Occupational exposure—dust, fumes, chemicals
4. Indoor and outdoor air pollution
5. Alpha1-antitrypsin deficiency
6. Lower socioeconomic status

Chronic ObstructivePulmonary Disease: Chronic Emphysema: Clinical manifestation

Bronchitis
First three manifestation leads to increase sputum
production
1.Chronic cough 13.Tachypnea - These larger air sacs move less oxygen
into the blood. This causes difficulty breathing or
2.Sputum production shortness of breath that gets worse over time.

3.Dyspnea (progressive)

4.Weight loss - decreased appetite- forceful breathing-

secondary to dyspnea

5.Use of accessory muscles - ( sternocleidomastoid,

scalene, trapezius, external intercostal, and
pectoralis major muscles )provide assistant

6.Barrel chest (emphysema) - trapped of air because of

obstruction
-
What causes barrel chest in patients with emphysema?

When emphysema develops, the alveoli and lung tissue

are destroyed. With this damage, the alveoli cannot
support the bronchial tubes. The tubes collapse and
cause an “obstruction” (a blockage), which traps air
inside the lungs. Too much air trapped in the lungs
can give some patients a barrel-chested appearance.

7. Cyanosis - (refers to a bluish-purple hue to the skin)

Central cyanosis late sign of hypoxemia

Central Cyanosis is a blue discoloration seen on the ASSESSMENT / DIAGNOSTIC EXAMINATIONS:

tongue and lips (thorough health history)

Peripheral cyanosis found in nail bed ● Pulmonary Function Test - show or evaluate how
the kidneys are working. Amount of air inhaled
8.Wheezing and crackles - The inflammation that comes and exhaled. (tidal volume, lung capacity)
with COPD can affect both your large and small airways ● Spirometry - evaluate the airflow obstruction (if
by causing them to narrow. A wheezing sound is the may obstruction may difficulty of exhalation)
vibration of air through these narrowed airways. This ● Arterial blood gas - evaluate if may acidosis
wheezing sound can sometimes be heard when you ● Chest x-ray - determine comorbidity
breathe in ● Computed tomography - for differential diagnosis
● Screening For alpha1-antitrypsin deficiency -
CRACKLES - MUCUS IN THE AIRWAYS check level of alpha 1. Younger than 45 years
old.
9.Peripheral edema - because di na sa right circulation
wala na right pressure
COPD: Complications
Destruction, decrease size of pulmonary, increase
resistance of blood vessels, right ventricle increase ● Respiratory insufficiency and failure - because of
blood pressure, lead to pulmonary hypertension the secondary gas exchange (malaki
obstruction)
10.Purse lip breathing - (control shortness of breath) ● Pneumonia - because of the increase mucus
maka help lang siya slow paced breathing production
● Chronic atelectasis - secondary over distention
11.Tripod position - The tripod position helps the of alveoli
diaphragm move downward to increase the volume in ● Pneumothorax - destroy the alveoli sac
the chest cavity, known as the thoracic cavity.This ● Pulmonary arterial hypertension (Cor pulmonale)
increased volume might force the lungs to expand. - increase resistance in the blood vessel kasi
People adopting the tripod position will be able to nag liit pulmonary bed because of the alveolar
increase the expulsion of carbon dioxide and the sac obstruction
inhalation of oxygen
COPD: MEDICAL MANAGEMENT
helps to lower your diaphragm and open your lung
space to decrease shortness of breath.
1. Risk Reduction
- smoking cessation

2. Pharmacologic Therapy (medication)

12.Depression - not really related to COPD. These
- Bronchodilators ; relieve
changes can lead to feelings of loss, frustration, or
(bronchospasm) and symptoms, dilate
sadness because you can no longer do the things you
airway
used to do
 - Corticosteroid ; anti-inflammatory (side 1. Allergic/Extrinsic (strongest predisposing factor)
effect: fluid retention, increases blood - Early onset in ife and often associated
pressure) with history of allergy.
2. idiopathic/ non allergic/ intrinsic
- alpha1-antitrypsin augmentation
- Not related to specific allergens and
therapy; often associated with environmental
- antitussive agents/mucolytic; cough factors common colds and infections.
suppressant 3. Exercise - induced
- vasodilators - Because of the increase oxygen
- Nicotine replacement 4. Occupational asthma
- Antidepressants - Exposure to irritants
5. Seasonal asthma
- Nicotinic acetylcholine receptor partial
agonist ETIOLOGIC FACTORS

3. Management of exacerbations 1. Atopy

- identifying the primary cause. - Genetic tendency to develop allergy
- Administering the specific treatment. 2. gender - female
- Optimization of bronchodilator - Hormones (estrogen and progesterone
increase the inflammation promote
medications.
inflammatory response)
3. Exposure to indoor and outdoor allergens
4. Oxygen 4. Occupational sensitizers
- Inhalation; first line of treatment 5. Respiratory infection
- Di pwede high flow kay ang pt may high 6. Air pollution
level of blood 7. active/passive smoking

5. Surgical Management
- Bullectomy
- Lung Volume Reduction Surgery
- Lung Transplantation
- Pulmonary Rehabilitation

COPD; NURSING MANAGEMENT

1. Assess the patient (vital signs/Oxygen

saturation).
2. Administer medications as ordered.
3. Eliminate all pulmonary irritants.
4. Instruct the patient to perform directed or
controlled coughing.
5. Perform chest physiotherapy with postural Reversible diffuse airway inflammation
drainage.
6. Encourage increased fluid intake.
7. Patient education:
- Educate on how to improve respiratory
patterns.
- Improving activity tolerance.
- Self care activities.
- Monitoring and managing potential
complications.
- Oxygen therapy - low flow
- Nutritional therapy - provide energy high
calories diet
- Coping measures.
- Palliative treatment

ASTHMA

- One of the obstructive but not part of chronic

obstructive pulmonary disorder but it is a type of
respiratory disorder that is also obstructive
- Heterogeneous disease characterized by
chronic airway inflammation cause:
A. Airway hyperresponsiveness
B. Mucosal edema
C. Mucus production
- A common chronic disease of childhood but can
occur at any age.
- Reversible

TYPES OF ASTHMA: