Periopera

tive
Nursing
Sharon R. Andress
DNP,RN,CEN,CNE
 Perioperative Nursing

Patient Safety #1
concern- Surgical Care
Improvement Project
Nursing care provided for (SCIP). Core measures to
the patient before, during reduce surgical
and after surgery infections, prevent
serious cardiac
complications, prevent
VTE.
Categories of Surgery
Urgency Reasons for Surgery
• Emergent: needs immediate • Diagnostic- exploratory
attention laparotomy
• Urgent: requires prompt attention • Curative- appendectomy
• Required: needs to have surgery • Restorative-total knee
• Elective: should have surgery replacement
• Optional: patient decides if surgery • Palliative- reduce symptoms
will happen
• Cosmetic
 Phases of
perioperative period
• Preoperative-beginning with the decision that the surgical
intervention is needed and ends with the transfer of the
patient onto the operating room (OR) table
• Intraoperative-begins with the transfer of the patient onto
the OR table and ends with admission to recovery
• Postoperative-begins with admission to PACU and ends with
complete recovery from surgery
 Preoperative Assessment
• Health history and physical
assessment
• Medications and allergies
• Risk factors for surgical complications
• Collection of information and
paperwork
• The role of the nurse is multifaceted:
educator, advocator, and admittance
nurse
Preoperative Nursing Interventions
• Assure informed consent is accurately signed, completed and witnessed.
• PREOP CHECKLIST: Medications to be given
• NPO SINCE: ____ PREOP Vital signs __________
• PREOP TEACHING
• Provide psychosocial interventions
• Reducing anxiety and decreasing fear
• Respecting cultural, spiritual, and religious beliefs
• Maintaining patient safety- (What safety issues might you anticipate and
prevent)?
• Remove jewelry, glasses, contacts, hearing aids (?) , undergarment, void.
Surgical Safety Checklist (WHO)
• Time-Out: Team communication:
• All team members introduce themselves
• Anesthesiologist, RN, and surgeon independently confirm patient ID,
procedure, site.
• Surgeon- any anticipated concerns
• Anesthesia- any anticipated concerns
• Nursing- any concerns/issues with sterility, equipment? Abx
prophylaxis within last 60 min? Essential imaging displayed?
This Photo by Unknown Author is licensed under CC BY-NC-ND
 Informed Consent
• A patient autonomously and cognitively grants permission to perform a
procedure after considering all alternatives, benefits and risks
• Signed form is a legal document as well as an ethical imperative
• Physician performing the procedure secures the informed consent
• Nurse may sign as a witness to the voluntary signature of the patient
• Nurse responsibilities consent-
• Responsibility to see that client signs consent
• Notify provider if client has additional questions or does not understand
• Nurse can reinforce teaching
• Provide a trained medical interpreter if not English speaking.

• Patient always has the right to refuse

• Which ethical principle plays primary consideration when obtaining an informed
 Informed Consent- Required
Components
• Patient’s voluntary agreement to undergo a particular procedure or
treatment after receiving information regarding the procedure in plain
language.
• Description of the procedure
• Underlying disease process and its natural course
• Name and qualifications of person performing the procedure
• Explanation of risks involved and how often they occur
• Alternatives to the procedure
• Explanation to the patient of the right to refuse treatment and the
consent can be withdrawn
• May include blood and/or blood components
Who can sign consent?
• 18 years of age or greater or emancipated minor
• Mentally capable of understanding risks, options, etc.
• Not under influence of meds that alter decision-making or judgment.
• Legal guardian
• Question: When is informed consent required?

• Who should not sign? Cognitively impaired, if a language barrier-

provide hospital interpreter
What would you do if…

• You as the nurse were preparing the patient for surgery, and it
became clear that the patient did not understand the surgical
procedure, the risks, and the consequences.
• E.g. Before an exploratory lap with a colostomy, the patient
stated, “I am so happy I won’t have to wear one of those bags
that collect my waste”.
The nurse is preparing to administer a premedication
sedation. Which of the following actions should the nurse
take first?
A. Have the family present
B. Ensure that the preoperative clipping is completed
first
C. Have the patient void
D. Make sure the patient is covered with a warm blanket
Gerontologic Considerations
• Cardiac reserves are lower
• Renal and hepatic functions are depressed
• Gastrointestinal activity is likely to be reduced
• Respiratory compromise
• Decreased subcutaneous fat; more susceptible to hypothermia in cold
operating suite
• May need more time and multiple explanations to understand and
retain what is communicated.
• Sensory impairment- sight, hearing
Preparing the patient for surgery
• Will have labs and IV placed (what labs?)
• May need imaging ( when and how? )
• Patient teaching ( what to expect?) –Include the
family , helps to decrease anxiety ( time frames,
etc.)
• May need specific bowel/bladder prep, skin prep,
medications

• What about post-op care?

Preoperative Labs
The nurse reviews preop labs prior to patient surgery. Which preoperative
laboratory findings would concern the nurse? (Select all that apply)

1. PT 18 INR 2.5 (INR 0.83-1.35)

2. Serum Potassium (K+) 3.1 mEq/dl (K+ 3.5 to 5 mEq/L)
3. Hemoglobin A1C 5.2 (<5.6)
4. Hemoglobin 14.2 (12-16)
5. Platelet count 156,000 (150,000-450,000)
6. WBC count 14.5 K with 3% immature granulocytes (4K-10K with no bands)
7. Serum Ca 14.4 (8.5-10.2 mg/dl)
Which preoperative laboratory findings would concern the nurse?
(Select all that apply)

• PT 18 INR 2.5 -risk of bleeding

• Serum Potassium (K+) 3.1 mEq/dl- risk of cardiac
dysrhythmias
• Hemoglobin A1C 5.2- normal
• Hemoglobin 14.2- normal
• Platelet count 156,000- normal
• WBC count 14.5 K with 3% immature granulocytes-
possible sign of infection
• Serum Ca 14.4- hypercalcemia
Preop Instruction for
Ambulatory Surgery
• Preparing the skin- chlorhexidine washcloths
• NPO instructions.
• Medications-
• What meds should be d/c before surgery? _________
• What to take in the morning?
• Completing the Preoperative Checklist (see textbook)
• Family needs
• Identifying the patient and what surgery is being
performed.
• Same day surgery- Who is taking you home????
Members of the Team

• Surgeon

• Anesthesia provider

• Perioperative RN

• Surgical technologists

• Scrub and Circulating RN

 The Surgical Environment
• Surgical asepsis: goal to prevent the contamination
of surgical wounds
• Health hazards associated with the surgical
environment:
• Electrical hazards- proper grounding.
• Laser risks
• Exposure to blood and body fluids
• Infection
• Unintentional retention of an object
• Burns- bovi pad, defibrillator
• Pressure injuries
• Fires- oxygen, fuel- rich environment
 Intraoperative Nursing Care:
ADVOCACY
• Positioning and padding-ensure patient
safety and skin integrity
• Safety- prevention of infection, fire, burns,
other injuries while patient is unable to
defend themselves
• Draping-sterile field and only area exposed is
the incision site
• Documenting-ongoing patient assessment,
item counts, monitoring data (vital signs,
urine output, blood loss) positioning,
medications, dressing and drains
Anesthesia
• Depending on its classification as general or regional, it produces such states
as loss of consciousness, analgesia, relaxation and loss of reflexes

• General anesthesia produces all of these responses whereas regional doesn't’t

cause narcosis but results in analgesia and reflex loss
• Narcosis = severe central nervous system depression

• Nurse anesthetists or anesthesiologists administer

General Anesthesia
• Inhalation or IV route to produce CNS
depression
• Inhalation- halothane, nitrous oxide with
oxygen
• IV- benzodiazepines, etomidate, Propofol,
ketamine,
• ALLERGY to eggs and soybean oil
contraindication to Propofol

• Adjunctive meds- opioids anticholinergics,

sedatives, neuromuscular blockers
• Desired actions are decreased LOC, analgesia,
relaxed skeletal muscle and depressed
reflexes
• Reversible unconscious state
• Usually need mechanical ventilation
Risks of general anesthesia
• Hypothermia
• Respiratory depression/intubation problems.
• Circulatory depression
• Postoperative nausea and vomiting
• Anesthesia awareness (0.1-0.2% cases)
• Anaphylaxis
• Anesthesia overdose
• Intubation problems- injury to teeth, mouth, gums, airway
• Malignant hyperthermia
 Malignant hyperthermia
• Malignant hyperthermia- Inherited muscle disorder that anesthesia induces chemically).
Needs prompt recognition; mortality rate 70%

• Tachycardia rate 150 (early sign), muscle rigidity from increased calcium,
hypotension, skin mottling, cyanosis, myoglobinuria, increased ET CO2 with
decreased SaO2

• Rise in temp late sign (up to 107).]

• Rx- STOP SURGERY, intubate, IV dantrolene, 100% O2, iced IV fluids, cooling blanket
Regional Anesthesia
• Occurs when an anesthetic agent is injected near a nerve or nerve
pathway around the operative site ( block a nerve or nerve fibers)
• Patient remains awake but loses sensation in a specific area or region
of the body
• Nerve blocks, spinal anesthesia, or epidural blocks

• Prevention of headache from CSF leakage:

• Treatment: HOB flat, quiet environment, hydration
 Moderate (conscious) sedation
• Used for short term procedures.
• Pre-procedure precautions:
Patient maintains resp function and can respond to verbal commands while the IV
administration of sedatives and analgesics raise the pain threshold and produces
an altered mood and some amnesia.
• Meds- etomidate, diazepam, midazolam, fentanyl, propofol
• Patient placed on heart monitor to observe cardiac rate, rhythm, pulse ox, RR,
blood pressure, LOC and skin condition. AIRWAY, SaO2, vital signs most
important.
• Nurse anesthetist or specially trained nurse. (ACLS training)
• What precautions do you take when pt receiving moderate sedation?
 Surgical Safety
Checklist
(WHO)
• Sign out (at end of procedure):
• Instrument, sponge, and needle
counts must be correct. Nurse
verbally communicates to team
• Labeling of specimen
• Handoff: Surgeon, anesthesia,
nursing review any key concerns
for recovery and patient
management.
• Anesthesiology gives
handoff to PACU nurses.
 Handoff
KEY safety procedure
• What information do you think is necessary
for the anesthesiologist to pass on to RN in
the handoff?
• S-situation:
• B-background:
• A-assessment (system-based)
• R-recommendation:
• ** handoff communication is 2-way
communication between provider and
receiver. Ask questions when receiving
handoff to clarify patient status and
priorities !!
Postoperative nursing care
Post Anesthesia Care Unit (PACU) –Go to after surgery or anesthesia
• Ongoing care- to the unit until discharge and follow up appointment
• Goal: Safely allow the patient who had had anesthesia to wake up
and resume normal function, minimizing pain and preventing
complications
• PACU assessments are continuous and ongoing (respiratory, CV, CNS,
fluid status, wound status and general condition) every 5 to 15
minutes with average stay 2 hours

• Airway, breathing, circulation first priorities.

Respiratory Assessment
AIRWAY:
• Patient may have artificial airway (endotracheal tube) or oral airway
and it can’t be removed until pharyngeal and laryngeal reflexes return
• Airway obstruction is most common PACU emergency. S/S- noisy,
irregular resp, decreased O2 saturation, cyanosis mouth and lips
• May be caused by secretions, obstruction of the tongue,
laryngospasm or edema, vomitus.
• Position patient on their side with vomiting or airway obstruction.
 Airways

LMA

Endotracheal tube
with laryngoscope
Used for insertion Oropharyngeal
airway
 Breathing
• Monitor resp rate, depth and rhythm. RR <10 resp depression.

• Rapid resp- pain, shock, cardiac complications. TREAT!

• Too slow resp- anesthetic effect. ALSO NEEDS immediate

attention!

• Auscultate breath sounds

• Monitor continuous O2 saturation. Less than 90-93% is

abnormal. Encourage deep breathing.

• Once patients are extubated, will wear supplemental oxygen

(mask or cannula). Frequent deep breathing exercises.
 Cardiovascular Status, fluid balance
• Vital signs, U/O, pulses.
• Monitoring ECG rate and rhythm.
• Vital signs- TRENDING.
• Assess IV, Administer correct solution at correct rate
• Assess surgical dressing site- any bleeding? If minimal, mark, time, and
reassess. If major bleeding, notify immediately! Assess for hidden bleeding.
• Assess drains- NG, JP, hemovacs, chest tubes, etc. Note drainage. Place to
suction if ordered.
• Hypotension and Shock-hemorrhage, 3rd spacing.
• Bleeding- can be noted from dressings, drains, or can be internal.
• Shock: patient will feel apprehensive, cold, air hungry, tachycardic.
• Hypovolemic shock- isotonic fluids, replace blood if bleeding, administer O2.
 Patient presents to PACU after
abdominal surgery:

In OR, BP 136/84, HR 84 U/O

Clinical 50ml/hr

judgment Now BP 100/60 HR 110, U/O 25

ml last hour.

Thoughts? What can be

happening?
 Fluid/Electrolytes/ Urinary
Monitor I/O. Patient may third-space significantly postop, depending on type
of surgery. Assess for s/s hypovolemia and adequacy of fluid replacement.
• Assess for urinary retention if no urine output - Palpate bladder, bladder scan
• Urine output at least >30cc per hour (actually 0.5 ml/kg/min- more
accurate).
• If the patient has an indwelling catheter, GET INDWELLING CATHETERS OUT
 Neuro Status
• Assess level of consciousness-
• The PACU nurse must distinguish between
arousal from anesthesia and lethargy,
restlessness, irritability for other reasons
(hypoxemia or shock for instance).
• Patients need frequent reorientation
during re-emergence from anesthesia.
• If regional block- assess for return of
movement and sensation in extremities
Discharge from PACU
• Patient is discharged from PACU when his/her physical status and LOC
are considered stable. May use a scoring system such as Aldrete
score. Usually scores 8-10 before discharge from PACU

• Family is notified

• Patient transferred to his/her room

• PACU nurse gives verbal handoff report.
• Safety- what do you think are important points to communicate in the
handoff?
 Postoperative Care when patient returns
to room
• ABCs!!!!
• Vital signs- q 15 x 4, q 30 x 4, q 1 hr x 2 then q4h if
stable.
• Assess IV patency; Maintain IV fluids
• Resp, CV, U/O, GI
• Check dressings and feel under patient for bleeding.
Mark and time drainage on surgical dressing.
Reinforce dressing. (What does that mean?)
• Verify all tubes and drains are patent..
• Check drain output with vital signs.
• Call bell and siderails up
• Relieve pain
• Record assessment
 Prevent Respiratory complications
• Pneumonia-atelectasis, aspiration
• Atelectasis- due to anesthesia,
hypoventilation, pain, Poor inspiratory
effort
• Preventing respiratory complications:
• Appropriate pain management
• Incentive spirometry or deep
breathing
• Coughing with splinting.
• Encourage turning in bed.
• Early ambulation
Venous thromboembolism (VTE)/Deep
vein thrombosis
is an inflammation of a vein associated with a thrombus formation –Can
result in pulmonary embolism- very serious, can result in death.
Prevention-
• Early ambulation,
• Heparin (either LMW (enoxaparin) or unfractionated)
• Pneumatic compression devices
• adequate hydration,
• leg exercises while in bed,
• DON’T MASSAGE CALVES if VTE suspected- can dislodge clot!
VTE/DVT Prevention

Q: proper administration of enoxaparin.

 Acute Pain Management
• Subjective and objective
• Verbal rating with scale of 1 to 10
• Opiates and nonsteroidal anti-inflammatory medications
• Watch for hypotension, respiratory depression- (opioid overdose).
• PCA- patient controlled analgesia
• Teach patients to splint incision for support and comfort when moving,
coughing.
• Nonpharmacological interventions-repositioning, backrub, applications of
hot/cold, guided imagery
• Assess, intervene, REASSESS!!!
PCA: Patient controlled analgesia with Et
CO2 monitor
• Greatest risk- respiratory depression
• Prevent-Only patient pushes button!
• Monitor Level of consciousness, resp.
rate, depth, adequacy of pain relief.
• Monitor doses/attempts
• Is the patient a good candidate?
Who would not be a good candidate
for PCA?
Gastrointestinal System
• Postoperative nausea/vomiting- occurs in 30% of patients in first 24
hours after surgery.
• IF VOMITING, TURN PATIENT TO SIDE TO PREVENT ASPIRATION!!!
• Delayed peristalsis usually for about 24 hrs. postop.
• Check for bowel sounds; however, best indicator of return of peristalsis is
passage of flatus. Ask postop pts!!
• Paralytic ileus- absent bowel sounds, distended abd, abd discomfort,
no flatus. Persistent ileus- NG tube
• Prevention of ileus- ambulation!
 Normal Incision healing
• A clean surgical incision heals in about 2 wks.
• Delayed or complicated healing- steroids, older
patients, smokers, obesity, diabetics, pts with
increased BMI , poor nutritional status
• Surgeon usually removes original dsg after 1-2
days. Not recommended to remove dressing
before fibrin and first epithelial layer seal the
incision (Not before 24 hours at least).
• Leave steri-strips on
• Specific instruction regarding dressing, showering
• NO tub baths, no hot tubs, no pool swimming til
otherwise ordered.
Surgical site complications
• Infection- called SSI- surgical site infection
• Assess incision every 8 hours for redness, increased warmth, swelling,
tenderness, or pain, and increased drainage, separation around
staples.
• Prevent SSI- proper skin prep, appropriate Abx…

This Photo by Unknown Author is licensed under CC BY

**SCIP Core measures- Joint
commission
• Prevent infection: Prophylactic antibiotic received within 1 hr. prior
to surgical incision cut.
• D/C prophylactic antibiotics within 24 hrs. after surgery end time.
• Cardiac surgery- avoid post-op hyperglycemia
• Preop hair removal- clippers, no shaving.
• POD # 1 urinary cath removal unless other indication.
• Perioperative temperature management (prevent prolonged
hypothermia )
• For pts on beta blockers before surgery, continue immediate postop
pd.
• Venous thromboembolism prevention
 Dehiscence or Evisceration
• Dehiscence-partial or total disruption of
wound layers- 5th-10th day highest
incidence.
• Evisceration-protrusion of viscera through
the incisional area 5th-10th day highest
incidence.
• High risk: obese, malnourished and
excessive coughing, vomiting or straining,
edema, edema, stress at surgical site.
• Also diabetes, steroid use, renal, heart,
lung issues, SMOKERS
• An increase amount of serosanguinous
fluid from wound between post op day 4-5
is sign of impending dehiscence
Evisceration
• A patient postop day 7 is getting OOB
and feels something “give”. You lift up
the patient gown and find this. What
do you do?

• Answer- back to bed, low fowlers, sterile

moist saline dsg to keep bowel moist, stat
page surgeon
Discharge considerations for same-
day surgery
• Needs transportation home! • Observe incision every
• Provide all instructions to day
patient and to person
accompanying patient. Provide • S/S infection: Call
verbally and in writing; use surgeon
plain language. • Redness, swelling, red
• Describe procedure, what to streaks in the skin near
watch for, who to call if
complications occur, follow-up the wound, pus or
appointment- who and when, discharge, foul odor,
activity, diet, medications. • Chills or temp greater
• Health promotion instructions than 100
(smoking cessation).
References
• Blomberg AC, Bisholt B, Lindwall L. Responsibility for patient
care in perioperative practice. Nurs Open. 2018 Apr
27;5(3):414-421. doi: 10.1002/nop2.153. PMID: 30062035;
PMCID: PMC6056433
• Gobbo M, Saldaña R, Rodríguez M, Jiménez J, García-Vega MI,
de Pedro JM, Cea-Calvo L. Patients' Experience and Needs
During Perioperative Care: A Focus Group Study. Patient Prefer
Adherence. 2020 May 27;14:891-902. doi:
10.2147/PPA.S252670. PMID: 32546983; PMCID: PMC7266520.
• Hoffman & Sullivan (2020). Davis Advantage for Medical-Surgical
Nursing (2nd ed.). F.A. Davis: Philadelphia
References
• Prasad Ravipati, L.N., Doran, M. (2022). Overview,
Updates, and New Topics in Perioperative Care. In: Conrad,
K. (eds) Clinical Approaches to Hospital Medicine. Springer,
Cham. https://doi.org/10.1007/978-3-030-95164-1_11
• Khambaty, Makela et al. Practice Changing Updates in
Perioperative Medicine Literature 2022. A Systematic
Review. The American Journal of Medicine, Volume 136,
Issue 8, 753 - 762.e
• Schonborn JL, Anderson H. Perioperative medicine: a
changing model of care. BJA Educ. 2019 Jan;19(1):27-33.
doi: 10.1016/j.bjae.2018.09.007. Epub 2018 Dec 3. PMID:
33456851; PMCID: PMC7808017.
Complex Concepts in Respiratory
Function and Alterations
Sharon R. Andress DNP,RN,CEN,CNE
Functions of the Respiratory
System
● Ventilation
● Perfusion
● Diffusion
● Respiration

● Acid-Base balance, Speech, Sense of smell, Fluid

balance
Physiology of Respiratory
System
● Diaphragm has to move for ventilation to happen
(phrenic nerve)
● When it contracts it moves down allowing chest
expansion
● This allows increase volume capacity
● This is inspiration

Expiration is the opposite - Relaxation

Terms
● Terms you may hear:

● Alveolar dead space

● Shunting
● V/Q mismatch is adequate ventilation with poor
perfusion or poor ventilation with good perfusion (PE
and pneumonia)
Assessment
of our
patient
Assessment
● Why are you here?
● Factors that improve or worsening symptoms
(movement, pain, cough)
● PMH, PMH, Social factors, Family, Recent travel
● Look at weight
● Medications, Allergies
 Physical
Assessment
Assessment
● Inspection (look at speech, use of accessory muscle )
● Chronic ( clubbing,barrel chest)
● Look at vital signs (pulse ox, respirations) (fast, slow,
absent)
● Palpation ( alittle) look for crepitus
● Percussion
● Auscultation (normal lung sounds)
● https://www.youtube.com/watch?v=2NvBk61ngDY
 ● Cardiac monitor (pulse ox, look
What will at waveform)

you do ● Oxygen ( do they need it?)

● Labs ( including ABGs, d-dimer)
first ? ● May been capnography (end
tidal Co2)
● Chest x ray
● Sputum
● What will be later?
Diagnosis ● Pulmonary Function
Test
for later ● Bronchoscopy
● Thoracentesis
● Lung Biopsy
 What
happens
to our
older
patients?
Why we need oxygen ?
To sustain life
21% oxygen, 78 % nitrogen, and 1% miscellaneous
Is it a medication?
Terms to remember:
Through ventilation, perfusion, and diffusion
Oxygenation and Respiration
Compliance
Hypoxia
Hypoxemia
● Occurs secondary to
insufficient oxygen to
● Develops when there are
low levels of oxygen in the
meet the demands of the arterial blood
body ● PaO2- < 60 mmHg or Sa02-
● Looks like: change in < 90 % on RA
mental status, anxiety, ● May be like that with
restlessness, and/or supplemental O2
confusion ● You can get hypoxia with
● Dyspnea, Increase rate hypoxemia
and heart rate
Indications for Oxygen
● Use your nursing judgement
● PaO2- < 60 mmHg and/or SaO2- < 90%
● The patient is sick (need more than 21% oxygen )
● Remember needs are unmet due to problems with
ventilation (intake) or perfusion (delivery)- cells will
become hypoxia
● You want Pa02 - > 80 mmHg and SaO2- > 93%
Remember to assess your
patient
Physical Assessment
What do they look like?
Vital signs ( pulse oximetry)
Labs (ABG’s)
Types of Oxygen Management
High Flow: provide set oxygen
Low Flow: mixed with air
concentration regardless of
● Nasal cannula ( 1- 6 breathing patterns
Liters)
● Venturi mask (2-15 L )
● Simple Face Mask ( 5- 10 ● Aerosol Mask ( humidification
Liters ) and/or meds)
● Partial rebreather ((8-10 ● Tracheostomy collar ( high )
Liters) ● T-piece Adaptor (extubation)
● Face Mask
● Non Rebreather ( 15 ● Vapotherm
Liters)
suction
● 2-3 max of suction and give them ● When inserting a trachea tube
break, intubation, listen the sound of lungs
● Aspirate them with stetoscope If there is
● Pt will coughn when u in the rigtht considilation then you on the right
place side
● do not hold the tumb area when ● Job as nurse is document the size and
inserting number of treachea tube
● Emphysima or copd c

● Nasal canula 6liter,

CPAP vs BIPAP
 Invasive Airway Management
● For emergency, you get an ET tube
● Long term is a tracheotomy
What is your role as a nurse during
intubation?
● Continuous monitoring of patient (cardiac monitor, vital signs
)
● Assist the HCP ( set up, bagging, suctioning, sedation,
Capnography)
● Look at the rise of the chest, end-tidal Co2
● Assessment
● Chest x ray (to confirm the placement)
● Documentation (location, size, number)
● Communication
Now what do I do since they are on a
vent?
❖ Full head to toe assessment (complex respiratory
assessment, neuro, skin )
❖ Continuous monitoring ( vital signs, cardiac monitor )
❖ Sedation
❖ Suctioning
❖ Repositioning
❖ Tube feedings
How can you prevent an infection?
What medications would you maybe give this patient?
If I need to be on a vent, long term
● Replaces the ET tube
● Cuffed or Uncuffed
What is my nursing care for a trach
patient?
● Suction look at policy
Always
● Good respiratory assessment ask your
● Look at vital signs Respirato
ry
● Good positioning
therapist
● Provide trach care s
● Communication (
What would you do if the tracheostomy tube fell out ? It’s called
Decannulation
Complications of mechanical
ventilation
● Unplanned extubation
● Aspiration (HOB >30)
● Infection : Ventilator acquired pneumonia ( antibiotics, frequent
mouth care)
● Hypotension
● Barotrauma
Therapeutic Modalities

This is for
medications
Pathophysiology,Clinical
manifestations, Diagnostic
criteria, and Treatment
Pulmonary Embolism
Obstruction of one or more ● Obstruction leads to an
branches of the pulmonary impaired ventilation to
arteries perfusion ratio (V/Q
mismatch)
Usually a thrombus but can be ● Decrease blood flow to
other things functioning alveoli where
gas exchange could happen
Biggest risk factor :DVT if perfusion was good but
it’s not so you get
Smoking, Obesity, Surgery,
hypoxemia
Birth control
● Can have a lot of issues
● Different classifications of
PE’s
Clinical Manifestations and Diagnosis
● Intense dyspnea ● Blood draw (CBC, Cardiac
Enzymes, D-dimer, BNP,
● Pleuritic chest pain ABG)
● Tachypnea ● Chest X-ray
● Anxiety ● EKG/ECG
● Pain in a leg ● May do an Ultrasound
● Dizziness Later
● May have hemoptysis CT Scan ( PE), MRI, VQ Scan,
Pulmonary angiography
How do you treat a patient with a PE?
❖ Ask yourself. Are they sick? ( what do I do ?)
❖ Anticoagulation
❖ Low-molecular-weight heparin (LMWH)
❖ IV heparin
❖ Warfarin (Coumadin)
❖ Fibrinolytic agents( only if patient is compromised)
❖ Tissue plasminogen activator (tPA)
❖ Alteplase (Activase)

❖ Surgery
❖ Embolectomy ( https://www.youtube.com/watch?v=JQ7aojMamSU )

❖ Green
Atelectasis
● Collapse or closure of a lung resulting in reduced or
absent gas exchange
● Usually happens post-operatively or patients who are
immobilized (can be caused by a tumor or pleural
effusion, too)
● Shortness of breath, cough, tachypnea, tachycardia,
decreased breath sounds
● See it on a Chest X-ray (later CT scan and bronchoscopy)
● Treat with O2, bronchodilators
Pleural Conditions

Pleural conditions involve the pleura, which is a double-layered

membrane surrounding the lungs and lining the chest cavity. The
pleura consists of two layers: the visceral pleura, which covers the
lungs, and the parietal pleura, which lines the chest wall.
Pleurisy (Pleuritis) vs Pleural effusion
Inflammation of the pleura caused Accumulation of excess fluid
by infection or PE between the layers of the pleura
caused by HF, pneumonia,cancer, PE
Sharp chest pain (worsened by
breathing) Shortness of breath
Pleural friction rub Chest pain
Shortness of breath Cough
Decreased breath sounds
● Physical examination ● Chest X-ray
● Chest X-ray ● Ultrasound
● Ultrasound ● CT scan
● Blood tests
● Underlying cause
Treat the underlie cause, NSAIDS, and
● Thoracentesis (fluid analysis)
steroids
Acute Respiratory Failure Type 1
hypoxemia or Type 2 hypercapnia
Characterized by elevated levels of
Characterized by a low level of carbon dioxide in the blood (PaCO2 >
oxygen in the blood (PaO2 < 60 50 mmHg), often accompanied by
mmHg) with normal or low levels of respiratory acidosis
carbon dioxide
Caused by: COPD, drug overdose,
Caused by: ARDS, pneumonia, PE , severe asthma, neuromuscular
asthma disorders

Looks like: V/Q mismatch, shunt or Looks like: impaired ventilation or

impaired diffusion hypoventilation

Tachycardia Shortness of breath

Tachypnea Rapid or shallow breathing
Hypertension Headache
Restlessness Confusion or drowsiness, decreased
LOC
Confusion
Flushed skin
How to diagnosis and treatment me?
● ABG’s, VBG’s, CBC, Sputum ● Oxygenation ( what do they
culture need?)
● CT scan ● May need a ventilator

Remember what is the Medications:

underlying cause and
● Inhaled bronchodilators
you need to treat that ● Steroids
too. The respiratory ● Diuretics
failure is caused by ● Sedation
something ● Antibiotics
Is this patient sick?
Acute Respiratory Distress Syndrome
(ARDS)
ARDS is a type of respiratory failure
that occurs when fluid builds up in
the alveoli (the tiny air sacs in the
lungs), preventing adequate oxygen
from reaching the bloodstream. This
can lead to organ failure if not
treated promptly and effectively

Direct : Pneumonia, Aspirination,

Inhalation, Embolism (related to the
respiratory system)

Indirect: Sepsis, Trauma, drug

overdose
ARDS
There are three stages to ARDS: Exudate,
Proliferative, and Fibrotic
Clinical Criteria (Berlin Definition):
● Acute onset within one week of a known clinical insult or
new/worsening respiratory symptoms.
● Bilateral opacities on chest imaging not fully explained by
effusions, lobar/lung collapse, or nodules.
● Respiratory failure not fully explained by cardiac failure or
fluid overload.
● PaO2/FiO2 ratio (arterial oxygen partial pressure to
fractional inspired oxygen) ≤ 300 mmHg with PEEP
(positive end-expiratory pressure) or CPAP ≥ 5 cmH2O.
Clinical Manifestations
Severe shortness of breath and dyspnea
Rapid, shallow breathing
Hypoxemia (low blood oxygen levels) despite
supplemental oxygen
Cyanosis (bluish skin color)
Crackles or rales on lung auscultation
Fatigue and confusion
Later: Increase WOB, change in mental status , increased
crackles
Diagnosis and Treatment
● Chest x ray (look for the Mechanical ventilation with PEEP
bilateral infiltrate)
● ABG’s, CBC, BPM, Keep them hemodynamically stable
Coagulation panel, CRP, Proning
Liver and Renal (WHY?
● Urine Fluids ?
● Sputum
Tube feedings

Medications

Antibiotics

Diuretics

May need ECHO

ARDS Complications
● Ventilator-Associated Pneumonia (VAP)
● Barotrauma
● Stress ulcers
● Renal failure
● MODS: the primary cause of death in ARDS, often
accompanied by sepsis
● 40 % of patients with ARDS die
COVID -19
Primary Mode: Respiratory droplets
from coughing, sneezing, talking, or
breathing.

Secondary Mode: Contact with

contaminated surfaces followed by
touching the face (eyes, nose,
mouth).

Airborne Transmission: Possible in

crowded or poorly ventilated spaces.

How
novel coronavirus SARS-CoV-2, is
it
diagnos
ed?
Risk factors and Complications
Older age (65 and above) Acute Respiratory Distress
Syndrome (ARDS)
Underlying medical
conditions (e.g., heart Pneumonia
disease, diabetes, chronic Sepsis and Septic Shock
respiratory disease,
cancer) Multi-Organ Failure

Immunocompromised Blood Clots

states
Long COVID
Obesity
Treatment
Oxygen therapy for hypoxemia
Mechanical ventilation for respiratory failure (may need a
tracheostomy)
Proning
Fluids and electrolytes to maintain hydration
Medications ( Antiviral- Remdesivirs, Steroids, Antibiotics, Anti-
inflammatory, Anticoagulants
ECHO
What is an ABG ?
● Acid/Base balance reflects hydrogen ions
● Ability of the lungs to provide adequate O2 and remove
CO2 (ventilation)
● Ability of the kidneys to reabsorb or excrete bicarb
(HCO3) to maintain normal body pH (metabolic state)
● Specimen obtained from radial, brachial or femoral
artery, or an arterial line
● Complications: pain, hematoma, hemorrhage
 Due to
hypoventil
ation
Caused by
hyperventil
ation
Caused by
DKA, GI
loss,
Vomiting,
Renal
failure,
Shock
 use of
diuretics,
anaticids,
low K
Resources
ABGs Made Easy for Nurses:
https://www.youtube.com/watch?v=URCS4t9aM5o
Partially vs Fully Compensated ABGs Interpretation:
https://www.youtube.com/watch?v=3neNB0w1P9M

https://www.elitecme.com/resource-center/respiratory-care-sleep-medicine/abgs-as-
easy-as-123/ (Links to an external site.)
References
Cascella M, Rajnik M, Aleem A, et al. Features, Evaluation, and
Treatment of Coronavirus (COVID-19) [Updated 2023 Jan 9]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;
2023 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK554776/
Burns GP. Arterial blood gases made easy. Clin Med (Lond). 2014
Feb;14(1):66-8. doi: 10.7861/clinmedicine.14-1-66. PMID: 24532749;
PMCID: PMC5873626
Hoffman & Sullivan (2020). Davis Advantage for Medical-Surgical
Nursing (2nd ed.). F.A. Davis: Philadelphia
Meissen, H. & Johnson, L. (2018).Managing the airway in acute care
patients. The Nurse Practitioner 43(7):p 23-29, July 2018. | DOI:
10.1097/01.NPR.0000534937.35090.f1
References
National Council of State Board of Nursing. (n.d.). Changes in education
requirements for nursing programs during COVID-19.
https://www.ncsbn.org/Education-Requirement- Changes COVID-19 pdf
Shereen M et.a l. (2020). COVID-19 infection: Origin, transmission, and
characteristics of human coronaviruses. J Adv Res. 16;24:91-98. doi:
10.1016/j.jare.2020.03.005. PMID: 32257431; PMCID: PMC7113610
Sood P, Paul G, Puri S. Interpretation of arterial blood gas. Indian J Crit
Care Med. 2010 Apr;14(2):57-64. doi: 10.4103/0972-5229.68215. PMID:
20859488; PMCID: PMC2936733
10.12968/bjon.2020.29.1.22. PMID: 31917939
References
Mouri, M. et al.(2022. Airway Assessment. StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK470477/

Toplis E & Mortimore G. (2020) The diagnosis and management of

pulmonary embolism. Br J Nurs. 29(1):22-26. doi:
10.12968/bjon.2020.29.1.22. PMID: 31917939
 Complex Concepts in Gastrointestinal
Function and Alterations
Sharon R. Andress DNP, RN, CEN,CNE
Responsibilities of the GI tract
Works with the nervous and endocrine system:
Ingestion
Digestion ( Mechanical/Chemical)
Absorption
Transportation
Secretion
Excretion
Immune Function
Parts of the GI system
Mouth Esophagus Stomach
★ Chemical and ★ Passes through ★ Specialized cells
mechanical the diaphragm secrete
breakdown of via the chemicals to
digested food esophageal digest foods
★ Saliva contains hiatus ★ Gastric mobility is
amylase and ★ Made of different influenced by the
lipase muscles types PNS & SNS
★ Pharynx, tongue, ★ Esophageal ★ Swallowing
and esophagus sphincter stimulates the
protects from medulla to tell
regurgitation the stomach to
stretch
Organs of the GI system
Liver Gallbladder Pancreas
★ Very vascular ★ Exocrine
★ Responsible for
★ Absorption and Function:
bile storage and
metabolism of
concentration Produces amylase
carbohydrates,
★ Need bile to help and lipase
fats, and proteins
★ Degradation of get rid of fat
★ Bile is released Secretes
toxins, hormones,
into the small bicarbonate
medications
★ Synthesis of intestines
clotting factors ★ Endocrine
Function:

Produces insulin and

glucagon
Last parts of the GI tract
Small intestine: duodenum, Large intestine: also known as the
colon, cecum, rectum, and anal canal.
jejunum, and ileum
Responsible for absorbing water and
The small intestines receives electrolytes from indigestible food matter,
partially digested food (chyme) from forming and eliminating solid waste
the stomach.
★ Vitamins A,D,E, and K, sodium and
★ Protein, carbohydrates, and fat water reabsorbed to form stool
digestion
★ Nutrients are absorbed through
the intestinal walls into the
★ Contains a diverse community of
bloodstream and lymphatic bacteria that ferment undigested
system carbohydrates and fiber, producing
★ Moves chyme through its length gases and short-chain fatty acids
by peristalsis, facilitating the that can be used for energy.
digestion and absorption
processes.
 GI ★ Physical, Medical, Surgical,
Family, Social History
Assessment ★ History of cancer in the
family
Need
their
★ Medications height
★ Dental care &
weigh
★ Nutritional t
★ Weight loss or gain
★ Loss of appetite
★ Changes in stool

★ How do you eat, what do

you eat?
★ Religious or culture
★ History of eating disorders
GI assessment & diagnosis
★ Labs: albumin, prealbumin ★ Inspection (mouth, skin,
and transferrin shape of abdomen)
★ CBC, BMP, PT/PTT, Liver
★ Cullen’s sign
enzymes
★ Urine, stools ★ Auscultation –RLQ

★ ★ Why are sounds important?

X-ray
★ Ultrasound (what can it mean?)
★ Endoscopy
★ ★ Palpation
Barium studies
★ Coloscopy
Disease and disorders
What is a hiatal hernia?

★ Sen ien people 50 years or older

★ Risk factor- obesity, pregnancy and smoking
★ Two types: Sliding or rolling (anatomical defect)
★ It is the stomach protruding through the esophageal
hiatus
GERD is a complication
Sliding vs Rolling hernia
★ Heartburn
★ Regurgitation ★ Feeling full after eating
★ Feeling breathless after eating
★ Chest pain ★ Feeling of suffocation
★ Dysphagia ★ Chest pain
★ Belching ★ Increased symptoms when laying
flat
Management
Surgical treatment:
★ Xray
★ Endoscopy Herniotomy (removal of sac)
★ Barium swallow
★ Herniorrhaphy (repair of defect)
EGD
Laparoscopic Nissen
Medications: Antacids, Proton pump fundoplication
inhibitors
Gastroesophageal Reflux Disorder
(GERD)
★ Chronic disorder caused by acid
reflux from the stomach into the Antacids
esophagus
★ Associated with a hiatal hernia H2 Receptor Blockers
★ Lifestyle is usually the cause Proton Pump Inhibitors (PPIs)
Prokinetics
Endoscopy (EGD)

Esophageal pH Monitoring: This test Surgery:

measures the frequency and duration of acid
reflux episodes by placing a small device in Nissen fundoplication
the esophagus for 24 hours LINX Device Signs
and
Esophageal Manometry: This test
measures the strength and muscle sympt
coordination of the esophagus during oms
swallowing, which can help identify motility
issues.

Barium Swallow
Interventions for GERD
•Avoid foods that can relax LES and
Lifestyle changes, diet, medications. make GERD worse: fatty, fried foods,
chocolate, caffeinated beverages,
•Keep weight under BMI of 30 peppermint, spicy, tomatoes, citrus,
•Stop smoking alcohol

•Limit or avoid alcohol •Avoid NSAIDS

•Low fat diet Medications:
•Avoid eating or drinking 2 hrs before bed Proton pump inhibitors. Reduce stomach
acid. (end in “azole”- omeprazole,
•No tight-fitting clothes esomeprazole
•Elevate HOB 30 degrees. •Antacids- make sure there are no
contraindications taking antacids with pts
•Position right side with HOB elevated 6- other meds. Caution with magnesium
12 inches containing meds and kidney disease.
•Small meals, eat slowly
•Histamine 2 receptor antagonists-
(ranitidine, famotidine…).
Gastritis
★ Acute:
Gastritis is an inflammation of the ★ Sudden, severe stomach pain or
stomach lining (gastric mucous) and discomfort
can be acute or chronic ★ Nausea and vomiting (sometimes
with blood)
Caused by increased permeability and ★ Loss of appetite
★ Bloating and belching
reduced mucus production
★ Indigestion
★ Chronic
Usually caused by Helicobacter pylori ★ Long-standing epigastric pain or
(H. pylori), NSAIDS, ETOH, repeat discomfort
exposure to irritants ★ Nausea and occasional vomiting
★ Bloating and a feeling of fullness
Acute or Chronic gastritis after eating
★ Loss of appetite and weight loss
Can lead to serious complications of ★ Fatigue due to anemia
hemorrhage and ulcerations
 Diagnosis and Treatment
★ Good History & Physical Take away the cause
★ Upper GI xray series
Can Treat underlie cause
★ EGD with biopsy the
Antibiotics
★ Barium swallow y
★ Labs eat? Medications ( Proton pump inhibitors,
antacids)
★ Urea breath testing
★ Stool antigen test Dietary changes ( small, frequent
meals, hydration, avoid spicy food)
★ Occult blood
★ Blood antibody test
Stress management

May need surgery

Peptic Ulcer Disease (PUD)
★ Includes ulceration and erosion in the Signs and symptoms depend on location
stomach and duodenum and patient’s age:
★ Pepsin plays a major role in causing
mucosal breaks Pain (may wake them up at night)
★ Damaged mucosa cannot secrete
enough mucus to act as a barrier Pain (duodenal in nature) burning
against gastric acid epigastric worse with fasting, better with
★ Can cause bleeding and perforations eating, relief with antacids
★ Can regenerate with scar tissue
Pain (gastric in nature) worsening by
Risk factors: H pylori and NSAIDS eating, no relief from antacids
ETOH
Weight loss
Cigarette smoking
Exposure to Irritants Bloody emesis or stool (melena) -this is a
Stress ulcers (trauma, sepsis late sign
Diagnosis and Treatment
Pain relief, ulcer healing, prevention of
ulcer recurrence and reduction of
★ Need endoscopy (Upper complications
GI)
Treatment:
★ EGD
★ May be anemic (look for Pain medication
GI bleed)- CBC
Antibiotics, Proton Pump inhibitors,
★ Serum antibody testing antacids,H2-Receptor Antagonists,
★ Stool antigen testing Sucralfate

Small frequent meals, avoid spicy food

GI bleed
Obstructi Surgery only really for complications,
controlled by medications
on
Perforati Gastrectomy, Vagotomy, Pyloroplasty
on
Complications of PUD
•GI bleeding- May be severe. can result in hypovolemic shock.
Hematemesis (vomiting bright red blood or coffee-ground emesis), melena,
(black, loose tarry stools), hypotension, tachycardia, dizziness, confusion
•Perforation- Surgical emergency and can be life threatening. Gastric
contents into the peritoneum causing Peritonitis. Sudden intense epigastric
pain, “Board-like abdomen”

Chronic
•Pyloric obstruction (blockage) occurs in small percentage. Rx-
NG tube
Hepatitis
★ Viral Hepatitis have different routes
★ Has to do with the liver
and transmission ( B & C are blood) (
★ Transmitted via fecal/oral route or
A & E are food or water)
blood and body fluid exposures ★ Signs and symptoms Signs
★ Risk factors: ★ Abdominal pain
★ ETOH abuse ★ Pruritus &
★ OTC medications
★ Autoimmune disorders
★ Malaise Sympt
★ Fever oms
★ Nausea/vomiting
Chronic hepatitis may lead to liver cancer ★ Jaundice depen
or cirrhosis ★ Clay stools, dark urine d on
Usually caused by a virus ( Hep A,B,C,D,E) You will see abnormal lab values ?
causes inflammation of the liver cells

Acute or Chronic ( can be lifetime)

Management and Treatment
Hepatitis A: rest, fluids
★ Good Physical & History
★ Labs (CBC, BMP, PT/PTT/INR, Hepatitis B: vaccine, may need
Bilirubin, Albumin, Ammonia, Liver supportive care,
enzymes, AST, ALT
★ Check for the virus hepatitis A- G Chronic hepatitis B can be treated with
antiviral medications, such as tenofovir or
entecavir

Hepatitis C: Antiviral medications called

Liver direct-acting antivirals (DAAs) are highly
transpla effective in curing hepatitis C ( example
Sofosbuvir (Sovaldi)
nt for
Hep C ? Diet: Low fat, high fruits , veggies

Small frequent meals

Vitamin supplement: A,D,E, K

Complications of Hepatitis
Chronic Liver Disease: Persistent
Acute inflammation can lead to ongoing liver
damage.
Fulminant Hepatic Failure: A rare
but severe complication where the liver Cirrhosis: Long-term inflammation from
suddenly fails, often requiring urgent chronic hepatitis (especially hepatitis B
medical intervention or a liver and C) can cause scarring (fibrosis) and
transplant. irreversible liver damage,

Liver Cancer
Dehydration and Electrolyte
Imbalance Liver Failure

Esophageal Varices

Ascites

Hepatic Encephalopathy
Nursing Education for Hepatitis
•Strict handwashing; normal contact with others at home as long as strict
handwashing.
•Do not share bathroom
•Individual washcloths, towels, etc
•Client must not prepare food for others
•Increase activity gradually to prevent fatigue
•No ETOH or OTC meds
•Hep B/C- no sexual activity until surface antigen negative
•Low fat, high fruits, veggies
•Vitamin supplements A,D, E, K
 Cirrhosis
★ End result of chronic liver disease, see extensive destruction
of liver, liver cells and is replaced with fibrous and
regenerative nodules -Poor blood flow resulting in portal
hypertension
★ Leading causes are: Hepatitis C, Alcoholic liver disease
★ Risk factors to predispose someone to cirrhosis: Chronic
infection with Hep A,B, or C, chronic alcoholism, biliary
disease, autoimmune, needle sharing, unprotected sex
Signs and Symptoms
Late signs:
Severe jaundice
Early signs:
Ascites/edema
★ Relatively few symptoms in Hepatic Encephalopathy
early-stage disease
★ Fatigue and enlarged liver Esophageal and Gastric Varices
may be early symptoms Muscle Wasting
★ Blood tests may be normal
(aka - compensated Gynecomastia
cirrhosis) Spider Nevi
May see: Shortness of breath,
jaundice, abdominal pain, Bleeding and Bruising
bloating, enlarged spleen, liver.
Increased abdominal girth
Diagnosis and Treatment
1. Treat the cause ( if it is
★ History and Physical hepatitis? What about alcohol
related liver disease? )
★ Ultrasound and CT
★ EGD You have to treat the
★ ERCP
complications that is what
causes the problems.
★ Liver biopsy (risk)
★ Labs (CBC, BMP, PT/PTT/INR,
If you have ascites, what do you
Bilirubin, Albumin, Ammonia, Liver do?
enzymes, AST, ALT
If you have esophageal and
gastric varices, what do you do?

What about hepatic

Encephalopathy?

Infection?
Treatment of Cirrhosis
•Restrict protein in diet, small frequent
•Eliminate cause (alcohol if applicable) meals
•Respiratory- elevated HOB, maintain •Low protein, Low fat, high CHO diet
ABCs. with vitamins.
•Safety- seizure and fall precautions •Hepatic encephalopathy:
•Fluid management: Daily weights; •Decrease production of ammonia from
•Monitor VITAL signs- BP may be elevated gut bacteria- neomycin orally and
or low lactulose. Lactulose- goal 2-3
•Watch for s/s fluid overload or difficulty stools/day.
breathing due to ascites
•Skin*- moisturizing lotion. Watch for
•Diuretics, esp. spironolactone breakdown. Cool baths for itching.
•Electrolyte replacement as needed
•INSTRUCT PATIENTS/FAMILY TO
•Restrict Na in diet DISCUSS ALL MEDICATION (ESP OTC)
•Albumin infusion (Salt-poor albumin WITH MD BEFORE TAKING.
(SPA)
Treatment of Cirrhosis
•Watch for bleeding complications (esophageal varices or coagulopathy)-
•Check H/H, coag studies.
•Administer Vit K, blood products, fresh frozen plasma
•Check stools for frank or occult blood
•Prevent GI bleeding
•Use electric razor
•Soft bristle toothbrush
•Prevent straining to have a BM
•Avoid injections, procedures that can cause bleeding
•Prevent infection- CAUTI, CLABSI, VAP bundles! Handwashing!
•Assess for and treat glucose abnormalities
Ascites
Portal hypertension resulting in increased capillary pressure and obstruction of venous
blood flow
•Liver can’t metabolize aldosterone, increasing fluid retention
•Liver not synthesizing proteins, low albumin
•Can affect breathing.
Treatment:
•KEEP HOB elevated!
•Low-sodium diet
•Diuretics- Spironolactone (aldactone): aldosterone-blocking diuretic used first.
•Bed rest- prevent activation of RAAS.
•Paracentesis- followed by administration of salt-poor albumin (25%). Pre-procedure- empty
bladder
•Transjugular intrahepatic portosystemic shunt (TIPS)
Bleeding Esophageal Varices
•If bleeding occurs, stabilize patient, airway,large bore IV’s, blood and blood
products
•Varices under pressure, so bleeding may be severe
•Drug therapy: Octreotide (Sandostatin)
•Endoscopic therapy to band, sclerose, or cauterize varices
•
•Sengstaken-Blakemore tube: temporary
•Danger- misplacement of tube, airway obstruction from balloon,
aspiration.
•monitor patient for s/s sudden resp. distress.
•Scissors at bedside. Cut if in resp distress
Hepatic encephalopathy
•Caused by inability of liver to S/S hepatic encephalopathy
detoxify by-products of metabolism •Early: slurred speech, tremors,
(normally liver breaks ammonia lethargy, asterixis, impaired
down to urea).
writing, impaired decision-
• Blood bypasses liver causing toxic making
substances to enter systemic
circulation, including ammonia. •Late: Severe confusion, difficult
to awaken, asterixis, coma
***Ammonia builds up in blood; acting
on CNS
•Neuro status can range from
sleepiness to coma
•Accumulation of toxins can cause
cerebral edema /increased ICP
If bleeding occurs,
stabilize the patient,
manage the airway, and For
provide IV therapy and varic
blood products es
Drug therapy

Octreotide
(Sandostatin)
 Pancreatitis
Can be acute or chronic, inflammation of the pancreas
Acute is usually caused by gallstones (obstructive) or ETOH
Acute is reversible, usually due to the release of pancreatic
enzymes that “autodigest” the pancreas
Look like: Sudden onset of epigastric pain, that feels like it’s in
the left upper quadrant and goes to the back or shoulder
blades, abdominal fullness
Aggravated by eating food high in fats
Pain is worse with laying flat
Hiccups
Signs and Symptoms and stuff
★ Upper abdominal pain that Diagnosis is the same as Acute
radiates to the back (LUQ) Treatment is very similar but:
and epigastric
You need insulin therapy (why?)
★ Worse with eating or
drinking You will need PERT (amylase,lipase, protease)
★ N/V
★ Weight loss
★ Clay-colored stool
★ Oily stools (steatorrhea)
★ Mild jaundice
Diagnosis and Treatment
★ NPO status
★ Abdominal pain and
tenderness ★ NGT tube
★ CBC, BMP, Amylase, Lipase,
★ May need TPN (depends)
AST, ALT
★ Diagnostic: CT abdomen, ★ IV fluids
MRI/ MRA, Ultrasound, ERCP ★ Pain medications
★ There are criteria to measure ★ Anticholinergics
mortality
★ Antibiotics are not found to
work
Find out the cause and fix it
Complications of Acute
Pancreatitis
★ Necrotizing pancreatitis (see on CT scan- air and gas around
the pancreas) - you develop Sepsis and Shock because of
this
★ Pancreatic hemorrhage (see Grey Turner’s or Cullen’s sign)-
not common
★ Pseudocysts (if infected, pancreatic abscess)
★ Pleural effusion
★ ARDS
Chronic Pancreatitis
Most common cause ETOH abuse
Can be autoimmune
It is so scarred from “autodigest” that it can’t make
the digestive enzymes for proteins and fats and it
can’t regulate glucose ( insulin and glucagon)
 Nursing Actions for Pancreatitis
•NPO during acute pd. Rest GI tract. May need TPN
•Administer analgesics, antiemetics, histamine blockers
•AVOID morphine in pancreatitis and gallbladder patients because it can cause spasm of spincter of Oddi (junction of CBD, pancreatic duct, and
duodenum). Instead, use other opioids for severe pain or anti-inflammatory medications.

•Antibiotics only if septic

•Bedrest in semi-fowlers for comfort or fetal position.
•Encourage coughing and DB (patients frequently have pleural effusions).
•If cause of pancreatitis is gallstones, may need lap chole

•May need pancreatic enzyme supplements until pancreas heals

•May need insulin until pancreas heals
Teach:
•Small frequent meals once eating. Advance diet very slowly. Avoid protein and fat-rich foods
•No alcohol or smoking
Biliary disorders
Signs and Symptoms:
Role of the Biliary system: transport bile
from liver (where it is produced) to the ★ Colic pain ( worse after eating fatty
gallbladder (where it is stored) to the food or laying down
duodenum (where it aids in digestion of
fats. ★ Pain (RUQ) goes to the right shoulder
★ May have a Murphy’s sign
Cholecystitis is the inflammation of ★ N/V
the gallbladder
★ Fevers/chills
Cholelithiasis are gallstones that are ★ If total obstruction: dark amber
stuck urine, clay color stools and pruritis
due to no bilirubin
You usually have both

It is usually women, older, multiple

pregnancy, obesity, weight loss
surgery, people who eat fatty foods
Diagnosis and Treatment
NPO
CT scan IV fluids
HIDA scan Pain medications ( try not to use
Morphine)
★ ERCP (this can be used as a
treatment) Antibiotics
Labs ( CBC, Liver enzymes, AST, ALT, Ursodeoxycholic acid (bile production)- not
bilirubin, amylase, lipase ) used

Anticholinergics

Cholecystectomy
Intervention (non-surgical and
surgical)
★Endoscopic Retrograde They try to do a laparoscopic
Cholangiopancreatography cholecystectomy or if not an open one
(ERCP)
This is a surgical patient
★ Extracorporeal Shock Wave
Lithotripsy (ESWL) May need to put a t-tube in for drainage if
there are stones ( only for a few weeks)
★ Oral Dissolution Therapy
★ Percutaneous Cholecystostomy
If not then, remove the gallbladder
Weight loss surgery (Bariatric
surgery)
Significant intervention for obesity and related health conditions
Genetic, environmental, and behavioral factors have been linked to
obesity
Strict criteria:
BMI
Health Conditions and Comorbidities
Previous attempts to weight loss
Psychological Evaluation
All typical preoperative work up
Types of surgical interventions
Roux-en-Y bypass or simple bypass which both interfere with the absorption
of food and nutrients
★ Creation of a 30ml gastric pouch and bypass of small intestines
★ Most maintain weight loss but are at risk for nutritional deficiencies
Bariatric surgery: Gastric restriction and malabsorption
★ Restriction: Laparoscopic adjustable band and Laparoscopic sleeve
gastrectomy (25% of its original capacity)
★ Both limit the volume of food intake
★ Long-term risk to regain weight without adherence to diet and lifestyle
changes
Intragastric Balloon ( limits the amount of room for food )
 Post-operative care
They are post-operative patients ( what do they need)
Pain medications
Hydration (but they are started on clear liquids, small amounts)
Early ambulation
Long term:
Vitamin supplements
Support groups
Monitoring
Complications
Long term:
Short term:
Vitamin and Mineral Deficiencies
Bleeding
Protein deficiencies
Blood clots
Bowel obstructions
Infection Gallstones

Anastomotic leaks Dumping syndrome

Body image disturbances

Eating disorders

Hair loss
 Dumping Syndrome
•Prone to occur in pts following
gastrectomy, partial gastrectomy •Manifestations****
(including bariatric pts), bolus tube •Vomiting during meal, full
feedings sensation, cramping pains, diarrhea.
Stool is liquid and fatty.
•Group of manifestations following •Vasomotor- (10-90 min after meal)
eating. pallor, perspiration, palpitations,
•Rapid emptying of stomach contents H/A, dizziness, drowsiness
(food bolus), or high CHO food bolus •S/S hypoglycemia: pallor,
into intestine weakness, fainting, dizziness,
palpitations, diaphoresis,,
•This Hypertonic content is suddenly
presented to jejunum. The hypertonic
contents draws fluid from the
circulation into the remaining jejunum
to dilute the contents of the jejunum.
•Causes bloating, Rebound
•Lie down for 30 min after a meal
to delay stomach emptying.
•Can have Fluids before or
after meals, but not with
meals.
•Meals with more dry than wet
items
•Eat more protein and healthy fats
rather than CHO. Eat fiber rich
foods
•Limit sugar and lactose
•Eat small, frequent meals
•Eat slowly
References
Aderinto N, Olatunji G, Kokori E, Olaniyi P, Isarinade T, Yusuf IA. Recent advances in bariatric
surgery: a narrative review of weight loss procedures. Ann Med Surg (Lond). 2023 Nov
1;85(12):6091-6104. doi: 10.1097/MS9.0000000000001472. PMID: 38098582; PMCID:
PMC1071833

Almeida PH, Matielo CEL, Curvelo LA, Rocco RA, Felga G, Della Guardia B, Boteon YL. Update
on the management and treatment of viral hepatitis. World J Gastroenterol. 2021 Jun
21;27(23):3249-3261. doi: 10.3748/wjg.v27.i23.3249. PMID: 34163109; PMCID:
PMC8218370.

Dunn R, Wetten A, McPherson S, Donnelly MC. Viral hepatitis in 2021: The challenges
remaining and how we should tackle them. World J Gastroenterol. 2022 Jan 7;28(1):76-95.
doi: 10.3748/wjg.v28.i1.76. PMID: 35125820; PMCID: PMC8793011.

Jabbour G, Salman A. Bariatric Surgery in Adults with Obesity: the Impact on Performance,
Metabolism, and Health Indices. Obes Surg. 2021 Apr;31(4):1767-1789. doi: 10.1007/s11695-
020-05182-z. Epub 2021 Jan 17. PMID: 33454846; PMCID: PMC8012340..
References
Mencarini L, Vestito A, Zagari RM, Montagnani M. The Diagnosis and Treatment of Acute Cholecystitis: A
Comprehensive Narrative Review for a Practical Approach. J Clin Med. 2024 May 3;13(9):2695. doi:
10.3390/jcm13092695. PMID: 38731224; PMCID: PMC11084823.

Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Skills [Internet].
Eau Claire (WI): Chippewa Valley Technical College; 2021. Chapter 12 Abdominal Assessment. Available
from: https://www.ncbi.nlm.nih.gov/books/NBK593213/

Wazir H, Abid M, Essani B, Saeed H, Ahmad Khan M, Nasrullah F, Qadeer U, Khalid A, Varrassi G,
Muzammil MA, Maryam A, Syed ARS, Shah AA, Kinger S, Ullah F. Diagnosis and Treatment of Liver
Disease: Current Trends and Future Directions. Cureus. 2023 Dec 4;15(12):e49920. doi:
10.7759/cureus.49920. PMID: 38174191; PMCID: PMC10763979.