Done - Skills Lecture
Done - Skills Lecture
Done - Skills Lecture
Rachel Alfonso
Veins Superior & inferior vena cava Right atrium tricuspid valve Right ventricle Pulmonary artery
Different Tissues Aorta Left ventricle mitral valve left atrium pulmonary vein lungs for oxygenation
RESPIRATORY PHYSIOLOGY
- transport of oxygen in and out of the system
Alveoli – functional unit of the body
3 processes:
1. Pulmonary ventilation – passage of gas in and out of the lungs
-inhalation – active process
- diaphragm – major muscle for inhalation
- goes down in inhalation to accommodate lung expansion
- goes up in exhalation
-exhalation
Possible factors that may affect ventilation:
a. presence of secretion
b. airway problem
c. environmental factors
2. Diffusion – process wherein substances move from an area of higher concentration to lower concentration
- process that discusses gas exchange
- happens in the lungs
CO2 O2
Pulmonary capillary membrane alveolar membrane
3. Perfusion – process where oxygen is transported to different parts of the body
- done by the cardiovascular system
- any disease of the cardiovascular system affects the perfusion
Physiotherapy
- a combination of treatment modalities to mobilize thick secretions
- if done, in combination, it is a dependent nursing intervention
Treatment modalities:
a. Postural drainage – therapy that utilizes position to drain secretion
- uses principle of gravity
- position affected lobe higher than the rest
Eg. Anterior Bibasal pneumonia – knee chest; trendelenburg
Posterior Bibasal Pneumonia- knee chest
Right lung – Left Sim’s/ left lateral position
Left Lung – Fowler’s position
b. Chest percussion/back tapping – application of short, brisk and rhythmic claps over the affected area using cupped hands that
produces air cushion and dislodges secretions
- increases ciliary action that increases mobilization of secretions
Don’ts:
Do not tap on bony areas
Do not percuss on bare skin
Do not percuss lower than the rib cage because there are organs that may be vulnerable to bleeding or rupture
Do not percuss too hard
Do not use jewelry while tapping because it can cause trauma
c. Chest vibration – application of fine, shaking movements over the affected lobe with palm placed flat against the chest wall
- improves/speeds up the turbulence of air
- improves expulsion of trapped air
- done during exhalation only
d. controlled coughing exercises – to help patient expectorate secretion
- trigger normal coughing reflex
Depressed coughing reflex:
o With anesthesia/sedated
o Paralyzed/immobility
Nursing responsibilities:
Provide patient with splint, abdominal binder, pillow or hand binding before letting the patient to do CCE
Types of CCE:
a. Cascade – instruct the patient to inhale gently through the nose and cough consecutively until breathing ends
b. Huff – same with Cascade but instead of coughing, just say “huff”
- stimulates normal coughing reflex
c. Quad – diaphragmatic stimulation
- indicated to patients with muscle weakness
- the process is the same with Cascade
d. Deep Breathing Exercise – promotes ciliary action
- enhances lung expansion
Types:
1. Diaphragmatic – can be done with pursed lip
- during inhalation, let the abdomen protrude slightly
- during exhalation, contract the abdomen as long as you can
2. Pursed lip – inhale gently through the nose and hold for 2-3 secs. then blow through the mouth like blowing a
candle
**best done after bronchoscopy; dependent nursing intervention
** materials: tissue, kidney basin, sputum collection bottle, towel lining, stethoscope, oral care tray
Guidelines in CPT:
1. Know the V/S of the patient – because CPT is a series of exercises and it has the possibility to increase metabolism/metabolic rate
that can be dangerous to the patient.
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2. Know the medications – CPT is best done before giving antihypertensives and antidiuretics because these drugs will decrease BP
3. Know pre-existing medical conditions
> hemoptysis – sign of PTB
- sign of internal bleeding
> CPT is contraindicated to patient who has possible increased intracranial pressure because it can increase cerebral tissue
perfusion
> CPT is also contraindicated to patient who had eye surgery because it can increase intraocular pressure that may cause
retinal detachment
4. Consider the cognitive ability of the patient
- explain and use terms understandable to the patient
5. Consider subjective complaint/tolerance
> ROM is performed within the patient’s level of tolerance
> Hard back tapping can cause pulmonary bleeding
> When the head of the patient is lower than the body, he may feel nauseated and vomits which may cause aspiration
> Bronchospasm can happen due to irritation of the bronchi
- alternate constriction and dilation
> Stridor and wheezing- sings of increased airway resistance
Considerations for CPT:
CPT is best done after administration of bronchodilators
CPT is best done before meals and at bedtime
CPT can only be performed at the maximum of 30 mins. Prolonged CPT can cause hypotension
Check the Dr.’s order for pre-meds and frequency
Assess the patient
Instruct gradual position change to the patient
Stop therapy if complications become evident; reposition the patient and ensure patent airway
Oxygen Therapy
- oxygen supplementation to receive hypoxia resulting from hypoxemia
Hypoxemia – increased arterial oxygen
Hypoxia – tissues are deprived of oxygen
Indications:
1. Decreased oxygen diffusion
2. Decreased pulmonary ventilation
3. Myocardial insufficiency
Chest pain – decreased myocardial tissue perfusion
Decreased oxygen lactic acid Myocardial Ischemia Infarction Irreversible necrosis O2 admin
Do’s:
C – Check the doctor’s orders
A – Assess patient
- Adequate oxygen supply
G – Ground electrical supplies/ devices
E – have available fire Extinguisher
Aerosol Therapy
- suspension of microscopic liquid droplet in the air or oxygen
- delivers moist fog into the airway continuously, mucus membrane is loosened as it absorbs the water which facilitates its
removal
- watery mist soothes inflamed airway
Nebulization
- production of fog or mist
- nebulizer used to deliver fine spray of medication (steroids and bronchodilator) and moisture into the client
Kinds:
1. Atomization
- atomizer – device that produces large droplet for inhalation
2. Aerosolization – droplets are suspended in gas (oxygen)
Kinds of nebulizer:
1. Large volume nebulizer – provides thermoregulated heat/cold mist
2. Handheld nebulizer – delivers steady stream of aerosolized medication that the patient breathes in over a period of
minutes
Jet propeller – uses high air pressure
Ultrasonic – high frequency vibration
- gives highly humidified medication
- most common type
- should be used with mask
3. Metered Dose Inhaler- provide patients with pressurized dose of aerosolized medication
- should be sitting upward
4. Small volume nebulizer – oxygen driven
- administer nebule using oxygen set up
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**hold the breath as long as you can to let the medication dispense inside the airway
**Wait for a minimum of 30 secs before giving the second dose to have enough pressure inside the cartridge and
prevent underdosage
Nasal spray – sitting and hyperextending; for allergic rhinitis
Mouth piece – pass through the lower airway
Hydration/Humidification
- adding/maintaining moisture into the airways
- done through humidifiers
- secretions are liquefied
Types:
1. Room humidifiers
2. Cascade humidifier – large volume nebulizer counterpart
- gives 100% thermoregulated humidity
- given through mechanical ventilator
- prevents dryness of mucus
3. Cold bubble Diffuser
- 20 to 40% humidity
- admistered through oxygen delivery system
Cylindrical Bubble Diffuser – refillable; Aqua Pack Bubble Diffuser – disposable
Steam Inhalation
- hydrates airway
- dilate airways due to increased temperature
Nursing responsibilities:
> Dry patient after the procedure
>10 to 15 mins only as tolerated
Diagnostic Procedures:
Pulse Oximetry
- non-invasive procedure
- measures the amount of hemoglobin saturated with oxygen
- 95 to 100% - acceptable range
- upper lobe- light emitting diob
- lower probe – photodetector
- measures oxygen-saturated hemoglobin
Spectrophotometry – process by which oxygen hemoglobin is measured through the light absorbed by the hemoglobin
- used in cardiac patients
- used to determine ABG sampling – frequency of ABG done
Limits:
It cannot determine acid-base balance
Cannot measure carbon dioxide retention
-Anything that interferes with transport of light alters the result. Eg. Nail polish, dirt, extra lighting
Motion artifacts alter results – tell patient to keep still
- Only capable to read oxygen saturation above 80%; can be + or – 2 in accuracy
- for neonates, the probe can be attached to the heel or big toe
- check area for adequate blood circulation
- never put off the alarm – assessed if it is attached very well
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Incentive Spirometry
-non-invasive
- requires patient to perform sustained maximal inspiration
- accomplished with Spirometer; for patients with PTB and COPD to prevent lung collapse
Types of Spirometers:
1. Flow-oriented
- not particular with the volume exerted
- to hyperinflate the lungs
- improves respiratory capacity
2. Volume-oriented
- we set the volume that the patient should reach
3. Hybrid Volume Accumulator – combination of flow and volume-oriented
- good, brisk inhalation
Nursing Responsibilities:
1. Position patient in fowler’s – help maximize lung expansion
2. Paint management is necessary – splint surgical side
3. Provide rest periods in between attempts – can result in hyperventilation
4. Reinforce that the patient should sustain a deep maximal inspiration
Sputum Collection
Purposes:
1. For Sputum C & S- to determine the specific anti-infective agent that the bacteria is sensitive to
2. For assessment and to quantify the patient’s response to regimens
3. For sputum acid fast bacilli determination – to identify PTB
4. For cell cytology
Procedure:
AFB and cytology
- specimen is collected 3 times
- expectorate in the sputum container early in the morning
1st – after the doctor’s order
2nd – early morning of the following day
3rd – after the submission of the 2nd specimen or within the day
- provide before and after oral care- lessen contamination of sputum
- know the character of the specimen
- collect sputum first before giving any anti-infective drug
Bronchoscopy
- invasive
- involves visualization of airways up until the lungs through the use of an endoscope
Nursing Responsibilities:
1. Obtain consent – valid
- patient should know what will happen, the risk, any alternative procedure and consequences
- patient should be aware of the procedure; should be aware that he can withdraw anytime before the procedure
- should be signed by a legal aged patient
- should be mentally capable
Buffer Systems:
a. Blood Buffer System – an imbalance will be neutralized by an acid or base; weak or strong
b. Kidney – excretes or retains substance
components:
c. Lungs – initially responds to respiratory alkalosis; acid-base imbalances when substances are volatile
- decrease carbon dioxide, decrease respiration
pH – negative logarithm of hydrogen ion concentration
acid – donates H+ ion, eg. Carbonic acid
base – accepts H+ ion, eg. Bicarbonate
PaCO2 is inversely related to pH
HCO3 is directly related to pH
Principles:
a. pH and PaCO2 are in opposite direction = respiratory problem
b. pH and HCO3 are in the same direction = metabolic problem
c. PaCO2 and HCO3 are in the same direction = body compensates for abnormal pH
d. PaCO2 and HCO3 are in the opposite direction = mixed imbalance
e. the body never overcompensates
Steps:
1. look at the pH for imbalance
2. look at the . PaCO2 /HCO3 for source of imbalance
3. determine the degree of compensation
Eg. pH - 7.32 – acid partially compensated
PCO2 – 48 – acid respiratory acidosis
HCO3 – 29 - base
4. Check if there is full, partial or no compensation
- if the pH is still not within the normal range = partial
7.35 – 7.39 – normal to acid
7.40 – 7.45 – normal to base
pH - 7.30 – acid
PCO2 - 50 – acid mixed metabolic and respiratory acidosis
HCO3 - 21 – acid
Nursing responsibilities:
1. Specimen should be from the arteries
2. Right after the specimen collection, apply pressure for at least 5 mins; if the patient is taking anti-coagulant, pressure for at least 10
mins.
Allen’s Test – to determine adequacy of collateral circulation
- when RT is planning to extract from radial artery
- done before puncturing the artery
- must have a minimum of 5ml of sample
- the angle of the needle is 45 degrees- radial
- 60 degrees – brachial
3. Assess area for bleeding
4. Label specimen as necessary
5. Immediate transport to lab
6. Wean the patient off from oxygen at least 15 mins before ABG is done to determine accurate finding/result
7. Document site
8. Monitor for bleeding, numbness, tingling sensation that can indicate impairment of circulation
Unexpected Situations
1. Severe pain – reached the bone
- arterial wall puncture
**withdraw needle
2. Withdraw needle after 2 failed attempts and relocate puncture site
3. Arterial spasm – secondary to overshooting/overmanipulation of puncture site
- no bood flow
4. Sluggish blood flow to the syringe – from the vein – dark purple
- bright red – artery
Principles:
1. Should be carried using aseptic technique – set up sterile technique
2. Suctioning of the oral cavity should be done after nasopharyngeal and oropharyngeal techniques
3. Suctioning is done PRN
- mech vent alarms (high pressure) if there is increased airway resistance
- coughing and gargling sound
4. All rest periods in between attempts – suctioning can cause hypoxia
- do DBE to compromise with lost pressure
- any attempt should last no longer than 15 secs
5. Pre-oxygenate the patient
- increase oxygen if it is too low
- give blows first before removing the AMBU
6. There should be separate suction tip and separate flushing solution (PNSS)
7. Suctioning should be atraumatic, aseptic and effective
Nursing Responsibities:
Check cardiac rate – suctioning causes dysrhythmia
Positioning – consider the patient’s condition
- do not suction when there is spinal injury/do log rolling
Oropharyngeal – conscious- semi-fowler’s with head to the side
Unconscious – semi-fowler’s to side facing the nurse
Stroke – elevate head part
Nasopharyngeal – semi-fowler’s, neck hyperextended
Artificial Airway
- mimics function of airway
- for respiratory failure, impending respiratory distress
Indications:
1. Relieve airway obstruction
Types:
ET – not indicated if obstruction is secondary to laryngeal spasm
Tracheostomy
Trichotomy
2. to facilitate removal of secretions
3. to protect lower airway from aspiration
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4. to facilitate artificial/mechanical ventilation; AMBU – effective with Artificial Airway
Types:
1. Oropharyngeal airway/tube – URT
- semi-curved piece of tubular plastic that terminates at the posterior pharynx
Purpose:
Facilitate suctioning
Opens the airway
Supports ETT – serves as bite block
Complication:
-vomiting – stimulates gag reflex
- bleeding
- trauma – due to insertion
Indications: semi-conscious, pt with GETA
Procedure:
1. Select appropriate size
2. Remove dentures
3. Wash hands and don gloves
4. Position patient properly – neck hyperextended
5. Lubricate
6. Insert gently
7. Secure with tape
8. Position to lateral/head-to-side – less chance of aspiration
9. Remove gloves after care
10. Observe position of airway
2. Nasopharyngeal airway – URT
- compliant tube, 15cm long
- better tolerated in semi-conscious patients with gag reflex; disadvantage – irritating
- inserted is best when aided by aesthetic lubricant
Indications; oral surgeries
Procedure:
1. Select appropriate size
2. Wash hands
3. Position patient
4. Lubricate
5. Insert gently, observe patient
3. Endotracheal tube – for emergency use
Types:
Oral – endotracheal tube
Nasal –nasotracheal tube
Indications:
-cardiopulmonary arrest
- uncorrected respiratory acidosis
- no spontaneous breathing – anesthesia (GETA) – affects medulla (respiratory center)
Procedure:
1. Preparation
2. Position properly
3. Suction as needed
4. Restrain patient PRN
5. Inflate with 5-10ml air
6. Ventilate
7. Assess placement
Artificial Ventilation
- for pts who cannot breath continuously
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- for pts who stopped breathing
Manual Ventilation
- AMBU
Nursing responsibilities:
Put gloves
Remove pillow
Position flat on bed
Head-tilt chin-lift maneuver- for patients with no injury
Jaw thrust maneuver – for patients with injury
- elbow resting in the bed
- opens airway
Neonate – 100 to 150ml of air
Tapered position – in the nose
Pedia 2-3 secs bagging
Adult 3-5 secs bagging
When resistance is met, it can indicate obstruction, failure to open airways
gastric distention= too much bagging
Mechanical Ventilation
-to reproduce the body’s normal breathing mechanism in order to maintain adequate ventilation by delivering 8-10ml/kg of BW
Standard Modes:
1. CMV – Continuous Mandatory Ventilation
- indicated in patients with respiratory arrest
- machine controls all breathing process
2. Assisted/SIMV – Synchronized Intermittent Mandatory Ventilation
- patient can breathe continuously/spontaneously
- for patients with respiratory failure
- patient inhales but the air is inadequate – mech vent blows the air
3. Positive End Expiratory Pressure
- for atelectasis
- leaves the alveoli inflated to prevent from collapsing
- blows off oxygen
- leaves residual volume
4. Continuous Positive Air Pressure
- lung maintains residual volume
- has spontaneous breathing
5. ECMO – Extracorporeal Membrane Oxygenator
-machine assumes the function of the heart and lungs
Peri-operative Nursing
- applied art and science of taking care of patients who will undergo an invasive procedure
- has 3 phases:
1. Pre-operative phase
- starts when the patient decides to undergo surgery and ends when the patient is transported to the OR
2. Intra-operative phase
-starts when the patient is transported to the OR bed and ends when he is transported to the recovery room
3. Post-operative phase
- starts when the patient is transferred to the recovery room and ends when the patient is discharged for follow-up care
Pre-operative Phase
Nursing responsibilities:
1. Know the type of surgery
rraphy – repair ectomy – removal plasty - enhancement
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ostomy – opening otomy - cutting into
Classsification according to degree of risk:
a. Major
- high risk
- with underlying disease condition
- prolonged surgery
b. Minor
- low risk
- minimal blood loss
- short surgery period
Classification according to purpose:
a. diagnostic – determination of the cause of signs and symptoms
b. palliative – relief from signs and symptoms but do not necessarily cure
c. reconstructive – repair an injury
d. cosmetic surgery – for aesthetic purpose
e. ablative – removal of a disease organ
Classification according to urgency and timing
a. emergency – life-threatening
b. urgent – unplanned but necessary
c. elective – planned but not necessary
2. Secure consent
- Surgeon should take the consent to be able to explain it to the patient
- ensure that the patient understood the procedure before signing – patient advocate
- ask if the surgeon had already explained the procedure to the patient
- Age of valid consent signing – 18 years old
- emancipated minor – below 18 years old but directly related to the patient
3. Assess the Patient
History
Previous surgery – can affect the patient’s reaction to surgery
Allergy – allergy to seafoods can indicate Iodine allergey
- allergic to medications like anesthesia (lidocaine/xylocaine) and antibiotics
Underlying disease condition
- bleeding disorders
- respiratory disorders – anesthesia can cause respiratory distress
- renal function– renal dysfunction may cause medication toxicity that can lead to acidosis and cardiac arrest
- motor function
- neurologic status
- medications taken
> aspirin – anti-platelet; should be stopped one week prior to surgery
> steroids – anti-inflammatory; delays wound healing
Physical Assessment- head to toe
35 y/o (males) and 45 y/o (females) – needs cardiopulmonary clearance
50 y/o and above – needs ECG tracing
Below 35 y/o and with underlying disease – needs CP clearance
Diagnosis of the Patient
Anxiety: mild/moderate/severe r/t complicated surgery/ 1st experience of surgery
Risk for decreased tissue perfusion
Patient is physically prepared for the contemplated surgery
Planning:
Assess the vital signs
Allow verbalization of feelings regarding the surgery
Pre-operative consent procedure
Time, IV level, method of transport to the OR
Non-sterile Members
1. Anesthesiologist
- 1st contact before surgery for pre-op visit to prepare patient for surgery
Check for surgical risks
Determine type of anesthetic agents to use and special needs of the patient during surgery
- responsible for checking that dentures, jewelry and contact lenses (may cause corneal abrasion) are removed in the OR
-position patient for anesthesia induction
Infection Control
1. Principles of aseptic technique
2. Surgical attire
3. environmental control - T°= 20-28°C
- clean all walls with Lysol
- (+) air pressure
4. Sterilization (aseptic practices)
a. Handwashing
b. Cleaning
- mopping
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- wiping
- washing
Symbols:
X – anesthesia started X – anesthesia ended
● - OR started ^ - OR ended
^ - DBP v – SBP
T – intubation ┴ - extubation
- PR ° - RR
Curve clamps ----- (mosquito – small), (kelly – medium), (pean – big; for intestinal surgery)---- straight clamps--- allis
Morphine precautions
- check for hypotension
- check for bradycardia
- check for RR<12/min
- check for urticaria
- check for urine output <30 cc/hr
Intra-op charting
1. Location of incision/by whom/time started
2. Surgical procedure performed (step by step)
3. Irrigations
4. Specimen taken (characterized)
5. Drain inserted
6. Sponge, sharps and instrument count certified complete
7. Unusual event or complication, action performed
8. Closure of incision
Post-op charting
1. Wound care
2. Dressing application
3. Immediate anesthesia care
4. Transfer to PACU
5. Special endorsement from OR – anesthesia post-op care, IV level
Sponges
Abdominal sponge – 10 to 15 cc blood loss
Visceral pack – 100 cc blood loss
4x8 – 10 to 15 cc blood loss
- used to clean instruments during operation
- used to wipe bleeders
Vaginal strip
Nasal strip
Peanuts – for small wounds
Cherries
Iodine balls – used for skin preparation
Tonsil balls – with strings
Eye pad
Top dressing – to cover wounds/incisions
Sponge count
- done before the operation, during (before closure of the cavity/organ and before closing the subcutaneous), and at the end of the
procedure
- Count the sponges on the sterile table (table count) first, then followed by operative site (field count), and lastly the soiled sponges
(floor count)
Instruments
Cutting and dissecting
Scissors
Post-Anesthesia Care
Goal: To assist patient in returning to a safe physiologic level after receiving anesthetic agent or after undergoing a surgical procedure
Focus:
- maintain ventilation and circulation
- monitor oxygen and level of consciousness
- prevent shock and manage pain
Respiratory Complications
Predisposing factors:
Type of surgery (thoracic or high abdomen surgery)
Previous history of respiratory problem
Age – greater risk if over 40
Obesity – high risk for airway obstruction
Smoking
Respiratory depression caused by narcotics
Severe post-op pain
Prolonged post-op immobility – can result to pneumonia
Prevention:
Encourage patient to cough every 1 to 2 hours
Instruct client to splint incision while coughing
Assist client to turn from side to side every 4 hours
Encourage early ambulation
Encourage use of incentive spirometer
Assess respiration – check status and auscultate lungs
- be alert for any signs of respiratory complication
A. Airway obstruction
- result of the movement of the tongue into the pharynx, anesthetic-induced changes in pharyngeal and laryngeal muscle tone,
laryngospasm, edema, and secretion
Signs and symptoms:
Wheezing
Stridor
Sternal and intercostals retractions
hypoxemia
hypercarbia
Management
Proper positioning
Use of artificial airway
B. Laryngospasm and Bronchospasm
Laryngospasm – partial or complete closure of vocal chords as an involuntary reflex action
Bronchospasm – contraction of smooth muscle in the walls of the bronchi and bronchioles
C. Aspiration
- entry of gastric, esopharyngeal and other substances into the lungs
Signs and symptoms:
Central cyanosis
Dyspnea
Gasping
Tachycardia
Lung collapse
Crackles
Management:
Remove as much aspirate as possible
D. Hypoxemia - pulse oximeter less than 90% and pO2 less than 60 mmHg
Causes:
Opiods
Insufficient reversal of neuromuscular blocking agents
Cardiovascular Complications
Predisposing factors:
Deep Vein Thrombosis
Lower Abdominal surgery or Septic Disease
Use of abdominal anesthesia
Causes:
Injury to the vein eg. tight leg straps during surgery
Previous history of venous problem
Increased blood coagulability due to dehydration and fluid loss
Venous stasis
Prolonged post-op immobilization
Management:
Ambulation
Adequate fluid
A. Hypotension
- SBP <90 mmHg or 20% less from patient’s baseline
Causes:
Hypovolemia
Blood loss
Inadequate fluid replacement
B. Hemorrhage
- abnormal internal or external loss of fluid from an arterial, venous,or capillary source
C. Hypovolemic Shock
-inadequate tissue perfusion resulting from markedly reduced circulating blood volume
D. Hypertension
- 20-30% increase from the patient’s pre-op or baseline level
Causes:
Vasoconstriction
Increased temperature
Sympathetic stimulation
Bladder distention
E. Coronary Thrombosis
- from severe hypoxia and lack of oxygen to coronary vessel
F. Air Embolism
- Trendelenburg and side-lying position
G. Venous Stasis
- slowed venous return from the lower extremities
H. Deep Vein Thrombosis
- formation of clots in the vein of the pelvis and lower extremities
Signs and symptoms:
Pain
Edema
Erythema
Local tenderness
(+) Homan’s sign
Thermoregulatory Complications
A. Hypothermia
- provide blanket and warm environment
B. Hyperthermia
- TSB and anti-pyretics
Gastrointestinal Complications
A. Nausea and vomiting
- relaxation of the stomach
Management:
Anti-emetics
Oral care
Ice chips
NGT – gastric decompression
B.Paralytic Ileus
- intestinal obstruction characterized by lack of peristaltic activity
- absent bowel sounds
Management:
Check for bowel movement
Ensure that peristaltic activity is present before food introduction
Geneto-Urinary Complications
- relaxation of sphincter
A. Urinary Retention
- inability to empty the bladder that results to accumulation of urine
Wound
- a disruption of normal anatomical structure and function that results from pathological processes beginning internally or externally tot
the involved organ
- a break in the continuity of skin, mucus membrane, base or a body organ
According to Cause:
1. Intentional – wounds resulting from therapy
- wound edges are usually smooth and clean, eg. surgical incision
- involves aseptic techniques
2. Unintentional – wounds that occur unexpectedly
- wound edges are often jagged that occurs under unsterile conditions, eg. laceration
According to Severity:
1. Superficial wound – involves epidermis
2. Penetrating wound – enters an organ
3. Perforating wound – enters and exits an internal organ
- ensure that the patient is stable
According to Cleanliness
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1. Clean – wound containing no pathogenic microorganism
- does not involve a cavity, eg. incision biopsy
2. Clean- contaminated – wound made under aseptic conditions but involving body cavity that normally harbors microorganisms
3. Contaminated – wound existing under conditions wherein the presence of microorganism is likely
4. Infected – bacterial organisms are present in the wound site
5. Colonized – wound containing multiple microorganisms, eg. pressure ulcers
According to Depth
1. Partial Thickness – involves epidermis and dermis
2. Full Thickness – involves epidermis, dermis, subcutaneous tissue and possibly muscle and bone
Wound Management
Prevent and manage infection – antibiotics
Cleanse the wound – inner to outer
Remove non-viable tissue – necrotic solution
- use wet to dry dressing; give analgesics 30 mins before the procedure
Manage exudates- fluids coming out from the blood vessels
Protect the wound
Wound Assessment
1. Location/site
2. Appearance
3. Drainage/drainage device – amount, consistency, color, odor, tube placement, function/patency
4. Swelling – palpate wound edges
5. Pain – present in the 1st 3 to 5 days; persistence may be due to bleeding or infection
6. Dressing – type and condition
Types of Drainage
1. Serous – clear
2. Sanguineous – bright red
3. Serosanguineous – pinkish, light red
4. Purulent – greenish, yellowish; pus
***Jackson-Pratt – low suction drainage
Assessment:
Weight, height and BMI
Lifestyle
Bodybuilt
Teeth – problem in grinding
- completeness, dentures, cavities
Lesions
Tongue – deviation
Symmetrical soft palate – check vagus nerve; swallow reflex
Gag reflex – glossopharyngeal
Condition of esophagus and esophageal sphincter
- check for heartburn
- vomiting: Red – active bleeding
Coffee brown – past bleeding
Green – biliary obstruction
Brown – fecal matter
Stomach – burning pain on the epigastric area
- older – MI
- younger – appendicitis
- Ulcer- duodenal (relieved by food); gastric (aggravated by food)
- RUQ pain that radiates at the back and is precipitated by fatty food intake – cholelithiasis
Small intestines – check for bowel sounds
Inspect – color, presence of lesions, stoma, scar
- visible pulsations
- flat on supine position; if globular, may indicate abdominal distention and fatty deposits
- check for intolerance to food, allergies, dietary intake
Large intestines – bowel movement
Stool – green – fats
Clay-colored – low bile
Bright red – bleeding
Black – Upper GI bleeding
Black tarry- Upper GI bleeding and increased peristalsis = decreased water absorption
Diagnostic Studies
1. CBG – hypoglycemic in alcoholic patients
2. Fecalysis – sterile collection – should be examined within 1 hour
- if watery, it should be examined within 30 mins
3. Fecal occult blood – avoid meat products for 3 days, dark colored foods, aspirin, Fe supplements, NSAIDs
28 | P a g e MERYL P. RAMIREZ, BSN, RN
4. Liver function test – fat breakdown
5. Flat plate of the abdomen
6. Endoscopy
EGD – proper preparation
- consent
- NPO post midnight
- check for allergies to lidocaine
- check for gag reflex before giving food
Colonoscopy and Sigmoidoscopy
- consent
- NPO
- bowel preparation – enema
7. UGIS – Upper GI Series
- Barium Swallow
- check for allergies
- instruct that the patient will be taking in Barium
- inform the patient that his stool will be whitish
- after 3 days and the stool is still whitish, this should be reported to the physician to remove the Barium via laxative
8. Small Intestinal Series – barium swallow
9. Barium Enema
- bowel preparation
- check for allergies
10. Ultrasound of LBP, CT Scan
11. Cholangiogram – visualization of gall bladder
- low fat evening meal
12. Liver biopsy – highly vascular
- after the procedure: check for bleeding for 36 hours
Check the vital signs every 2 hours for 36 hours
Position on right side lying with pillow as a splint
Bowel Elimination
A. Diarrhea
Food poisoning – proper food handling
Stress – eliminate the stressor
Medicine – do not give medications
Lactose intolerance – avoid dairy products
B. Constipation
Environmental factors
o (-) privacy
o Delaying the urge
Decreased activity, fluid and fiber
Gas-forming food, with seeds
Age
Diseases
Signs and symptoms:
> abdominal distention
> Decreased bowel sound
> Flatulence
> Loss of Appetite
> Headache
Management:
> increase activity, fluid and fiber gradually as tolerated
> do not delay the urge to defecate
Urinary Problem/Incontinence
Urinary retention problems
> catheter
> surgery – Urostomy
Dialysis
- may cause hyperkalemia
-intracorporeal and extracorporeal
-AV shunt – 3 to 4 weeks use only; red tag for artery, blue tag for vein
- AV fistula – for prolonged dialysis
-toxic blood is drained from the artery
Exchanges Vol. infused Inflow Dwell Drain Amt. drained Output Total
1 1000 15’ 30’ 30’ 1500 +500 +500
2 1000 15’ 30’ 30’ 800 -200 +300
3 1000 15’ 30’ 30’ 500 -500 -200
4 1000 15’ 30’ 30’ 1200 +200 0