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SKILLS LECTURE

Rachel Alfonso

CARDIOVASCULAR SYSTEM PHYSIOLOGY


-transport of nutrients
- deoxygenated blood in the capillaries

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

Factors that may affect oxygenation of a person:


I. Physiologic/Pathologic
a. decreased oxygen-carrying capacity of the blood
b. any condition that affects chest wall movement, eg. Rib fracture
c. any disease condition of the respiratory/cardiovascular system
II. Developmental
- people in the extreme ages are possible victims of respiratory diseases
III. Environmental
a. Occupational
b. house location
IV. Behavioral
- lifestyle
>vices like cigarette smoking
-nicotine- potential vasoconstrictor that affects perfusion
- carbon monoxide – destroys RBC
> alcohol – increases fatty plate deposition inside the blood vessels that alter perfusion

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- stress and anxiety – respiratory alkalosis/hyperventilation

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

4. Any condition and O2 saturation


Eg. Paralysis

Criteria for Type of Oxygen Administration (CVP)


C – concentration required O2 Saturation = 95-100%
V – ventilatory assistance – if patient is not breathing spontaneously
P – patency of airways
O2 is highly flammable
Safety Measures:
Don’ts:
U – no Use of materials that generate static electricity, eg. Woolen blanket
S – no Smoking
E – no Exposure to extreme temperature
- durability of tank is affected
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- can make the tank moisten inside – O2 is corrosive
R – never roll the tank
- it alters the tank’s durability and increases pressure
C – don’t Completely empty the tank
- moisten sets inside and affects the durability of the tank
- when oxygen is below 100, have another tank standby
V – no Volatile substance

Do’s:
C – Check the doctor’s orders
A – Assess patient
- Adequate oxygen supply
G – Ground electrical supplies/ devices
E – have available fire Extinguisher

Oxygen delivery system:


1. Nasal cannula – most common and safest
- with prongs 1 to 1.5 cm long
Advantage- patient is more free to move
- do not regulate more than 6 LPM because the fluid from the humidifier will be pushed out to the cannula
- can give 24 – 44% oxygen
Inhalation on cannula depends on the tidal volume of the patient
Tidal volume – amount of air inhaled and exhaled at normal respiration
Nursing consideration:
 If oxygen is given at a long line, assess the skin where the cannula lies
 Put a pad on the bony prominences
 It should not be lubricated
- not irritating but it dries up the mucous membrane
2. Mask – cone-shaped device applied over the nose and mouth of the patient
a. Simple face mask – gives 40 to 60% oxygen
- minimum regulation is 5 LPM; maximum regulation is 8 LPM
- saturate oxygen to prevent suffocation
b. Venturi mask – gives constant oxygen concentration
c. Partial rebreathing mask – has 100% oxygen
- has a reservoir
- gives maximum of 90% higher than 6 LPM
Nursing responsibilities:
 Make sure that the reservoir will not collapse during inhalation; there should be residual volume because it will
be concentrated with oxygen
- increase oxygen
d. Non-rebreathing mask – have a valve that automatically locks after inhalation
- can give 95% oxygen
- no exhaled air in the reservoir
Nursing responsibilities:
 Make sure that all ports are not blocked
 Find another anchorage if patient is allergic to elastic band or pad it with a cotton
**if there is respiratory acidosis and the doctor is not around, shift to other types of oxygen admin
3. Oxygen catheter – 24 to 48% oxygen
- assess patency of airway

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- used for pedia patients; ends in nasopharynx
Disadvantage:
 gives more risk for patients to have mucosal irritation – dries mucus membrane and lodges in the mucosal
lining
Advantage:
 less chance of dislodging compared to cannula
Pre-removal and insertion:
 clean nose of the patient
- removes impacted debris in the nose – put plain NSS drops to soften it
4. Transtracheal catheter – assess patency of airway before putting it
- direct in the lower airway
5. Oxygen hood – keep device and face dry
6. Oxygen tent – encloses patient inside
Pre:
- bombarded with max regulation of oxygen inside for the first 5 mins then regulate as required
7. Mechanical ventilation

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

Reasons for administration:


1. to add moisture to oxygen delivery system
2. to hydrate thick sputum and prevent clogging
3. to administer various drugs into the airways – nebulization

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

Peak Expiratory Flow Rate/Peak Flow Meter


- fast/hard strong exhalation as long as you can
- document the highest
- provide rest in between
- non-invasive

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

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- should be signed 24 hrs before the procedure
2. Do lidocaine skin test prior to the procedure
3. NPO 6 to 8 hrs prior to the procedure

Arterial Blood Gas Analysis


- radial, brachial, femoral
- diagnostic test which uses a sample of arterial blood to assess effectiveness of breathing and efficiency of the kidneys in
acid-base balance – carbonic acid; serum base bicarbonate

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:

Parameter Arterial Sample Venous Sample


pH 7.35- 7.45 7.32 – 7.38
PaCO2 35-45 mmHg 42-50 mmHg
PaO2 80-100 mmHg 40 mmHg
O2 saturation 95-100% 75%
HCO3 22-26 mEq/L 23-27 mEq/L
Base excess -2 +2

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

Eg. pH - 7.47 – base alkalosis


PCO2 - 30 – base respiratory alkalosis
HCO3 - 21 – acid partially compensated

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pH - 7.47 – base alkalosis
PCO2 - 47 – acid metabolic acidosis
HCO3 - 28 – base partially compensated

pH - 7.30 – acid acidosis


PCO2 - 40 – normal uncompensated
HCO3 - 21 – acid metabolic acidosis

pH - 7.35 – normal acidic acidosis


PCO2 - 34 – base metabolic acidosis
HCO3 - 21 – acid fully compensated

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

Reasons for Error of Sampling (Inaccurate Result)


1. Air bubbles in syringe – inaccurate result
-remove bubbles carefully
2. Inadvertent venous sample – due to overshooting
3. Effects of metabolism of WBC samples – after reading
- send specimen at least 20 mins of extraction
- should be covered with ice

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

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Suctioning
- application of the negative pressure into the airways/respiratory tract
- independent nursing intervention
- applied in the LRT and URT
Purpose:
1. to clear the airways – patent respiratory tract = promotes respiratory ventilation
1. obtain specimen for diagnostic studies
2. to prevent primary or secondary infection
, eg. In cases of ineffective cough reflex
Pneumonia – depressed cough reflex – respiratory failure
Comatose pt – altered LOC
Seizures – suppressed coughing reflex
- involuntary muscle contraction then relaxation
Newborns
Techniques:
-site and area where suction tip terminates
1. Bulb syringe suctioning
-oral and nasal cavity
- before inserting the nozzle, press the bulb first
2. Oropharyngeal – limited to URT only
3. Nasopharyngeal – limited to URT only
4. Orotracheal – for LRT
5. Nasotracheal – for LRT
- sever neuromuscular impairment
- absent coughing reflex
- done in the absence of artificial airway
6. Via artificial airways
- tubes that mimics the function of the respiratory tract
Eg. Tracheostomy tube
ET tube
-receive more aggressive respiratory resuscitation
- open and close method – applicable to patients with mechanical ventilator

2 kind of suction catheter:


1. Open tip – round tip; less irritating
2. whistle tip – has started opening
- tendency to stick to the mucosal lining
*distributed negative pressure – better suctioning

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

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Recommended range of negative pressure
Wall Unit Portable Unit
Infant 60-100 mmHg 3-5 mmHg
Child 100-120 mmHg 5-10 mmHg
Adult 120-150 mmHg 10-15 mmHg

Sizes of Catheter/suction tip


Newborn to 18 months Fr. 6 to 8
18 months to 24 months Fr. 8 to 10
2-7 years old Fr. 12
7-12 years old Fr. 12-14
13 years old to adult Fr. 12-16

8. Do not apply suction during insertion


9. Catheter should be inserted while inhaling – epiglottis opens
10. Adults 20-24 cm
Children 14-20 cm length of catheter insertion
Infant 8-14 cm
11. Once resistance is met, pull one inch then apply negative pressure
- resistance indicates reaching carinii that is prone to mucosal damage

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

Suctioning via Artificial Airway – best done with assistance


 Assess air entry
 Auscultate lung sounds
 Assess intactness of artificial airway
 Give pain reliever 15-30 mins before procedure
 Check for anchorage
 Auscultate for Cardiac Rate – suctioning can cause vagal stimulation ( 20/ 40 from CR baseline)
 Position on semi-fowler’s to prevent aspiration and promote lung expansion
 Flush 1 to 1.5ml

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

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 If with AMBU, oxygen saturation
Pre-requisite prior to OR entrance:
Mask – completely covers the mouth and nose; replaced q4°
Turban – completely covers the hair and ears
Sterile (scrub nurse and Surgeon) and non-sterile field( circulating nurse and anesthesiologist)
Bio-medical technician – repair equipments in the OR
4. Know by heart the principles of aseptic technique
Moisture – causes growth of bacteria
Unsterile – keep away from sterile
Sterile – remain well on sterile area
Table – sterile only at table level
Gown - sterile waist to shoulder, infront and on the sleeves
Edges – anything that encloses a sterile article is unsterile; 2.5cm from the edge of the table
Minimum exposure – open pack as close as possible to operation time
Sterile person – sterile
Field – do not lean on unsterile field; unsterile persons should avoid reaching over the sterile field
Articles – all materials inside the OR are previously sterilized
Doubt – if in doubt of sterility, discard and consider unsterile
Elimination of bacteria – kept in irreducible minimum

Specific Responsibilities of the OR Team


Sterile Members
1. Surgeon – has knowledge and skills about the procedure
- have met the patient during the consultation
- does PA and history taking and formulate pre-op diagnosis
- identifies surgical procedure
- explain risks and benefits of surgical procedures to the patient
- obtains a valid consent
- performs the procedure
- does post-op management
2. Scrub Nurse – set up sterile field
- scrubbing, gowning and gloving
- continue setting sterile field
- serves the gown and gloves to other scrub members
- do sponge , instrument and sharps count with circulating nurse
- assists surgeon in draping the patient
- position materials
- give instruments to the operating team
- check for any break in the aseptic technique among the scrub team
- count before, during, and after the procedure
- assist in applying the dressing
- after care: wash instruments – discard blades; sharps – soak in disinfectant; non-sharps – autoclave
3. 1st Assistant/ assistant to the surgeon – assists in:
- exposing the tissues
- hemostasis – for better visualization and prevent hemorrhage
- suturing

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

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- attaches patient to monitoring device - vital functioning is dependent on the anesthesiologist
- acts as medical physician of the patient post-op for respiratory distress, pain, etc until the patient is discharged
2. Circulating Nurse
– responsibility starts when the patient enters the OR during endorsement
- introduce self to patient
- assist in transferring patient to OR bed and maintain the patient’s safety
- verify the patient’s name, procedure to be done and the surgeon
- listen to endorsement and make sure that the patient is prepared- CP clearance and recommendation
- check for pre-op checklist
- check for initial vital signs in the holding area
- once the patient is wheeled on the holding area, do pre-op chart until before the patient is incised
- before starting the operation, apply cap to patient for protection
- help the wheeling the patient to the OR
- OR pre-op:
 Help in positioning the patient
 Assist anesthesiologist during the induction of anesthesia
 Help attach monitoring devices
 Fasten gowns of the scrub team
 Helps scrub nurse in preparing the sterile field
 Document sponge and instrument count
 Attach tubing to the equipment
 Identify and manage any hazard to the patient and surgical team
 Properly label and ensure that specimens are sent to the laboratory
*** “entered OR” – when the patient is transferred to the OR table
 Types of anesthesia:
o GETA – General Endotracheal Anesthesia
- patient is unaware of the surgery; loss of consciousness
o GA by LMA – General Anesthesia by Laryngeal Mask Airway
o SAB – Sub-Arachnoid Block can go
o CEA – Continuous Epidural Anesthesia together
o PNB- Peripheral Nerve Block
o Local Anesthesia – site of Injury
o Regional Anesthesia – specific region
o TIVA – Total Intravenous Anesthesia
 Note for size, appearance and type of specimen in the OR tech
 Call lab for available blood/ tell watchers to look for blood
- communicate with the personnel outside of the OR
 Anticipate the needs of the surgical team
 Document when the suturing will end
 Gown patient post-op
- check patency of drainage and infusion tubing
- inform PACU nurse of the post op orders
 Clean OR

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
16 | P a g e MERYL P. RAMIREZ, BSN, RN
- wiping
- washing

-disinfecting – remove source of infection


 Physical – boiling
 Chemical
o antiseptic – for living objects
o disinfectant – inanimate objects
o bacteriostatic – suppress growth
o bactericidal – kills
- sterilization – completely removes all microgranisms
 Steam sterilization – autoclave
 Gas sterilization – Ethylene oxide
 Radiation
c. Use of barriers
d. Isolation Precaution
5. Surgical Hand Asepsis – done to remove as many microorganisms from the skin as possible
- processes:
a. Mechanical washing – use of scrubs
b. Chemical anti-sepsis – use of antiseptics
Methods of Traditional Scrubbing
1. Counted Brush Stroke Method – specified number of stroke to a specified part of the arm
2. Timed Method – specific time allotted to each part of the arm

Levels of Unconsciousness/Stages of General Anesthesia:


1. Induction phase – induction of anesthesia to loss of consciousness
- patient becomes drowsy
Nursing responsibility:
 provide safety
2. Delirium/Excitement Phase – loss of consciousness to excitement
- patient is easily stimulated
- with regular respiration and BP
Nursing Responsibility:
 safety of the patient and provide a quiet environment
3. Surgical Anesthesia Phase – excitement to depression of reflexes and vital functions
- BP is normal; RR is regular
- pupils are constricted
Nursing Responsibility:
 Prepare patient for operation
4. Danger Phase – loss of vital function to respiratory arrest
- pupils are dilated
Nursing Responsibility:
 Initiate CPR

Symbols:
X – anesthesia started X – anesthesia ended
● - OR started ^ - OR ended
^ - DBP v – SBP
T – intubation ┴ - extubation
- PR ° - RR

Gloving – to exclude skin as a contaminant


Closed gloving – no skin bared; with gown
Open gloving – without gown
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Blades 20 Blades 10
21 Bladeholder #4 11 Bladeholder #3
22 12
15

Arrange instruments according to use:


Blade holder #4------ bladeholder #3------ Metzenbaum scissors (smooth, for cutting tissues) ----- Mayo scissors (sutures)
------ thumb forceps------ tissue forceps ----- army navy retractors

Curve clamps ----- (mosquito – small), (kelly – medium), (pean – big; for intestinal surgery)---- straight clamps--- allis

**clamps should be away from the surgeon


**1st instrument to be used should be near the scrub nurse
**tip to tip
**curved tip facing the scrub nurse

Morphine precautions
- check for hypotension
- check for bradycardia
- check for RR<12/min
- check for urticaria
- check for urine output <30 cc/hr

Charting prior to transport to the OR


Contents:
1. Patient’s verbalization regarding surgery
2. Indication for surgery
3. Schedule and type of surgery
4. Consent by whom
5. Clearance by whom
6. Patient’s condition upon transport to OR
- level of consciousness/alertness
- attachments
- Vital signs, respiratory and cardiovascular status
7. Verification of surgical site
- if shaving or initial prep is done
- presence of stoma, wound, dressing
8. Drainage tubing
9. Venoclysis
10. Procedure done related to surgery
 Blood transfusion
 Ultrasound
 Enema – bowel preparation
 NPO orders
 Other Dx tests like CBC, blood typing, PTT
11. Last meal, last bowel movement
12. Pre-op meds
13. Method of transport/by whom/special endorsements (IV level, Oxygen sat, BP)

Circulating Nurse Pre-op charting


1. Arrival at OR, IVF, IV level

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2. Scheduled surgery
3. Consent
4. Level of Consciousness
5. Clearance by whom
6. Vital signs
7. Transfer to OR table
8. Anesthesia induction/by whom
9. Position
10. Type of restraint and supports used (pulse oximeter)
11. Skin condition and antimicrobials used for skin preparation/ by whom
12. Insertion of drains, tubings
13. Initial sponge, sharps and instrument count

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

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- Mayo – straight for sutures; curved – for tougher tissues
- Metzenbaum – for tissues
 Scalpel – bladeholder + blade
 Biopsy punch – used in endoscopy
 Curette – used in D & C for scraping the uterus
- dull and sharp
 Clamping and occluding – for blood vessels
- used to control bleeding
 Clamp – mosquito – straight
- kelly – curved
 Grasping and holding
 Thumb forceps – for delicate tissues
 Tissue forceps – for skin/tough tissues
 Adson – used for lesser injury/trauma
- with fine bite
- with teeth and without teeth
 Towel clip – holds towel in place
 Tenaculum – holds uterine fetus
 Allis and babcock – holds tubular structure
used for appendectomy because it is bigger
 Ochsner – holds tissue firmly
 Ovum forceps – holds ovaries
 Exposing and retracting
 Handheld retractors – needs manpower
 Army-Navy – for small and superficial to deep
 Richardson
 Malleable/ribbon – can put to contour
 Deaver – narrow and wide
- for abdominal and thoracic surgery
 Bladder retractor – avoids bladder puncturing in Ceasarean Section
 Self-retaining
 Balfour retractor
 Suturing and stapling
 Needle holder
 Needles:
 Round – for suturing tissues
 Cutting – for suturing the skin
 Traumatic – no thread
 Atraumatic – with thread
 Sutures (the higher the number, the finer the thread, the needle is smaller as well)
 Chromic – brown
 Plain – yellow absorbed after 90 days
 Vicryl – violet
 Silk – black non-absorbable
 Cotton – white
 Ethilon – green
 Viewing
 Speculum
 Endoscope
 Suctioning and aspirating
 Yankauer Suction tip – with curved tip; used for abdominal surgery
 Poole Suction tip – with straight tip; OB use
20 | P a g e MERYL P. RAMIREZ, BSN, RN
Post-operative Nursing
-the focus is to assist the patient in returning to optimal functioning as quickly as possible
- while the client is still in the OR, prepare the bed and room for post-op
-obtain set up and special equipment , eg. IV pole, suction, oxygen, cardiac monitor

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

PACU- Post-Anesthesia Care Unit


- specialized area for patient care during recovery from anesthesia
- adjacent to the OR

Immediate Post-op Care


1. Assess and maintain patent airway due to decreased muscle strength
- suction
- provide oral airway
- turn patient’s head to side to prevent aspiration
2. Administer oxygen as ordered
3. Assess RR, depth and quality of respiration
4. Check vital signs every 15 mins, then every 30 mins
5. Note level of consciousness – reorient patient to place, time and situation
- tell the patient that the surgery is done and he is in the RR
-sense of hearing is the 1st to come back
6. Assess color and temperature of skin, color of nails and tips
- patient may become hypothermic
- provide warmth with drop light
7. Monitor IV infusion
8. Connect drainage tubing
9. Assess dressings for intactness, drainage and hemorrhage
10. Provide a warm environment
11. Encourage patient to do coughing and breathing exercises unless contraindicated. Eg. Eye surgery, increased ICP
12. If spinal anesthesia is used, maintain flat position and check for sensation and movement of lower extremities
13. Monitor I&O and check for bladder distention

Discharge from PACU


 Conscious and coherent
 Able to maintain a clear airway and do DBE and coughing exercises frequently – check for gag reflex
 Stable vital signs
 Presence of protective reflexes – coughing
 Able to move four extremities
 Afebrile or febrile condition has been attended to- fever up to 3 days is normal due to inflammation
 Urine output is adequate
 Dressings are dry and intact – reinforce to prevent interruption of wound healing

Post Anesthesia Recovery Score


Aldrete’s Score – used for establishing post-op discharge criteria

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Post-operative Complications

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

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 Decreased lung and chest wall compliance

E. Pulmonary Embolism – a clot that breaks and occludes a pulmonary vessel


Signs and symptoms:
 Tachypnea
 Tachycardia
 Dyspnea
 Pleuritic chest pain – sudden
 Cyanosis
 Hypoxia
Management:
 Trendelenburg and side-lying
 Removal of embolus
F. Pneumonia
- inflammation and infection of one or more lobes of the lungs resulting from infection
- crackles
G. Atelectasis
- collapse or incomplete expansion of the lungs
- mucus plug or (-) air exchange
Signs and symptoms:
 Dyspnea
 Crackles
 Diminished to absent breath sounds
H. Pulmonary Edema
- abnormal accumulation of water in extravascular portions of the lungs, including alveolar and interstitial spaces
Signs and symptoms:
 Bounding, rapid pulse
 Crackles
 Dyspnea
 Engorged peripheral veins

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

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 Shock

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

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- (+) bladder distention
B. Urinary Tract Infection
– inflammation of bladder, urethers or urethra
Wound Complications
- results from improper wound care
A. Wound infection
- inflammation and infection of incision or drain site
Management:
 Wound care
 antibiotics
B. Dehiscence
- separation of suture line before it heals
Management:
 Re-suturing
C. Evisceration
- protrusion of loop of bowel to the incision
Management:
 Cover with sterile gauze soaked in saline solution
 Elevate head and legs to 30 degrees
 Re-opening and resuturing

Wound and Wound Management

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 Status of Skin Integrity:


1. Open – involves a break in skin or mucous membrane
2. Closed – wound involving no break in the skin
- should be prioritized because it is not readily assessed
- x-ray is needed
3. Acute – wound that proceeds to an orderly and timely reparative process
- heal within 3 to 5 days
- there should be absent redness and pain after 3 to 5 days
4. Chronic – wound that persist beyond healing time
- infection/internal hemorrhage

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 Descriptive Qualities:


1. Laceration – tearing of tissues with irregular wound edges
2. Abrasion – superficial wound involving scraping or rubbing off skin’s surface
3. Contusion – closed wound caused by a blow to the body by a blunt object
4. Puncture – small circular wound with edges coming together toward the center
5. Vesicle – with blister less than 1 cm
6. Cyst – fluid-filled

According to Depth
1. Partial Thickness – involves epidermis and dermis
2. Full Thickness – involves epidermis, dermis, subcutaneous tissue and possibly muscle and bone

Phases of Wound Healing


1. Inflammatory Phase/Defensive Stage
- body’s reaction to wounding begins within minutes of injury and lasts approximately 3 days
Process:
 Hemostasis – platelet aggregation (macrophage go to the site of injury)
 Phagocytosis – formation of fibrin
2. Healing/Proliferative/Reconstructive Phase
- lasts 3 to 24 days
- filling of the wound with granulation tissue, contraction of the wound, resurfacing of the wound by epithelialization
3. Maturation/Differentiation/Remodelling
- collagen scar regain strength and reorganize

Types of Wound Healing


1. First intention/ Primary Union
- no tissue loss
- minimum scar formation
- no granulation and tissue formation
- well approximated edges
2. Secondary intention
- healing from the inside out with gaps filled with granulation tissue
- antigen-antibody response
3. Tertiary Intention/ Delayed Primary Closure
- purpose – wailing off an area of gross infection on where extensive tissue was removed
- Daikin’s Solution – 450cc saline + 50cc bleach

Factor Influencing Wound Healing


1. Wound classification
2. Circulatory status
3. Age
4. Nutrition
CHON – provides essential amino acids for new tissue construction
CHO – energy resources for cells
Vit. B complex – for CHO, CHON and fat metabolism
Vit. C – aids in collagen synthesis
26 | P a g e MERYL P. RAMIREZ, BSN, RN
5. Fluid and Electrolyte balance
6. Hematology
7. Inflammatory and immune responses
- allergic responses
- immunosuppression
8. Drug therapy
9. Radiation therapy

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

Type of Wound Dressing


1. One-layered dressing – clean incision with no or slight drainage expected
2. Skin closure dressing – placed over the entire length of incision to hold the skin edges in apposition
3. Dry sterile dressing – single layer or multilayered dressing applied over a clean incision from which no or slight drainage is
Expected
4. 3-layered dressing – moderate to heavy drainage
a. Contact layer
b. Intermediate layer
c. Outer layer – hold a & b in place
5. Pressure dressing – prevents edema or hematoma and absorbs drainage
6. Wet-to-dry drainage – soaked in sterile NSS applied to the wound and allowed to dry thoroughly
7. Wet-to-wet dressing – soaked in NSS and applied wet

Type of Dressing Materials


1. Gauze
2. Non-adherents – sterile dressing saturated with antibiotic or disinfectant in oil base to prevent sticking to the wound
3. ABD’s – absorbent dressing
4. Moisture vapor permeable transparent dressings – thin plastic sheets applied to the wound
5. Hydrocolloid dressings – soft wafer
- absorbs drainage at wound surface and provide moisture for wound repair
6. Montgomery straps – cloth or synthetic material
- allow or secure lying in large dressings that easily soak and needs frequent changes

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

27 | P a g e MERYL P. RAMIREZ, BSN, RN


Digestive System
 Mouth
 Teeth – breaks down particles into smaller pieces
 Salivary gland – ptyalin = breaks CHO – amylase
- mucus = aids in swallowing
 Tongue – pushes the food to the pharynx – swallowing reflex
 Esophagus
 Stomach
 Small intestine
 Duodenum
 Jejunum absorption takes place
 Large intestine

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

29 | P a g e MERYL P. RAMIREZ, BSN, RN


C. Fecal Impaction
-hardened fecal matter

Signs and symptoms:


 Halithosis
 Abdominal distention
 Liquid fecal seepage
Management:
 Suppositories, fleet enema – oil retention enema
 Manual/digital extraction – use lubricant if dry
- remove per tidbit
- do not remove fecal matter completely

Removal of fecal matter by surgery or colostomy


Right ileostomy – liquid
Ascending – liquid
Transverse – semi-formed
Descending – formed

Urinary Problem/Incontinence
Urinary retention problems
> catheter
> surgery – Urostomy

TURP – Transurethral Ressecton of the Prostate


CBI – Continuous Bladder Irrigation
- until bloody output becomes clear
- increase regulation if the output is dark until it becomes clear
**No output with hypogastric pain
- check for bladder distention
- assess the patency of the tubing
- refer to the physician
- anticipate for the preparation of syringe for flushing
- detach port of IFC, insert 50cc then flush

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

30 | P a g e MERYL P. RAMIREZ, BSN, RN


31 | P a g e MERYL P. RAMIREZ, BSN, RN

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