Medical and Surgical Nurs tion of Diseases a ‘of a Nurse in Medical and Surgical nomadic life from place to place, their ne *Best for the Most’ He ruled by This period was known as stone sickness comes due to anger it and dead due to their by sickness due their own ociated with good and evil fe and houses _{ “carter ourtines ——— Introduction “+ Wound Healing - Stages, Influencing Factors 4+ Wound Care and Dressing Technique are of Surgical Patient “+ Preoperative + Postoperative ‘Altemative Therapies used in Caring for Patients with Medical ‘Surgical Disorders ‘emphasized the practice of hospitality to strangers and ‘Acts of charity (Genesis, Old Testament). Promulgated laws of control on the spread of communicable disease ‘and the ritual of circumcision of the male child. They referred to nurses as midwives, wet nurses or child's nurses whose acts where compassionate and tender ‘outpouring of material instincts. In Rome, the first organized visiting of the sick began ‘with the establishment of the order of the Deaconesses. ‘They endeavored to practice the corporal works of mercy such as feed the hungry, give water to the thirsty, clothed the naked, visit the imprisoned, shelter the homeless, care of the sick and bury the dead. Phoebe was the first deaconesses and visiting nurse. Marcella was considered the first educator, she taught the care of the sick to her followers. Paula was one of the most learned wornan in. this period, who built shelters for pilgrims and hospital for the sick. Fabiola was has given her lavished immense ‘wealth on the poor and sick. Through her efforts the first general public hospital was built in Rome for the sick Parabolani was provided an opportunity for the male "nurses in the early church period. They took care of the sick and buried the dead, Greece, the Greek God Asklepios, was Goddess of yealth and was revered by some as the embodiment ‘nurse, Nursing was the task of untrained slaves. ks introduced the caduceus, the insignia of the pfession today. Hippocrates came to be known pital was staffed by male nurses who ;meet four qualifications which has nner in which drugs should be a & Scanned with OKEN Scanner° red + bye 193% however advocates recom nee jy Eopatencandpurtyteindcndbedy tndlanworven medical und wire! uring be AE In ig je bral bel T i bers. In interdisciplinary course, becau eta Sar he two aie ae eee alee by was conedeed an ric dtncion. ln Sean Seca | Sacutemers te ere create! pa we neaeme nee meee about nursing while eed ened sein va etna ale Scmeemcicesteleminrnrnda Sudmrmecractlwiensereetiey Sear ee plisiologial conditions nya SS SU Se ere teeta Mert Eamcrmeonteeegeny tnt altar goverment during 1854 in Madras (now Chennai) physical: et ap a ealth Whee cou ton ofthisapproach into nursing school ene Seecmaafemauntsiaythcel » joensen wm na Rese [practice of medical and surgical nursing Bec Commie ateagacee ingest, Hasan edn Aeveloped fn (1943-48) acted as the foundation rere br mas . ‘committee ofthe division on medical-surgieal nase ‘American Nurses! Association (ANA), was publche 1274. Iefocused on the collection of data, develonna of nursing diagnoses and goals for nursing development implementation and evaluation of yt! cae. A statement on the scope of medical sure nursing practice followed in 1980, * [a Ugeh the Academy of Medical-Surgical Nursey GGMSN) was formed to providean independent perc: Prcfessional organization for medical-surgieal ant on) nurses. © 271206 the AMSN published its own scope and standards of medical-surgical nursing practice. ‘+ The second edition appeared i AMSN documents stated that din History of Surgical Nursing ‘© In 1840s, all ‘Surgery was conducted in hospital setting Teapeputses are required special training for nae Patent ies Such as assisting, preparing, caring a Patient in surgical unit, frat arin Massachusetts, general hospital provided the Perating room education for nurse's. The trend ‘nurses in the operating room. ge Occurred in nursing education with Importance of nurses acquiring a broad Tesulted in less emphasis on operatiné There has also been a new developmen ‘operative procedures. ‘Surgery, itwas also referred to as outpatient US On the . ea a & Scanned with OKEN ScannerOne-day-surgery, this health care service is growing rapidly in numbers and various types, ys procedures such as invasive non-invasive procedures are performed. Medical-surgical nursing has a very long history. In fa inean be viewed as one of the first kinds ert es ae develop. tisa backbone forall specialty. tis one ofthe major specialty with widen syllabus which includes ll systems and super specialty (Neurology nursing, gastroenterology nursing, nephrology nursing, urology nursing, immunology nursing, cardiovascular-thoracie nursing, oncology nursing, disaster nursing, tele-nursing, etc.), related to medical and surgical condition of adult health. All nurses workin the medical and surgical specialty field in their careerin different setting such ‘as wards, ICUs, operation room, special clinic, e.,, diabetes clini, stork clinic, hypertension clinic, ete, and outpatient department. Once considered an entry-level job position, medical-surgical nursing has now gained the respect it deserves, as an important profession, Medical-surgical nurses have an impressively large skill set, a result of working across variety of medical specialties and subspecialties. They are knowledgeable about all aspects of human health, including psychology and mental health, and work with patients ofall ages. Its not uncommon for medical-surgical nurses to also actas advocates for patients, and nearly all adult patients are seen at some point in their care by a medical-surgical nurse, ‘Traditionally general hospital medical surgical areas are very wide because many wards, ICUs, OPDs, special clinics, emergency departmentbelong to the medical surgical related Trends in Medical-Surgical Nursing Nowadays, medical-surgical nursing spectalty itself many sub-specialties. Medical-surgical nursing expanding day-by= day through increase number ofspecialty, volume of content, and enlarge scope of medical surgical nurses d ‘ole of nurse means enlargement within the b nursing, They have different kind of carrier opportt is expanded such as critical care nursing, emergency nursing, cardio-vascular nu hursing and hospice nursing, etc., medical extended within the sub-specialty diabetes specialty nurse, hypertensive anesthesia nurse, congestive ¢é hse, ight nurse, et, Jack of efficient nursing care. For example, robotic surgery has developing gradually in mordents healthcare setting. So, robotic nursing also should be developing in medical- surgical nursing then only nurse can deliver efficient patient care. Influences on Future Medical-Surgical Nursing Practice ‘© Expanding knowledge and technology Healthy people initiatives Evidence based practice Standardized nursing terminologies Health care informatics cee INTERNATIONAL CLASSIFICATION OF DISEASES International Classification of Diseases (ICD) is the international “standard diagnostic tool for epidemiology, health management and clinical purposes’ It can be defined asasystem of categories to which morbid entities are assigned according to established criteria. It is used to translate diagnoses of diseases and other health problems from words into an alphanumeric code. Box 1.1 depicts the history of ICD. Purposes of ICD. © Toallow easy storage, retrieval and analysis of data © Toallow systemic recording, analysis, interpretation and ‘comparison of mortality and morbidity data between hospitals, provinces and countries. To allow co in the same location across uonanponuy & Scanned with OKEN Scanner‘1860, Florence Nightingale—made fist model of system 1898, American Public Health Association—recomm WHO—responsibilty for preparing and put 1910-1920, ICD-2 renamed as International Clos 1930-1938, ICO-4 transfer to categories based on etiology 1939-1948, ICD-4 comparability between successive ICD oeeeee ‘time included morbidity 1955, ICD-7 revision conference was held in Pats 1968-1978, expanded crossindexing hospital clinical records eoeses 1994. ndia adopted this classification in 2000 1CD-11 launched on 18th June 2018 * letter D, which is used in chapter 2 and chapter 3, and letter H which is used in chapter 7 and chapters. ‘© Chapter 1, 2, 19, 20 use more than one letter in the first position of their codes. Each chapter contains suflicient 3 character categories to ‘cover its contents, ere 2 Webra ce ethene en cen eH versions lassifcation of Disease, 1949-1957, 1CD.6 WHO entrusted ICD ass citerionAnermationa Clasicatios New main category: Mental, psychoneurotic and personality disorders 1979-1994, CD.9, 1978 refined classification and diagnosis of mental disorders 1982, diagnostic instruments and algorithms shaped and refined 1990, CD 10 was endorsed by the forty third World Health Assem ‘of death. The International List of Causes ofp fof siekness and Death. Injuries and causes of death: forthe iy in May 1990 and came into use in WHO Member States as ‘© Most of the 3 character categories are subdivided by ‘means of a 4th numeric character after a decimal pin, allowing up to 10 subcategories. Z22-carriers of infectious Diseases © 722,0—carrier of thyroid * 722,1—carrier of intestinal infectious diseases © 222.2—carrier of diphtheria '¢ 222,3-cartier of specific bacterial diseases ‘* 722.4—carrier of infections with predominantly sexi ‘mode of transmission 222.5—carrier of viral hepatitis ‘artier of human T-lymphotropic virus type! )) infection urier of other infectious diseases rier of infectious disease, unspecified ‘of ICD-10 which came into forcelt tions of ICD-10th revisions are: fo for ambulatory and managed @ scanned with OKEN Scannereee Limitations > Festagaresationofheath > Discusion is imted vo sera classified dseares > Tekrow therealtine - ||» Comments information aboutcurent diseases Sesibtons of heath station Scotia > Wider analysis of diseases m= community health > Country specific modi > Global health assessment Y specific modifications of certain diseases ROLES AND RESPONSIBILITY OF A NURSE IN MEDICAL AND SURGICAL SETTINGS Hospital services in Medical and Surgical settings depicted in Table 1.3. Outpatient Department Outpatient department (OPD) is ambulatory medical and surgical care provided to patients who are not confined tobed can be provided ata general practitioner's clinic, a specialist clinic, a health center or a hospital. Outpatient department is defined as a section of the hospital with allotted physical as well as medical facilities, medical and other staff in sufficient number, with regularly scheduled hours, to provide care for patients who are not registered as inpatients, Types of OPDs © Centralized OPDs: All department OPDs grouped together in the form of one complex. Consultants from different departments come to this atea for OPD work. Decentralized OPDs: Each department provided OPD service in their respective departmentitselfin the hospital. General OPD: All specialty patient attends the OPD for their health issues. Emergency OPD: Emergency patient who have the severe signs and symptoms such as lift threating condition (chest pain, respiratory difficulty, sever hemorrhage, etc.) attend the OPD for their health issue to re the immediate treatment to save the life and prevent the further complications. ‘ Referred outpatient OPD: The patient referred. side hospitals. * ‘Common Function of OPDs * To provide specialist diagnostic, outpatients. ‘To teat patients on ambulatory basis or domiciliary Screen patients for hospitalization, Follow-up treatment of discharge patients. Early diagnosis, curative, preventive and rehabilitative care on ambulatory basis. © Promotion of health by health education program. © Training and education of medical, paramedical and ‘nursing staff ‘Collection, compilation and analysis of medical records. Provide primary health care by health education, counseling based on their respective patients’ needs and problems, ¢¢,, immunization, well baby clinic, voluntary counseling and testing center for HIV/AIDS. Location of OPDs ‘© Usually on ground floor for general hospital ‘© Insuper speciality blockall OPD services in one complex it may in floor wise also. © It may be connected with annexure of inpatient department also, © OPDs share with diagno: © Unidirectional flow © Scope of expansion. Bureau of Indian Standards Recommended Size of OPDs 2 sq m/bed for entrance 10sq m/bed for ambulatory zone 6 sqm/bed for diagnostic zone 60 sq m/bed for total hospital area. ‘Table 1.4 shows the zones of OPDs and Table 1.5 shows the common equipment needs for OPDs. and therapeutic facilities. von2nponu} CE Scanned with OKEN ScannerIntroduction » Entrance » Reception > Registration » Record room > Desks > Waiting area > Public utility services > Snack bar > Cloakroom ‘Administrative zone > Administrative office > Publictelation ofice > Aecounts and biling » Security > Transport » ‘Store room lnkslzone > sobating 02 = Stating chambers > Samintonreom > Drssingroom > iro > ats > ramacy > mdaegy > ysothrapy > plooabank Girculation zone » Stairs Lifts Conveyor belts Corridors Easy accessibility of eevatay Security check post at strategic point Availabilty oF STO/SD facy > ATM machine Sa ne TABLE 1.5: Common equipment! animes 3 > BP apparatus > Endoscope > Portable Xray machine > Portable USG > echo > Otoscope > Thermometer > Pulse oximeter » Cardiac monitor > €CGmachine © Nursing chamber: Vitals collect preliminary data, © SEM area: Patients walt for thelr turn ouside the chamber. * Consultants chamber: Once the patient's tum hei Sento the chamber for examination, check-up, Nebulizer Laryngoscope Bronchoscope Defibrillator Wset diferent size Syringe diferent sae Catheters diferent size Ryle tube Tracheostomy set Instrument trolley of the patients are taken and $ Biling counter: OPDs fees is paid at * Report colection: Once the report co collect the report. > Computer with internet connection > Printer > Intercom facilities > OPD register > Prescription admission register > Investigation forms > Patient case sheet > Work table > Patient's couch > Chairs > Physician's desk » Revolving stool > Stretchers > Wheel chair > Patient assessment forms * Gssist to the physician to examine the patient and therapeutic procedure * Guide and counsel the patients like how to take sccation, next follow-up althcare advice through educating patients ilies te smooth running of clinics to the dissemi ation of good practice by in teaching and learning activities Papal tole as communicator in maintaining mation between patients, caregivers and n More about inpatient care and the 4 general hospital stay. we ta the Procedure requires the patiett | Primarily so that he/she the procedure and afterward & Scanned with OKEN Scanner«- Toprovide facilities to meet the needs ofthe visitors and attendants & # Toprovide highest degree of ob satisfaction for the nurs. ingand medical staffincluding training and research organizing Medical-Surgical Inpatient Unit Organizing inpatient unit based on hospital policy such as general hospital, super speciality hospital, specific hospital, Jocation and type of patients, H Shape or Design ‘© Open ward or Rig’s ward, ‘Ancillary accommodation such nursing station, treatment room, clean utility room, ward kitchen, day room, stores, water and electricity supplies, duty room for doctors, seminar room, side room laboratory, locker room for staff and wheel chair. Ward Size ¢ Area per bed within the ward—70 to 90 sqft © Obstetrics and orthopedics—100 to 120 sq ft © 1CU—12010 150 sq ft © Single bed room—125 sqft © Standard dimensions of hospital bed—6"6” x3°3” © Bed strength—Iess than 200 beds (usually horizontal explanation) ‘© More than 300 beds (usually vertical expansion). Location of the Medical-Surgical Unit Hospital * Itshould be at the backside of hospital complex to avoid ttalficflow and congestion * Itshould have direct access from OPD, OT and emer- gency It should door entrance to ward complex to restrict the ttaficand visitors Good intramural transportation systems like wide: comidors lifts, et, Size of Medical-Surgical Unit ‘Size of the ward or nursing unit varies from: ‘* ‘Size of the depend on type of patient car like ICU, CCU, postoperative area, bi wards where constant attention is beds Patient requiring frequent atte size 40 t0 50 beds. For chronic long duration 7010 90 beds Availability of n ‘Open ward width should be 20 ft Bed are—70 sq ft Space between 2 row beds—5 ft Space between 2 beds—3.5 to4 ft Clearance of bed head from wall 1 ft and from other bed aft © Size of each bed 6.5 «3.25 ft. & eeeee Nursing Station Design in Medical-Surgical Unit Minimum area 20” x20” Sister's changing room and toilet ‘Cupboards for medicines and linen arrangement Hanging pockets for forms and case sheets Case sheet racks Space for table, stool and chairs. Medical-Surgical Unit Treatment Room ‘© Physical examination © BP instrument, thermometer © Dressing trolley, washing facility | ‘© Examination couch, spot light Electricity and Water Supply 24 hours water supply 300 Lt/bed. ‘© Glare free lights, fans and suction Gas pipelline connection @ Aircondition/cooler J uonanponu| Scanned with OKEN ScannerEffective use ofbeds Quantum of workload. Sufficient man power Administration such as employee wellness program, salary. eee ‘Nurses’ Duty and Responsibilities in Medical-Surgical Unit * Senior nursing officer is responsible forthe overall ward ‘management with inter departmental co-ordination. ‘¢ Ensure the implementation of organization policy and. "update the hospital policy. ‘* Planning of daily unit work schedule and policy. * Implement the doctors order to patient such administration of medication, prepare patient for investigation, collect samples from patients. ‘Communicate the patient health status to their family members. Prepare the duty roster to junior nursing officers. Supervise the nursing officers, housekeeping staff and ‘other sanitary workers’ activities. ‘Maintain the all patient register and records. Intend medicine, equipment, sanitary materials and all necessary items for the ward management. Establishment or ward routine (night report, handing taking report, specimen collection, nursing care, vital recording, teaching and supervision). Planning of daily work schedule and policy. Staring work in time, Planning for logistics. Planning and preparation for oper Orientation of new nursing staff ‘Adequate storage and check m Indent and receipt for ward used ‘Maintenance of environment s a ee corsa cron lneses Sls help manage ot illnesses. Clinical Responsibilities as a Care Taker pct rd ass Sain goal so a sey oie while ensuring they ae comforable ae ocx includes treatment of syeptone cag Falla cca loss of appetite, the sess of inset FE Onset es ovlre car gee Sr patei condtion ening nied\oters aa hal phyial sistance, ifmecessay. pee ernest ate Be eens pt by colatoacng a ‘Managerial Responsibilities as. a Ward Manager i © Inpatient nurses’ duties extend to managerial level, ‘They maintain patient files, update patient statisticsand provide reports to doctors and other staff members when necessary. § '* For admissions, inpatient nurse consultants verify member coverage and ensure accuracy of member information. Inpatient nurses also serve as representatives ‘ofthe health care facility in nursing forums and meetings that discuss issues such as the facilty’s quality of health lent care nurse consultants engage in staff ments in the inpatient department. The mandate f regular staff performance reviews standards of inpatient care remain high. npatient cate services and providing falls within their responsibilities: > assist in identifying signs of employees. de the necessary support. @ scanned with OKEN Scanner‘¢ Document patients’ medical histories and assessment findings © Document patients’ treatment pl outcomes, or plan revisions. ‘© Consult and coordinate with health care team members about whole patient care plans, ‘Modify patient treatment plans as indicated by patient's response and conditions. ‘¢ Monitor the critical patients for changes in status and indications of conditions such as sepsis or shock and institute appropriate interventions, ‘© Administering intravenous fuids and medications as per doctor order. ¢ Monitor patients’ fluid intake and output to detect emerging problems such as fluid and electrolyte imbalances. ; ‘© Monitor all aspects of patient care, including diet and physical activity. ‘© Identify patients who are at risk of complications due to nutritional status. Direct and supervise less skilled nursing/health care personnel, or supervise a particular unit on one shift to patient's response and conditions, Treating wounds and providing advanced life support. Assist physicians with procedures such as bronchoscopy, endoscopy, endotracheal intubation, and elective cardio- version. Ensuring that ventilator, monitors and other types of medical equipment function properly. © Ensure that equipment or devices are properly stored afteruse. ‘© Identify malfunctioning equipment or devices. * Collaborating with fellow members of the critical care team * Responding to life-saving situations, using nursing standards and protocols for treatment. * Grtical care nurses may also care for pre- and post- operative patients when those patients require ICU care, * In addition, some act as manager and policy makers, while others perform administrative duties * Assess patients’ pain levels and sedation requirements, * Prioritize nursing care for assigned critically ill patients based on assessment data and identified needs. * Assess family adaptation levels and coping skills to determine whether intervention is needed. Acting as patient advocate. Providing education and support to patient fa * ICU nurse must be able to draw blood sample for blood gas (ABG) analysis and interpret report * ICU nurse should have enough knowl (Glasgow Coma Scale) and also Patient condition, s, interventior INTRODUCTION TO A SURGICAL ASEPSI called as hospital acquired infections (HAH) or nosocomial infections. I is defined as infections which ate not present or not incubating when the patient is hospitalized and are acquired during the hospital stay. [tis usually defined as an infection that is identified at least 48-72 hours following admission to health institution, According to World Health Organization stated that hundreds of millions of patients are affected by healthcare associated infections worldwide each year, itleads significant mortality and financial burden to the health care system all over the world. Out of 100 hospitalized patients, 7 in developed and 10 in developing countries will acquire atleast one health care-associated infection in given time. Newborns are athigher risk of acquiring health care-associated infection inddeveloping countries, with infection rates three to 20 times higher than in high-income countries, Urinary tractinfection is the most frequent health care-associated infection in high-income countries, surgical site infection is the leading infection in settings with limited resources, affecting up to ‘one-third of operated patients; this s up to nine times higher than in developed counties, The study conducted in West Bengal on hospital acquired infections among the patients in a tertiary care hospital on 2018 by Maumita et al. The study found that Incidence rate of hospital acquired infections as 19,6% and incidence density as 26.35 per 1000 patient days. Surgical site infection was most common type (57.2%) followed by 2 stream infection blood cultures, O Scanned with OKEN Scanner‘Surgical site infection (S61): This infection occurs atthe site of surgical incision and may manifests pain, redness and pus discharge from local site with fever. © Clostridium difficile infections (CDY): Necrotizing enterocolitis in patients on broad spectrum antibiotics ‘mostly in critical eare and acute care hospital. Types of Infection ‘© Primary infection is when the host cell is first time primarily exposed to infection by organism. The host does not have any defense against the organism (antibodies), eg, Ist time the person acquired tuberculosis infection. Reinfection is the host cells getting infection again after recovery of the disease by the same organism, eg. the person get tuberculosis again after recovery. Secondary infection which is occurs due another infection during and after the treatment of disease, £8 the person get extrapulmonary tuberculosi Focal infection is the person getting infection in a particular organ result the causing symptoms in elsewhere in the body, eg. the petson get tuberculosis ‘cause symptom fever and headache, ‘Cross infection which is transfer the organism from one person to other person during hospitalization or exposed in contaminated environment by shacking hand, using infected equipment, eg, the person get urinary tract infection after hospitalization or common cold. Hospital-acquired infection (nosocomial infection) isa person getting infection during hospitalization due 1 lack sterilization or improper hand washing, e., the person get throat infection after the endoscopy. Tatrogenic infection is the result of diagnostic and therapeutic procedures undertaken on a patient, eg the person is getting the multitude of drugs prescribed by a physician which cause adverse drugreactionsto the pati Endogenous infection brain cause meningitis. ‘Exogenous infection is host affected by ‘organism through inhalation, direct conts ingestion etc. which is caused dise ‘person is inhaling the Mycobacterium tuberculosis. . ission, through director indirect oral contact © Orta arng a dining ss Carte ¢ Veriieal transmisston, directly from the mother to an Nethrjo fetus of baby during pregnancy or childbirth, ‘s Introgenie transmission, due to medical procedures retires injection or transplantation of infected material, « Veetor-borne transmission, transmitted by a vector, vet is an organism that does not cause disease itsel, Tin that ransmits infection by conveying pathogens from, fone host to another. ‘table 16 shows the types of infection based on organism, Risk of Infection in Hospital «Prolonged and inappropriate use of invasive devices and antibiotics ‘¢ High-risk and sophisticated procedures; immuno-sup. pression and other severe underlying patient conditions einen > Common cold, manly caused by the ino Coronas and adenovirs cause encephalls She meningits, caused by enteroviruses and the herpesruses i > Warts and skin infections caused by thehuman papilomaviruses (PV) nd herpessimplex -as 50) : > Gastroenteritis caused by the Novavius infection is ess helt afecta ‘body than a viral one a bacterial infections are bacterial oe Eres eer! Viral Infections Scanned with OKEN Scanner¢ Application of standard and isolation precautions Inadequate environmental hygienicconditions and waste disposal Poor infrastructure Insufficient equipment Understaffing Overcrowding Poorknowledge and application of basic infection control measures «Lack ofprocedure # Lackofknowledge ofinjection and blood transfusion safety ‘© Absence of local and national guidelines and policies. Principles of Infection Epidemiological principles of infection shown in Figure 1.1 Itinvolves three components: pathogen, environmental and. host. Stages of Infection © Incubation period: Organism enterinto the body and pro- duce first symptoms in between period, but damage is in- sulficientto cause symptoms, several hoursto several years * Prodromal period: Mild and generalized symptoms appears like fever, weakness, headache and no specific complication. ‘* Window period is the time between potential exposure to infection (antigen) and development of antibodies against the infection. According to WHO the time between original infection with HIV and the appearance of detectable antibodies to the virus, normally a period of about 14-21 days. ‘© During the window period a person can be infected with HIV and be very infectious but still test HIV negative. © Invasive stage: Multiples at high levels, because well- established symptoms specific to the disease. © Decline stage: Person begins to respond to the infection, symptoms subside, © Convalescence: No symptoms, health returns to normal. Figure 1.2 shows the chain of infection and Table 1.7 shows the process of chain of infection. Figure 1.3 depicts the preventive measures to break the chain of infection. Preventive Measures for Catheter-associated Urinary Tract Infection ‘© Perform hand-hygiene before insertion of catheter, before each manipulation of catheter and accessing the catheter drainage system and between each patient contact Insert catheter only for appropriate medical indication. Avoid catheters for use in incontinence, for obtaining urine for culture or other diagnostic tests, o forprolonged Postoperative duration without appropriate indications. Alternatives to indwelling catheterization are ™ Suprapubie catheter may be used in patients requiring long term catheterization for bladder obstruction or urinary retention. ™ Condom catheters are associated with reduced risk of infection and may be used for incontinent men. ‘* The need for catheterization should be daily assessed. ‘Removeurinary cathetersassoonasitisno longer required. ‘© Smallest bore uri er should be used for cath- OE Scanned with OKEN ScannerFo Anyone [sakes] \ os omeesd < aaa -aele { ee i Chien | ESS i a Z [How germs get in (Portal of entry) Mouth “ Animalsipts (dogs, * Cuts inthe skin eats replies) + Eyes: + Wild animals ‘Germs get around (Mode of transmission) + Contact (hands, toys, sand) “Bop rene srk it) + Mouth (vomit, saliva) + Culs in the skin (1008) {During alapenng and taleting stoo)) Fig. 1.2: Chain of infection. ‘Minimize the duration of ventilation by daly interruption Use aseptic techniques while handling respiratory ‘ofsedation. equipment. Maintain hand hygiene before and after Daily assessment of readiness to extubate, ‘suctioningand.use disposable sterile gloves for suctioning. Prophylaxis for deep vein thrombosis and peptic ge gloves between patients and decontaminate disease. ~ after removal. Daily oropharyngeal cleaning and decont ; for prevention of contamination of ‘an antiseptic solution. # Adherence to hand hygiene with soap tion and in-use care of ventilator alcohol based hand rub during intubation tors, and humidifiers to limit Avoid nasogastric intubation and p intubation. Nasogastric intubation for suctioning every time increased risk of sinusitis and VAP. ld be used to rinse reusable piratory. The ventilator circuit should increases the risk of VAP 6-21-fold. dor damaged ‘Continuous sterile suctioning of subglo ing within the ventilator circuit secretions, whenever feasible, : @ scanned with OKEN Scannercl see, ® Infectious agent / Rapid dently 4 “organism \ + Sanitization + Disinfection ‘ + Sterization + Rickettsiae Susceptible host *Protozoal ak, + immune defisency jabetes ra Reservoir =a People 3¢ (babies and elderly) oes Ajo wih immuy ined (peop tchguee ‘hema + Proper catheter aie + Handwashing “Proper wound care |, tbe ) sFistaid Portal of entry I Mucosis membrane ve + Digestive system + Broken skin i + Eyes Mode of transmission Physical Contact Droplets Airborne disposed of carefully and prevent it from entering, either the endotracheal tube or inline medication nebulizers. The circuit should be managed so that. condensate does not drain towards the patient : Wash hands after the procedure Nebulizers should be filled with sterile water only and should be single patient use only if possib Otherwise use sterilization or high level dis for changing nebulizers in between patients Aseptic technique must be used when filling the _ humidifier Maintain oxygen flow meter humidifiersand ven humidifier chambers using sterile water which must be changed every 24 hours or sooner, ‘when not in use and sterilize humidifiers in b Patients Education of staff about hand hygiene compl other measures for preventing VAP, to look for in the nature of secretions especially purulent ot Purulent and inform early and cross t ‘multidrug resistant organisms (MDRO) to other} Surveillance of VAP should be carried out in are units caring for mechanically ventilated) Fates for each unit should be expressed as the VAP per 1,000 ventilator days. VAP rates & Scanned with OKEN ScannerSurgical hand scrub using chlorhexidine or alcohol with proper procedure. ‘As per the WHO global guidelines for the prevention ‘of surgical site infection (851), alcohol based antisep' solution, based on chlorhexidine gluconate (CHG) should be used for surgical site skin preparation. Antiseptic solutions should be applied from the center to the periphery of the incision site. Sterile drape should be placed on patient and on any equipment placed in sterile ied Maximal sterile barriers such as sterile gloves (double gloves for procedures with high risk of puncture such as {otal joint arthroplasty for operations on patients with HIV, HepatitisB or infection), gowns, masks, face shields, surgical caps, footwear should be used. Gloves should be immediately changed after accidental puncture. All personnel entering in the operating suite must remove ‘any jewellery;nail polish or artificial nails mustnotbe worn. Operative room (OR) discipline—restricted entry in OR should be ensured and limit unnecessary trafficking in and out of theatre; identify and treat methicillin resistant Staphylococcus aureus carriers; restric staff with skin or ‘upper respiratory infection from working in OR. Regular training of all OT staff on safe practices, maintaining sterility of instruments until use. ‘Conventional operative room ventilation with filtered air using filters with an efficiency of 80-95% to remove airborne particles 25 um in conventional ventilated (OT, Regular monitoring of the efficiency of ventilation system should be carried out. Air change rates should be satisfactory (20 air changes per hour in clean areas such as OR and preparation room). Ensuring proper cleaning of instrument before sterilizing them. Regular training and monitoring oftafton OT d hand hygiene, use of PPE, strict monitoring sterilization of instruments, cleanliness of OT Preventive Measures for Vascular Catl Infection © Practice high level of tic technique the catheter. a = Hand hygiene should be practic after inserting, replacing, access intravascular catheter (IVC) u ‘headwear, sterile gown, body drape) while inserting Use 2% chlorhexidine-based for skin antisepsis before palpation of catheter ‘changes thereafter. The todry. Tincture ofiodin can be used if 2% ck not available. Selection of the catheter insertion site should be rowest risk of complications for the anticipated type ang duration of intravenous therapy. aon adults, an upper-extremity subclavian site fop tntheter insertion rather than the lower extremi Should be selected. Avoid jugular or femoral ste jp ‘tdulis for non-tunnelled CVC insertion. ss In pediatric patients, the upper or lower extremities ‘can be used for catheter insertion. a tnease of hemodialysis or pheresis, jugular or femora vein should be selected to insert catheter. = Central venous catheter (CVC), peripherally inserted ‘central catheter (PICC), hemodialysis catheter should not be routine replaced to reduce the incidence of Infection unless there are any signs of catheter-related bloodstream infection (CRBSI), vascular insufficiency, thrombosis. = Use a CVC with the minimum number of ports or jumens essential for the management of the patient. Gover the site with sterile, transparent, semi-permeable dressings to allow observation of CVC insertion sit. Review need for CVC removal on daily basis and promptly remove unnecessary central lines. Vascular catheter care: Practice strict aseptic precautions ie manipulating/ repositioning of devices, accessing catheter. = Adhere strictly to hand hygiene. = Perform dressing changes under aseptic technique using clean or sterile gloves. = Inspect catheter site on regular basis for signs of central venous catheter (CVC) infection and replace dressings that are wet, soiled, or dislodged. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting seal infection or bloodstream infection (BSI), the ; should be removed to allow thorough ;portor hub immediately prior toeach antiseptic (eg.. chlorhexidine an iodophor, or 70% alcohol). d be prepared using sterile, aseptic ite immediately or refrigerate dose vials for parenteral additives swhen possible. Refrigerate multi-dose discard the vials if sterility ® peripheral catheters more 2-96 hours to reduce risk 2 Replacement need note of phlebitis. Replace peti clinically indicated in ntral venous or rout infectio™ who OF Scanned with OKEN ScannerEducation and training of health care workers on central line insertion, handling and maintenance to reduce central line associated bloodstream infections (CLABSI) rates. Surveillance of CLABSI should be carried out in all critical care units caring for patients with central line, CLABSI rates for each unit should be expressed as the number of CLABSI per 1000 catheter days, CLABSI rates should be fed back to the ICU staff and healthcare facility management on a regular b: Infection Control Precautions for All Patients Wear disposable gloves when caring for the patient or touching the patient's equipment at the dialysis station; remove gloves and wash hands between each patientand station. Items taken into the dialysis station should be either disposed of, used only for a single patient, or cleaned and disinfected before being taken to acommon clean area or used on another patient. Non-disposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth-covered blood pressure cuffs) should be dedicated for use only on a single patient. Unused medications (including multiple dose vials containing diluents) or supplies (e.g., syringes, alcohol swabs) taken to the patient's station should be used only for that patient and should not be returned to a common. clean area or used on other patients. ‘When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to | station. Do not use common medication carts to deliver medications to patients. Do not carry medication vials, syringes, alcohol swabs, or supplies in pockets. Iftrays: sed to deliver medications to individual patients, they must be cleaned between patients. Clean areas should be clearly designated for preparation, handling, and storage of medications at unused supplies and equipment. Clean areas should clearly separated from contaminated areas where supplies and equipment are handled. Do not hand and store medications or clean supplies in the sam adjacent area to where used equipment or blood are handled. Use external venous and arterial pressure transducer fil protectors for each patient treatment to prevent Contamination of the dialysis machines’ pressure! Change filters/protectors between each patient and do not reuse them. Internal transducer fi need to be changed routinely between patients. Clean and disinfect the dialysis station (e.g, tables, machines) between patients. Give special attention to cleaning control dialysis machines and other surfaces that are touched and potentially contaminated blood. Discard all fluid and clean and disinfect all surfaces and. containers associated with the prime waste (including ‘buckets attached to the machines). For dialyzers and blood tubing that will be reprocessed, cap dialyzer ports and clamp tubing. Place all used dialyzers and tubing in leak proof containers for transport from station to reprocessing or disposal area. Steps of hand hygiene using alcohol-based hand-rub according to WHO (Fig. 1.4): Duration of the entire procedure: 20-30 seconds © Step 1: Apply palm full ofthe product in a cupped hand, ‘covering all surfaces. Step 2: Rub hands palm-to-palm. Step 3:Right palm over left dorsum with interlaced fingers and vice versa. Step 4: Palm-to-palm with fingers interlaced. Step 5: Backs of fingers to opposing palms with fingers interlocked. ‘Step 6: Rotational rubbing of left thumb clasped in right palm and vice versa. Step 7; Rotational rubbing, backwards and forwards with. clasped fingers of right hand in left palm and vice versa. Once dry, hands are safe. Nursing Administrator is Responsibilities for Infection Control Scanned with OKEN ScannerRub hands palm o palm Xe hee Right palm over lft dorsum with Palm to palm with fingers interfaced Backs of fingers to opposing palms intertaced fingers and vice versa ‘th fingers intertocked Rotational rubbing of eft thumb ‘clasped in ight palm and vice versa & Scanned with OKEN Scanner@ Lack of adherence to precautions # Inadequate isolation facilities Detrimental effects ofisolation on patients INFLAMMATION Inflammation is an immune response in the body caused harmful or irritating stimuli by organism or chemicals, Inflammation means the human body have self-productive mechanism that remove the harmful stimuli (bacteria, viruses) and start the healing of infection. Its a continous process. It is defined as the local response of living tissue to injury due to any agent. Causes of Acute Inflammations (Flowchart 1.1) i, Exogenous causes, and ii, Endogenous causes, Causes of Chronic Inflammations (Flowchart 1.2) Itoceurs more than 48 weeks, months, years Types © Acute inflammation: It is begun rapidly and becomes severe in a short space of time. Initially no symptoms but develop within following days. For examples of acute inflammation include: acute bronchitis, infected ingrown ‘toenail, sore throat from a cold or flu, ascratch orcuton the Flowchart 1.1: Causes of acute inflammation, TABLE? Variables Causes Events ‘Onset Duration Outcomes Acute Harmful bacteria or tissue injury Vascular events: Hemodynamic changes, altered vascular permeability Cellularevents: Exudation of leukocytes, phagocyto: Irritant eliminated- macrophage disappears Rapid and short duration Afew days Inflammation improves, fluid accumulation, meee ee Chronic Pathogens that the body cannot break down, including some types of virus, foreign bodes that remaininthesystem, or verative immune responses Persistent macrophages accumulation occurs dhe to platelet derived growth factors, transformation growth factors lca proliferation of macrophages, immobilization of macrophages Slow andonge duration From months to years Lymphocytes, ‘macrophages, plasma cells as inflammatory cel. Tissue death and the 9 4 & Scanned with OKEN Scanner1 Chemical signals released by Fluid, antimicrobial proteins Chemokines released by various Neutrophils and macrophages activated macrophages and and clotting elements move kindsofcelsattractmorephagocytic_phagocytose pathogens and ‘mast cells at the injury site from the blood to the site cellsfromthe blood to the injurysite cell debris at the site and the ‘causes nearby capillaries to clotting begins tissue heals widen and become more permeable Fig, 1.5:Steps of inflammatory response. Steps in Inflammatory Responses (Fig. 1.5) ‘© Heat due to more blood flows to the affected area lead. ‘© Recognition and attachment of particle ‘© Enguliiment with formation of phagocytic vesicle © Degranulation stage © Killing and degradation stage. ‘Table 1.10 shows the major chemical mediators involved in inflammatory process. ‘Symptoms of Inflammation CELSUS famous four cardinal signs that is Rubor (redness) © Tumor (swelling) © Calor (heat) '* Dolor (pain) © Functio laesa or loss of function add later by’ ‘Acute inflammation symptoms: In Mnemonic -| © Pain in the inflamed area, especially during touching due to chemicals released in the ‘area stimulates nerve endings. (© Redness occurs due to the capillaries d ‘with more blood than usual, © Ammobility loss of function in the inflammation. © Swelling caused by « buildup of uid, CE Scanned with OKEN Scanner@ Turmeric treating arthritis, Alzheimer’s disease, and PPPS EEN EESTSaEenreEeeerenY other inflammatory conditions. u a ¢ Food sources shovn to help reduce the risk of [O18 Lia inflammation, like olive oil, tomatoes, walnuts, almonds,» Tonsilsand > Lymphocytes > Antibodies leafy greens, salmon fish, blueberries, and oranges, adenoids = Tlymphocytes > Complement «Ald ain foods that cegurteintarcait ock ae PTT = Siymetaores, > Grins foods, French fri read, past la > Lymph nodes plasma cells. > Interleukines crnks redineat nnnread: pasty sod, togary a = Natural killer > Interferons , > Payer'spatches Iymphocytes > Ropendix > Monocytes, IMMUNITY ee EEE ee macrophage vessels > Granuloc Infection and immunity are veryimportanttermsin clinical > $exttamow ” Shes microbiology. Infection and immunity are resultofinteraction = Eosinophils between host and infecting organism, Immunity is the = Basophils resistance in body against the pathogens like bacteria, virus, and their toxic effects to product the body. Immune system means cells, tissues, and molecules that mediate resistance [\QUMAREN ett ieee ae aan tia to infections. Immunology refers as the study of structure RMRCUIStANELEY) and function of the immune system Immune response is__ Active immunity Passive immunity the collective and coordinated response to the introduction (Individuals own immune _(Immunityis transferred from of foreign substances in an individual mediated by the cells _$¥stem-causethe immunity) another person) and molecules ofthe immune system, Natural Artificial Natural Atificial Antigens are “Antigensare Antibodies rom Antibodies Role of Immune System introduced y mother through ‘© Defense against microbes natural ‘© Defense against the growth of tumor cells and kills the exposure growth of tumor cells ‘* Homeostasis ‘© Destruction of abnormal or dead cells (e.g, dead red or ‘white blood cells, antigen-antibody complex). Innate or natural or nonspecific immunity: Itis inherited by the organism from the parents and protects it from birth throughout life. Table 1.11 shows the immune system in human body. Flowchart 1.3 depicts the types of immunity. Mechanism of Innate Immunity it is mechanical barriers to many © Physical barr pathogens, = Skin barriers: tis prevent microbial entry into the body. "= Mucous membrane: Itis secrete mucosa that is traps and immobilizes the microorganism. ‘© Physiological barriers: The skin and mucous membranes secrete certain chemicals which dispose the pathogens from the body such as acid secretions in the stomach CE Scanned with OKEN Scannerae | Classification basedon > Tidy wound eee Rr ay Wateneid Aaa Ce oes 2 ee SADENER Bcd USN rea Se ised pratense ead Sperctwoun See reser wound Skene io smoke” > ec > Lacerated wound '» Mechanical » Infection » Neuropathy > Bruising and contusion wound injury » Edema »® Wound stress Bererecnn 5B, > Reincratonct > Lact or Semone” wont Sate erring «- Wépairis a healing outcome in which tsouesall mr eee return to thelr normal architecture and function, Repay eee earns a te cypleally raul tn the formation of scar Gesu fied eb Tabts 114 soy the fetes otiencing hea Chemteshwoand > Acid and base Stages of Wound Healings (Fig. 1.6) oo Ail wound heal folowing » spec icitencs eam Soe ‘shld aay ofan. The phases of wound heel mm ne ee) Cowianon tae een ‘pe ee eee ane a en agence ectatary o aoe # Hpinepiine i released in an etemot to mini scion aid orig Oe aE ata ote ‘depth epidermis involved) = From initial injury to approximately 3 hours past cee MMMM Sl Hlinjury lati cats aroretponnticte coe cacti cine incied lll anuleas cytokines > Fullthickness wound = Increased platelets aggregation to complete clotting (epidermis, dermis, and ‘process capping blood to sealing bleeding, is 2 Destmetve sage ‘and macrophages diately following the hemostasis phases from | ls such as leukocytes are destroyed bacteria erophages cleanse the wound of cellulat ‘onangiogenesisand granulation fibroblasts, immature collagen blood nd substance make-up granulation from fibroblast, ‘macrophages key factors devel®? @ scanned with OKEN Scannersuture EIS Dermis Collagen matrix kits bssues together } Subcutaneous fat Musclefascia 1A2) Epidermis GI | Demis 3 Blood vessels i ‘own ed blood ase wound J 6 calls O¢ ood vewate POUMORS SS ar] Epitiotal ces begin to bridge ‘wound i 5 gs Figs. 1.6A and B: Stages of wound healing: (1) Inflammat I (43) Proliferative stage; (A4) Maturator Table 1.15 depicts the difference between the PHAR secondary wound healing. Principles of Wound Care © Identify and control underlying causes © Support patient centered concerns © Optimize local wound care. Optimizes Local Wound Care * Decreased dehydration and cell death ‘Increased angiogenesis Enhanced autolytic debridement Increased re-epithelialization Bacterial barrier and decreased infection rates. Decrease pain Decreased costs. ‘Table 1.16 shows the wound management, ‘Complications of Wound Healing * Deficient scar formation—wound d ulceration, @ scanned with OKEN Scanner@ scanned with OKEN Scannera © Get informed written consent from patient, or from spouse or from parents for children, # Preoperative education about deep breathing or incentive spirometer, cough technique, leg exercise, early ambula- tion, recovery room orientation, and family members’ responsibilities in pre-and postoperative periods, ‘¢ Diet and fluid restriction prior to the surgery. Nil per oral should be maintain depend up on surgery, almost restrict the intake from night. Remove all jewels, metal hair pins, dental dentures, contact lens, and hearing aids. Document the items removed from the patients keep it in safety locker orhand ‘over to the family members. © Check the patient arm band patient's name, hospital number, etc., as per hospital protolcol © Preoperative medications like benzodiazepines/ barbiturates used for their sedative, anti-cholinergic to reduce secretions and can reduce cramping, opioids for analgesic and decrease pain. © Document the time when the patients leave the wards and handover to the operation in-charge nurse. Nurses Responsi Responsibilities of Circulating Nurse + Deal with management of unsterile activites in the operation area, Document the nursing care of the patient, ‘Labeling and transporting specimens. ies in Inter-operative Period Responsibilities of Scrub Nurse * Arrange the surgical trolley based on type of surgery. * Count the surgical equipment and note inthe wall board ofoperation room. * Check the functioning condition of the diathermy and: suctioning Check the patient identity with name wrist band and Patient's case sheet. a Position the patient depended up of surgical procedure appropriately. * Draping the surgical table and initial preparation ofthe Patient for surgery * Assist to surgeon and supply surgical instrument during surgery in the sterile area Before closing the surgical incision again countall the equip-- ent such suture material, needles, swabs, mobs, pads eC Remove all the equipment used for surgery. Ensure the patient's surgical site is sterile, isposing the used items in appropriately. Maintain and document the operation registers. Operative area. surgical suite is acontrolled environment esigned to minimize the spread of infectious 0 low smooth flow of patients, personnel and the instrum and equipment. * Unrestricted area: Any one with normal dress Interact with those in scrubs. * Semi-restricted: Peripheral support areas and. allindviduals need to be surgical scrubs and co ait, ‘© Restricted area: Masks must be worn with above surgical ire, includes the operation room, sinks and the clean Principles of Aseptic Technique in Operation Theater Only sterile items are used within the sterile field. Sterile persons are gowned and gloved. ‘Tables are sterile only at table level. Sterile persons touch only sterile items orareas. Unstei persons touch only unsterile items or areas. Unsterile persons avoid reaching over sterile field. Sterile persons avoid leaning over unsterile areas. Edges of anything that encloses sterile content are considered unsterile, Unsterile persons avoid sterile areas. Sterile field is created as.close as possible to the time of use. Sterile areas are continuously kept in view. Sterile persons keep well within sterile area. Sterile persons keep contact with sterileareastoa minimum. Microorganisms must be kept to irreducible minimum, Destruction of integrity of microbial barriers results in contamination Criteria for Positioning the Patient in Operation Room © No interference with res & Scanned with OKEN ScannerPostoperative Care ‘© Initialassessment like level of consciousness, initial quick assessment airway, breathing, circulation, emotional status. ‘© Read the postoperative instruction given by surgeon, surgical procedure from the patient case sheet. ‘© Keep read the postoperative bed with extra linens, extra pillows for positioning. © Keepready oxygen setup, suctioning setup and emergency. tray depending on the type of surgery. © Proper placement and positioning the patient as per order depend upon the surgery. © If the patient is semiconscious, side lying with head Of the bed flat, if fully conscious, semifowlers if not contraindicated, ‘© Lock the side rails to prevent fall injury. © Review the postoperative plan of care with the recovery oom nurse stich positioning, medication, intravenous {luid, nil per oral intake, activity, diagnostictests, dressing changes and any special instructions, ‘* Emotional support to patientand family members. (© Assess the pain status, vital signs every 15 minutes up to, st hours, every 30 minutes upto2nd 4hhours, every one hour up to 3rd 4 hours till the patient is stable and every four hours as routine. ‘© Assess the respiratory status such patency of the airway, ‘need for suctioning ifthe patient cannot move sections, depth of respiration, © Assess the neurological status lke level of conscio the patient get help to ambulation with help of nurse: ‘24-48 hours for Gl surgery, clear liquidsafter sounds. Proper diet to promote ‘vitamin A 25000 IU to enhance land suppor epithelial cell g/day to prevents prolonged Sraciia Cd gaan ‘ambulation. pera Hematological hemorrhage Respiratory atelectasis, pneumonia, pulmonary er CVS — hypotension, cardiac dysarthythmia, venous thro bosis Urinary — urinary retention, low urine production Gif- paralytic ileus, constipation Neurology = stroke ‘Wound ~ infection, dehiscence, eviseration. Psychological - body image problems ambulation, Postoperative Complications and Nursing Management (Box 1.2) Hemorrhage ‘¢ Observe any bleeding in surgical site especially in th dependent areas ‘Monitor the vital signs, assess the skin colour any, like ischemia report the duty incharge Assess the level of consciousness, restlessness impaired cerebral circulation. @ scanned with OKEN Scanner‘¢ Apply compression stockings and leg exercise to prevent Maybe pass nasogastric (NG) tube if orderasper institute e deep venous thrombosis, feral «Coughing and deep breathing exercise and start early ambulation. Stroke canideDystyt te . ier pei ee Caused by hypokalemia, hypoxemia, hypercarbia, acid/ ® Assess the level of conscious, motor and sensory function, base imbalance, heart disease, circulatory instability. pupils reaction. ‘© Auscultate the heart sound and compare the peripheral ¢ Prophylaxis for deep venous thrombosis and venous pulse with heart sounds heard. stasis. © Treat underlying causes as per order. Early ambulation. ‘© Prevent increase intracranial pressure (ICP). Venous Thrombosis ‘* Caused by venous stasis due to inactivity, body positioning, pressure, dehydration. ‘¢ Body image disturbance, eg., colostomy. Elderly and obese are high-risk of developing deep vein ¢ Need to provide empathetic support | thrombosis (DVT). ‘© Teach to the patient about colostomy care. I Support family and provide referral social workers Body Image Problems Provide active and passive range of motion exercise and cocouiapdear aiantintoe oe «Apply compression stockings and anticoagulants a5 crucial 1 > Infection © Due to inadequate nutrition, fluid imbalance, poor Urinary Retention aseptic technique and lack of environmental cleanness. Assess the incision site skin color, drainage and discharge Anesthesia depressed the sensation of bladderfillingand * 2 ou interferes with the ability to void. ! Provide aseptic wound care. ‘© Assess the urinary output, color, and amount, Urine : 5 utput should be 0.5 ml/kg/hr and patient sould be) gaat aia eu agr urinating within 6-8 hours of surgery. * Nurse should facilitate voiding by normal position of patient to void urine, make the patient to hear the running tap watersoundto stimulate voiding, pouring warm water over perineum helps to void urine and ambulation the patient to toilet also assist to void urine. a Low Urinary Production ‘© Assess the bladder, urinary output color, amount the renal function. * Low urinary output indicates renal impairm renal ischemia from poor renal perfusion. Urinary output 0.5 mL/kg/hous, if low amount blac full eportincharge person. Constipation ‘© Assess the bowel distention, bowel sounds, p flatus, any nausea and vomiting. ‘* Early ambulation help to regain the bowel sot © Positioning on the right allow the gas to m transverse colon and out the rectum. ‘© Use stool softeners, suppositories and en Paralytic ileus © Due to bowel manipulation, anesthesia, drugs. ‘© Assess the bowel distention, nausea, sound, presence of flatus and stool. ‘© Maintain nil per oralis patientis showing ileus. * Educate to the patient about importance 0 CF Scanned with OKEN Scanner@ scanned with OKEN Scanner~ = Deep breathing—instruct the patient to do the | “Heart rate returns to baseline 5 min after activity. > following: ‘© Chest pain with activity may be absent. + Situp straight or lean forward slightly while sitting Patient reports tolerance to activity. on edge of bed or chair (if possible), 5, Activity intolerance related to prolonged immobility or + Take in a slow, deep breath. deconditioning as evidence by decrease in systolic blood + Pause slightly, orhold breath for atleast 3. pressure may be >20 mm Hg, increase in heart rate is >20 + Exhale slowly. beats/min with postural change, syncope with postural omRest and trocay ‘change, patient reports lightheadedness with postural change. Incentive spirometry—instruct the patienttodothe | “"8"P: following. Nursing interventions ‘© Collaborate with the practitioner regarding the patient's activity level and the need for physical therapy to ensure the patient’s safety. © Collaborate with the physical therapist to develop Inhale slowly and as deeply as possible, noting the ut iarienae coe l progressive activity plan for the patient to return to prior level of function, ¢ Hold maximal inhalation for3 s. { + Take the mouthpiece out of mouth, and slowly For patient on bed rest * Exhale normally + Place lips around the mouthpiece, and close mouth tightly aroundit. exhale. Instruct the patient how to perform straight-leg raises, | + Rest, and repeat. dorsiflexion or plantar flexion, and quadriceps-setting ‘© Assist the practitioner with intubation and initiation of and gluteal-setting exercises to increase muscular and mechanical ventilation as indicated. vascular tone, Expected outcome ‘© Reposition the patient incrementally to avoid syncope: = Head ofbed to 45" and hold until symptom-free ‘© Respiratory rate, rhythm, and depth return to baseline. jem { Mininalorabsentuse ofaccesorymusdies, Head fed 090° and hold unt symptom-free ‘© Chest expands symmetrically. = Dangle until symptom-free © ABG values return to baseline. = Stand until symptom-free and ambulate. 4, Activity intolerance related to cardiopulmonary "Patient on ventilator : dysfunction as evidence by chest pain with activity, electrocardiogram (ECG) changes with activity, heart rate is >15 beats/min above baseline with activity for patients on beta-blockers or calcium channel blockers, heartrate remains elevated above baseline 5 min after activity, breathlessness with activity, SpO, <92% with activity, postural hypotension when moving from supine to upright position, patient reports fatigue with activity. Nursing interventions * Encourage active or passive range-of- motion exercises while the patient is in bed to keep joints flexible and muscles stretched, ‘Teach the patient to refrain from holding breath while performing exercises and to avoid Valsalva maneuver, * Encourage performance of muscle-toning exercises: at least three times daily because a toned muscle uses less oxygen when performing work than an untoned muscle * Progress ambulation to increase tolerance to activity. Teach the patient to take pulse to determine act ‘olerance: Take pulse fora full minute before exercise then for 10s and multiply by 6 at exercise peak. * Collaborate with the practitioner regarding administration of fluids to ensure that the patient hydrated to 24-h fluid requirements per body area to increase preload and increase stroke volume cardiac output. Expected outcome * Heart rate may be <20 beats/min above baseline activity and <10 beats/min above baseline with activity for patients on beta-blockers or calcium ch blockers, a & Scanned with OKEN Scanner. & 6. Acute confusion related to sensory overload, sensory © Readjust alarm limits on physiologic monitg jevices as the patient's condition changes (improves deprivation, and steep pattern disturbance as evidence devices as t byearly symptoms such as sudden onset of global cognitive deteriorates) to lessen unnecessary alarm states, function impairment (hours to days), restlessness, agitation, © Consideruse of headphones and digital music player and combative behavior, drowsiness, slurring of speech, _the patient's favorite music and/or subliminal or cl inappropriate statements or “word salad,’ mumbling, or musi ef , inappropriate gestures, shortattention span; inabilitytoleam _critical care environment and supplant it with, ‘new material, disordered sleep/wake cycle, disorientation _ soothing sounds and rhythms. to person, time, place, and situation, difficulty in separating Modify lighting—day and night cycles need to dreams from reality (nightmares), angeratstafffor continued simulated with environmental lighting, questions about his or her orientation and later symptoms Never turn on overhead fluorescent lights aby such as symptoms that tend to fluctuate throughout the day and night, continuations of early symptoms, which may be of the supine position, and shielding his or her ‘more frequent or oflonger duration, illusions, hallucinations, with gauze or a face cloth. Continuous bright lig extreme agitation (e.g, attempts to climb out of bed, pull ‘out catheters, rip off dressings), calling out in loud voice, desynchronization, swearing, or attempting to bite or hit people who approach Shield patients from viewing urgent and emergent. Patient. the critical care unit, Resuscitation efforts, albeit ‘Nursing interventions difficult to conceal, engender fear in the patient and ‘© Determine and document the patient's dominant spoken sense of instability and vulnerability (e.g., “I'm next"). language, his or her literacy, and the languages in which = Whensuchaneventoccurs, elicit the patient's « he/she is literate. Sometimes people are not literate in and emotional reaction; thoughts, impressions, theirspoken language, ot less commonly, they ae literate feelings need to be shared, and misconceptions only in thelr second language tobe clarified. ‘* Determine and document the patient’s premorbid degree ® Ensure patients’ privacy, modesty, and dignity. of orientation, cognitive capabilities, and any sensory/ exposure and nudity, although they seemingly pale perceptual deficits, . ce compared with priorities such as physio For sensory overload ‘assessment and stabilization, are primal indignities ‘Initiate each nurse-patient encounter by callin a patient by name and identifying yourself by nat fosters reality orientation and assist filtering irelevant or impersonal convers ‘Assess the patien’simmediatephysiale his/her viewpoint, and explain equi and its therapeutic purpose. Der decreases alienation of the patient from environment and reduces the inherent. ‘shown that noise levels produced by exceed levels designated as @ scanned with OKEN ScannerFoster liberal visitation by family members and significant others. Encourage significant others to touch the patient, as consistent with their individual comfort level and cultural norms. Structure and identify opportunities for the patient to exercise decision-making skills, howeversmall. Although not so designated, patients with sensory alterations also, experience a type of cognitive deprivation. Assist patients to find meaning in their experiences. Patients need to find meaning and to identify their roles in the experience of critical illness and critical care. = Explain the therapeutic purpose of all they are asked to do for themselves and all that is done with them. ‘and for them. = Avoid statements such as, “Will you turn to that side for me?” or “I need you to swallow this medication” ‘These statements implicitly convey that the maneuver thas some value for the nurses instead of the patients. = Similarly, use “thank you" judiciously. This simple salutation, when used indiscriminately, suggests something was done to benefit the nurses, not the patients. 7. Acute pain related to transmission and perception of cutaneous, visceral, muscular, or ischemic impulses as evidence by patient verbalizes presence of pain, patientrates pain on scale of 1 to 10 using a visual analog scale, increase in blood pressure, heart rate, and respiratory rate, pupillary dilation, diaphoresis, pallor, skeletal muscle reactions (e.g., grimacing, clenching fists, writhing, pacing, guarding or splinting of affected part) apprehension, fearful appearance, may not exhibit any physiologic change. ‘Nursing interventions ‘® Modify variables that heighten the patient's experience of pain. = Explain to the patient that frequent, detailed, and seemingly repetitive assessments will be conducted to allow the nurse to better understand the patient's pain experience, not because the existence of pain is in question, a Explain the factors responsible for pain prod the individual. Estimate the expected duration of dl pain if possible. Explain diagnostic and therapeutic procedures to the patient in relation to sensations the patient shoul ‘expect to feel. Reduce the patient's fear of addiction by exp dependence. Drug tolerance is a physiolo phenomenon in which a medication begins to. effectiveness after repeated doses; drug is a psychologic phenomenon in which opioid used regularly for emotional, not medical, Instruct the patient to ask for pain medicati pain is beginning and not to wait until itis able. Explain that the practitioner will be consulted reliefis inadequate with the present Instruct the patientin the importance ofadeq especially when it reduces pain to maintain and coping abilities and to reduce stress. ‘© Collaborate with the practitioner regarding pharmaco- logicinterventions. = Medicate with an opioid analgesic to break the pain cycles as long as level of consciousness and vital signs are stable, = Check the patient’s previous response to similar dosage and opioids. = Establish optimal analgesic dose that brings optimal pain relief = Offer pain medication at prescribed regular intervals rather than making the patient ask for it to maintain more steady blood levels. = Consider waking the patient to avoid loss of op blood levels during sleep. = If administering medication on as-needed (PRN) basis, give it when the patient's pain is just beginning, rather than at its peak. m= Advise the patient to intercept pain, not endure it, or several hours and higher doses of opioid analgesics | may be necessary to relieve pain, leading to a cycle of undermedication and pain alternating with overmedication and drug toxicity. = Perform rehabilitation exercises (turn, deep breathe, leg, exercises, ambulate) shortly before peak of drug effect because this will be the optimal time for the patient to increase activity with the least risk of increasing pain. = When making the transition from one drug to another, or from intramuscular or IV to oral medication, use an equianalgesic chart. Equianalgesic means approximately the same pain reliet. The patients @ scanned with OKEN Scannerby pushing the button to activate the PCA machine. For example, “When you have pain, instead of asking the nurse to bring medication, push the button that activates the machine ‘and a small dose of the pain medicine will be injected into your IV line. You can keep your pain under control by administering additional medicineassoonasyourpain begins toretunor increases. Push the button before undertaking a painful activity, such as ambulation. Try to balance your pain relief against sleepiness, and don't activate the machine if you start to feel sleepy. If your pain medicine seems to stop ‘working despite pushing the button several times, call the nurse to check your IV, Ifyou are not receiving adequate pain relief, the nurse will ell your doctor” Monitor vital signs, especially blood pressure and respiratory rate, every hour for the first 4h, and assess postural heart rate and blood pressure before initial ambulation. Monitor respiratory rate every 2h while the patient is on PCA. If the patient's respiratory rate decreases to <<10 breaths/min or if patientis overly sedated, anticipate administration of naloxone. epidural opioid analgesia is used: 2 Keep the patient’s head elevated 30 to 45° after injection to prevent respiratory depressant effects. Observe closely for respiratory depression for 24h after injection, Monitor respiratory rate every 15 min for 1h, every 30 min for 7h, and ‘every hour for the remaining 16 h. Assess for adequate cough reflex. Avoid use of other central nervous system depressants, such as sedatives, Observe for reports of pruritus, nausea, vomiting. 7 Anticipate administration of naloxo respiratory depression. a ‘Assess for and treat urinary retention, Assess epidural catheter site for local infect Keep the catheter taped securely to p ‘catheter migration, For peripheral vascular ischemic pain socularoccicion of), do the fe Correctly identify and differentiate ischemic from other types of pain, (Note: Ischemic pai usually aburning, aching pain made worse by e heart level. Rubor and mottling of the evident from prolonged tissue anoxia of damaged vessels to constrict, = Administer pain medications, and evaluate th effectiveness as previously described. The pain of ischemia is chronic and continuous and can make the patient irritable and depressed. Treat the cause of the ischemic pain, and inst measures to increase circulation to the affected part, ‘© Initiate nonpharmacologic interventions. m= Treat contributing factors. Apply comfort measures. j 4 Use relaxation techniques, such as back rubs, massage, warm baths, music, and aromatherapy, © Use blankets and pillows to support the painful part and reduce muscle tension. © Encourage slow, rhythmic breathing. 4 Encourage progressive muscle relaxation techniques. © Instruct the patient to inhale and ten (tighten) specific muscle groups and then relax the muscles as exhalation occurs. q © Suggestan orderfor performing the tension and relaxation cycle (e.g., start with facial mus and move down body, ending with toes). Encourage guided imagery. © Ask the patient to recall an experienced image that is very pleasurable and relaxing involves at least two senses. Have the patientbegin with rhythmic breat and progressive relaxation and then tra mentally to the scene. © Have the patient slowly experience the scen howit looks, sounds, smells, feels). he patient to practice this imagery to end the imagery and saying, “Now |does not end theim @ scanned with OKEN Scanner‘Nursing interventions Instruct the patient in the following simple, effective relaxation strategies: a Ifnot contraindicated for cardiovascular reasons, tense and relax all muscles progressively from toes to head. Progressive toe-to-head relaxation releases the muscular tension that may be a stress-related effect resulting from the threat or change in the patient's health status and outcome of illness. = Perform slow deep-breathing exercises. Deep- breathing exercises provide slow, rhythmic, breathing pattems that relax the patient and distract him or her from the effects of his or her illness and hospitalization. Focus ona single objector person in the environment. Focusing on a single object orperson helps the patient dismiss myriad disorienting stimull from his or her visual-perceptual field, which can have a dizzying, distorted effect. A clear sensorium allows him orher to feel more in control ofhis or her environment. Listen to soothing music or relaxation tapes with eyes closed. Music or words expressed in soft, low tones tend to produce soothing, relaxing effects that counteract or inhibit escalating anxiety and provide s from the patient's situational erisis. Closed eyes eliminate distracting visual stimuli and promote ‘a more restful environment. Actively listen to and accept the patient's concerns regarding the threats from his or her illness, outcome, and hospitalization. Active listening and unconditional acceptance validate the patient as a worthwhile individual and assure him or her that his or her concerns, no matter how great, will be addressed. Knowledge that he or she has an avenue for ventilation will assuage anxiety. Help the patient distinguish between realistic concerns: and exaggerated fears through clear, simple explanations. Sample statements: “Your lab results show that you're doing okay right now." “The shortness of breath you're experiencing is not unusual” “The pain you described 's expected, and this medication will relieve it” A patient ‘who is informed about his or her progress and isreassured. about expected symptoms and management of carewill be better equipped to maintain a more realistic perspective of his or her illness and its outcome. Anxiety emanating from imagined or exaggerated fears willlikely beassuaged | oraverted. Provide simple clarific and stimuli that are not related to the patient's illness nn of environmental events. and care. Sample statements: “That loud noise is coming, from a machine that is helping another patient” “The visitor behind the curtain is crying because she’s had an upsetting day” “That gurney is here to take anot patient to X-ray.” Clarification of events and stim that are unrelated to the patient helps to dis him or her from the extant anxiety-provoking sit surrounding him or her, avoiding further anxiety apprehension. Assist the patient in focusing on building on prior cop strategies to deal with the effects of his or her illness an care. Sample statements: “What methods have hi you get through difficult times in the past?” “How can we help you use those methods now?” Use of previously successful coping strategies in conjunction with newly learned techniques arms the patient with an arsenal of weapons against anxiety, providing him or her with greater control over the situational crisis and decreased. feelings of doom and despair. Give the patient permission to deny or suppress the effects of his or herillness and hospitalization with which he or she cannot cope or control. Sample statements— “It’s perfectly okay to ignore things you cannot handle right now.’ “How can we help ease your mind during this time?” “Whatare some things or tasks that may help distract you?” Adaptive denial can be helpful in reducing feelings of anxiety in patients with life-threatening illness. Expected outcome Patient effectively uses learned relaxation strategies. Patient demonstrates significant decrease in psychomotor agitation. Patient verbalizes reduction in tingling sensations in hands and feet. Patient is able to focus on the tasks at hand. Patient expresses positive, future-based plans to family and staff. Patient's heart rate and rhythm remain within limits OF Scanned with OKEN Scannerise , mentation, restlessness, agitation, confusion, dimii ea een .0 into severe contractions and sublingual area, systolic blood pressure is <90 mm ae en aoe torecur, subjective complaints of fatigue and reduced preload such; eit Pe eangiontietar is in place, check the _rightatrial pressure is <2mm Hg, nunca ‘catheter and tubing for kinks, folds, constrictions, _ pressure is <6 mm Hg, excessive os, ad, ri al pressure or obstructions and for correct placement. If _is>8mm Hg, pulmonary artery occlusion pressure is>12 mm. problem is found, correct it immediately. Hg. . If catheter is plugged, irrigate it gently with no more than 10 to 15 mL of sterile normal saline" Coljaborate with the practitioner regardingadministration solution at body temperature, of oxygen to maintain oxygen saturation measured b ¢ Iunabletoirrigate catheter removeitand prepare Pulse gximetry(SpO,) >92% to prevent tissue hypoxia, {0 reinsert a new catheter—proceed with its Maintain surveillance for signs of decreased tissue ‘wbrication, drainage, and observation asoutlined perfusion and acidosis to facilitate early identification above. and treatment of complications, © roid manually compressing or tapping onthe Monitor fluid balance and daily weights to facilitata re proveedtona.6 _Téblation ofthe patients fuid balance. . If systolic BP is >150 mm Hg, proceed to no. Betas cheng for focal ionpacis For reduced preload resulting from volume loss * With a gloved hand, instill a topical anesthetic Collaborate with the practitioner regarding administra agent (2% lidocaine jelly) generously into the _tion of erystalloids, colloids, blood, and blood products ‘rectum to decrease flow of impulses from bowel, to increase circulating volume. '* Wait 2 min if possible for sensation in area to. ® Limit blood sampling, observe intravenous lines fo ‘Nursing interventions decrease. accidental disconnection, apply direct pressure to ‘* With a gloved hand, insert a lubricated finger into bleeding sites, and maintain normal body tempe: the rectum and check for the presence of stool. to minimize fluid loss. + Ifstool is felt, gently remove, if possible. = Skin: ‘Loosen clothing or bed linens as indicated, ‘Inspect skin for pimples, boils, pressure ulee ‘and ingrown toenails, and treat as indi ‘© Ifsymptoms of dysreflexia do not subside, ‘with the practitioner regarding the administra hypertensive medications (eg, nifedipine fin telease form), nitrates {sodium nitroprusside, isoso dinitrate, or nitroglycerin ointment], mecamylamine, diazoxide, Position the patient with legs elevated, trunk flat, and) ‘= Assess BP and heart rate, Instruct the patient about causes, symptoms, ‘and prevention of dysreftexia, a Encourage the patient to carry a medical b informational card to presentto medical event dysreflexia may be developing, Expected outcome BP returns to patient’s baseline level, Heart rate and rhythm returns to pi level. ‘Headache is absent. Sweating, flushing, and piloerection, are absent. Visual disturbances and nasal 10. Decreased cardiac output preload as evidence by cardiac out ‘cardiac index is <2.5 L/min/m h @ scanned with OKEN ScannerForexcessive preload resulting from venous constriction ‘© Collaborate withthe practitioner regardingadministration of vasodilators to promote venous dilation. ‘© Maintain surveillance for adverse effects of vasodilator therapy to facilitate early identification and treatment of complications. Ifthe patient is hypothermic, wrap him or her in warm blankets or administer hyperthermia blanket to increase temperature and promote vasodilation, Expected outcome Cardiac output is 4-8 L/min, © Cardiac indexis 2.5-4 L/min/m:, ‘© Rightatrial pressure is 2-8 mm Hg. ‘¢ Pulmonary artery occlusion pressure is 6-12 mm Hg. 11, Decreased cardiac output related to alterations in afterload as evidence by cardiac output is <4 L/min, cardiac index is <2.5 L/min/m’, heart rate is >100 beats/min, urine output Is <30 mL/h, decreased mentation, restlessness, agitation, confusion, diminished peripheral pulses, blue, gray, or dark purple tint to tongue and sublingual area, ‘stolic blood pressure is <90 mm Hg, subjective complaints of fatigue. [Nursing interventions ‘© Collaborate with the practitioner regarding administration ofoxygen to maintain SpO, >92% to prevent tissue hypoxia. ‘* Maintain surveillance for signs of decreased tissue perfusion and acidosis to facilitate early identification, and treatment of complications. For reduced afterload © Collaborate with the practitioner regarding administration of vasoconstrictors to promote arterial vasoconstriction and prevent relative hypovolemia, If decreased preload is present, implement nursing management plan for decreased cardiac output related to alterations in preload. Maintain surveillance for adverse effects of vasoconstrictor therapy to facilitate early identification and treatment of complications © Ifthe patient is hyperthermic, administer tepid bath, hypothermia blanket, or ice bags to axilla and groin to decrease temperature and promote vasoconstriction, For excessive afterload * Collaborate with the practitioner regarding administra~ tion of vasodilators to promote arterial vasodilation, * Collaborate with the practitioner regarding initiation of intra-aortic balloon pump to facilitate afterload reduction, * Promote rest and relaxation and decrease environmental stimulation to minimize sympathetic stimulation, © Maintain surveillance for adverse effects of vasodilator therapy to facilitate early identification and treatment of complications. © Ifthe patient is hypothermic, wrap the patient in warm blankets or administer hyperthermia blanket to increase temperature and promote vasodilation. * Ifthe patient isin pain, treat pain to reduce sympathetic stimulation, Implement nursing management plan for acute pain related to transmission and perception of cutaneous, visceral, muscular, or ischemic impulses. Expected outcome © Cardiac output is 4-8 L/min, © Cardiac indexis2.5-4 L/min/m*. 12, Decreased cardiac output related to alterations in contractility as evidence by cardiac output is <4 L/min, cardiac indexis <2.5 L/min/m?, Heart rate is >100 beats/min, urine output is <30 mL/h, decreased mentation, restlessness, agitation, confusion, diminished peripheral pulses, blue, ‘gray, or dark purple tint to tongue and sublingual area, systolic blood pressure is <90 mm Hg, subjective complaints of fatigue, right ventricular stroke workindexis <7 g/m?/beat, left ventricular stroke work index: <35 g/m*/beat. ‘Nursing interventions © Collaborate with the practitioner regarding administration ‘ofoxygen to maintain SpO, >92% to prevent tissue hypoxia. © Maintain surveillance for signs of decreased tissue perfusion and acidosis to facilitate early identification and treatment of complications. Ensure preload is optimized. If preload is reduced or excessive, implement nursing management plan for decreased cardiac output related to alterations in preload. Ensure afterload is optimized. If afterload is reduced or excessive, implement nursing management plan for decreased cardiac outputrelated to alterations in afterload. CE Scanned with OKEN Scannery * Maintain surveillance for signs of decreased tissue perfusion and acidosis to facilitate early identification and treatment of complications. ‘© Monitor ST-segment continuously to determine changes, in myocardial tissue perfusion. If myocardial ischemia is, present, implement nursing management plan foraltered. cardiopulmonary tissue perfusion. Expected outcome © Cardiac output is 4-8 L/min. © Cardiac indexis2.5-4 L/min/m?, © Dysthythmias are absent or return to baseline. Heart rate is >60 beats/min or <100 beats/min. 14. Decreased cardiac output related to sympathetic blockade as evidence by decreased cardiac output and cardiac index, systolic blood pressure is <30 mm Hg or below patient's baseline, decreased right atrial pressure and pulmonary artery occlusion pressure, decreased systemic vascular resistance, bradycardia, cardiac dysthythmias, postural hypotension. ‘Nursing interventions © Implement measures to prevent episodes of postural ‘hypertension: = Change the patient's position slowly to allow the cardiovascular system time to compensate, "Apply pneumatic compression stockings to promote. ‘venous return. ; ™ Perform range-of- motion exercisi blood ‘© Monitor cardiac rhythm for br ‘dysrhythmias, which can further d right atrial pressure is <2 mm Hg, tachycardia, n pressure, systolic blood pressure is <100 mm Hg, ‘outputis <30 L/h, pale, cool, moist skin, appreh ‘Nursing interventions © Secure airway and administer oxygen to maintain oxyp saturation >92%, Place the patient in supine position with legs ele to increase preload. For the patient with head injy consider using low-fowler position with legs elevated, © For fluid repletion, use the 3:1 rule, replacing 3 par fluid for every unit of blood lost. © Administer crystalloid solutions using the fluid chal technique: Infuse precise boluses of fluid (usually mL/min) over 10-min periods; monitor hemodyn pressures serially to determine successful ch thepulmonary arteryocclusion pressureelevates>7m above beginning level, the infusion should be stop If the pulmonary artery occlusion pressure rises only! 3mm Hg above baseline or falls, another fluid should be administered. Replete fluids first before considering use of vasop because vasopressors increase myocardial oxyge ‘consumption out of proportion to the re-establishn of coronary perfusion in ood replact @ scanned with OKEN Scanneri coping mechanisms, past experience with stress, and support system. ‘¢ Appraise the response of the family and significantothers. Body image is derived from the “reflected appraisals” of family and significant others. ‘© Determine the patient's goals and readiness for learning. Provide the necessary information to help the patient and family adaptto the change. Clarify misconceptions about future limitations. + Petmitand encourage the patient to expressthe significance ofthe loss or change; note nonverbal behavior responses. # Allow and encourage the patient’s expression of anxiety, ‘Anxiety is the most predominant emotional response to a body image disturbance. © Recognize and accept the use of denial as an adaptive defense mechanism when used early and temporarily. © Recognize maladaptive denial as that which interferes with the patient's progress and/or alienates support systems, ‘© Provide an opportunity for the patient to discuss sexual ‘* Touch the affected body part to provide the patient with sensory information about altered body structure and/ or function. ‘© Encourage and provide movement of altered body part to establish kinesthetic feedback. This enables the patient to now his or her body as it now exists. ‘Prepare the patient to look at the body part. Call the body part by its anatomic name (e.g., stump, stoma, limb) as opposed to “it” The use of impersonal pronouns increases a sense of fantasy and depersonalization of the body part. © Allow the patient to experience excellence in some aspect of physical functioning—walking, turning, deep breathing, healing, self-care—and point out progress and accomplishment. This helps to balance the patient's sense of dysfunction with function. ‘Avoid false reassurance. Acknowledge the difficulty of ree healtered body part or function nto ones prone, Tis evidences the nurses sensitivity and * Talk with the patient about his or her life, generativity, and accomplishments. Patients with disturbancesin body image frequently se themselves ina distortedly “narrow” Fe pnCoureging a wider focus of themselves and their life reduces this distortion, ae the patient explore realistic alternatives, ‘ ‘Recognize that incorporating a body change into one's body image takes time. Avotd setting unrealistic expectations and inadvertently reinforcing a low self-esteem. Suggest the use of additional resources such as trained \isitors who have mastered situations similar to those of the patient. Refer the patient to a psychiatric nurs, Psychologist, or psychiatrist ifneeded. Expected outcome * Patient verbalizes the specific meaning of the change to ‘him or her. 3, Patient requests appropriate information about self-care: Patient completes personal hygiene and grooming daily With or without help. ‘© Patient interacts freety with family or other visitors. © Patient participates in the discussions and conferences related to planninghisorhermedical and nursingmanage- ‘mentin the critical care unit and transfer from the unit. Patient talks with trained visitors (support group representatives) at least twice abouthis or her loss. 17, Disturbed sleep pattern related to fragmented sleep as evidence by decreased sleep during one block of sleep time, daytime sleepiness, decreased sleep, less than one-half ‘of normal total sleep time, decreased slow-wave or rapid- eye-movement (rem) sleep, anxiety, fatigue, restlessness, disorientation and hallucinations, combativeness, frequent awakenings Nursing interventions ‘© Assessnormal sleep pattern on admission and any history of sleep disturbance or chronic illness that may affect sleep or sedative/hypnotic use. Promote normal sleep activity while the patient is in the critical care unit. Assess sleep effectiveness by asking the patient how his or her sleep in the hospital compares with sleep athome. Promote comfort, relaxation, and a sense of well-being. = Treat pain; change, smooth, or refresh bed linens at ° CF Scanned with OKEN Scannerctitioner regarding use g Collaborate with the Prac milena See ina intravenous ov) eo ca fluids to maintain ad . Dole haath of uninterrupted sleep per shift, hydration of ‘Pat ittern disturbance is diagnosed, treated, and resolved, ‘Temperature is within normal range. a Irate aly docimeedinhismanneteniatry rate and heat rote are within pate Expected outcome baseline range. ‘© Patient's total sleep time approximates patient’s normal © Skin is warm and dry. sleep time 19. Hypothermia related to decreased metabolic rate or fatentinn copie ep cycler of 0 min) without.|stideaa be eauioiin baty diate below interruption. range, shivering pallor, piloerection, hypertension, skin og ‘ Patienthas no delusions or hallucinations, to ouch, tachycardia, decreased capillary rfl, Patent has reality-based thought content. ‘Nursing interventions 18. Hyperthermia related to increased metabolic rate as © Monitor temperature every 15 min to 1h until wi cre painewased body temperatureabovenormalrange, ° Menito ange and stable and then every 4 h to maim sim isan, raureasedrespiratoryrate,tachyeardia, Gyo surveillance for temperature fluctuations and skin’ mas to touch, diaphoresis, evaluate effectiveness of interventions, . Nursing interventions Use temperature taken from pulmonar catheter or bladder catheter if available because! body temperature, brane ‘temperature if core ‘devices are: ‘unavailable, US this so manetPom (Le, shivering) et the Place ice packs in patient” froin ang heat loss by conduction, - ‘ the patient on bed x Patient's metabo eta the of ® Provide ee tolerate, wht fects heat 5 the patient's oss" temperature pp with ic 1 alow hen & Scanned with OKEN Scanneraction may induce severe alkalosis and precipitate ventricular fibrillation, Maintain cardiopulmonary resuscitation and advanced cardiac life support until core body temperature is atleast 29,5°C (85.1°F) before determining that patient cannot be resuscitated. Flectrical defibrillation is usually successful in terminating ventricular fibrillation if the temperature (82.4°F). ter cardiac resuscitation drugs sparingly because as the body warms, peripheral vasodilation occurs. Drugs that remain in the periphery are suddenly released, Jeadingto abolus effect that may cause fatal dysthythmias. © Monitorarterial blood gas values to direct further therapy, and ensure that pH, arterial partial pressure of oxygen (Pa0,), and arterial partial pressure of carbon dioxide (PaCO,) are corrected for temperature. © Rewarmn the patient rapidly because the pathophysiologic changes associated with chronic hypothermia have not had time to evolve. = Institute rapid, active rewarming by immersion in warm water (38°C to 43°C) (100.4°F to 109.4°F), = Apply thermal blanket at 36.6°C to 37.7°C (97.9°F to 99.9°F), Some researchers suggest rewarming only the torso or trunk first, leaving the extremities exposed to room temperature. This is done to prevent early ripheral vasodilation with abrupt redistribution of intravascular volume. This also prevents colder blood trapped in the extremities from returning to the body core before the heart is rewarmed. = Perform rapid core rewarming with heated (37°t0.43°C [98.6°to 109.4°F}) intravenous infusion, hemodialysis, peritoneal dialysis, and colonic or gastric irrigation fluids. ‘© Monitor peripheral circulation because gangrene of the fingers and toes is a common complication of accidental hypothermia. Expected outcome © Cote body temperature is >35°C (95°F). ‘© Patients alert and oriented. © Cardiac dysrhythmias are absent. Acid-base balance is normal. Pupils are normoreactive, 21. Imbalanced nutrition: Less than body requ related to lack of exogenous nutrients and increas metabolic demand as evidence by unplanned weight lo 0f 20% of body weight within past 6 months, serum is <3,5 g/dL, total lymphocytes are <1500/mm*, energy, negative nitrogen balance, fatigue; lack of energy and endurance, nonhealing wounds, daily caloricintakeless «timated nutrition requirements, presence offactors ‘o increase nutrition requirements (e,, sepsis, ti ‘multiple-organ dysfunction syndrome), maintenane Aothing by mouth (NPO) status for>10 days, long of intravenous 5% dextrose, documentation of sub calorie counts, drug or nutrient interaction decrease oral intake (eg., chronic use of bro laxatives, anticonvulsives, diuretics, antacids, Physical problems with chewing, swallowing, ehok Salivation and presence of altered taste, Yomiting, diarrhea, or constipation. ‘Nursing interventions ‘© Inquire if the patient has any food allergies and food preferences to ensure the food provided to the patient is. not contraindicated. © Monitor the patient’s caloric intake and weight daily to ensure adequacy of nutrition interventions, © Collaborate with the dietitian regarding the patient’s nutrition and caloricneeds to determine the appropriate- ness of the patient's diet to meet those needs. ‘© Monitor the patient for signs of nutrition deficiencies to facilitate evaluation of extent of nutrition deficient. © Provide the patient with oral care before eating to ensure optimal consumption of diet. ‘© Assist the patient to eat as appropriate to ensure optimal ‘consumption of diet. Collaborate with the practitioner and dietitian regarding administration of parenteral and enteral nutrition as needed. Expected outcome © Patient exhibits stabilization of weight loss or weight gain of 0.5 Ib daily. | © Serum albumin is >3.5 g/dL. | ‘© Total lymphocytes are <1500/mm. | ‘© Patient has positive response to cutaneous skin antigen testing. Patient is in positive nitrogen balance. © Wound healing is evident. © Daily caloric intake equals estimated nutrition require- ments. ‘© Increased ambulation and endurance are evident. * acne Scanned with OKEN Scanner11, Mention the functions of IPD. ‘ 12, List the factors influencing the IPD in medical-surgical units 13. Discuss the nurses’ duty and responsibilities in IPD in medical-surgical unit. 14. Explain the nurses’ duty and responsibilities in ICUs. 15. List the common hospital acquired infections. 16. State the types of infections. 17. Explain the mode of transmission of infection. 18, State the epidemiological principal of infection. 19. Explain the chain of infection and its preventive measure to break the chain. 20. Explain the preventive measure for ventilator-associated pneumonia (VAP). 21, Explain the preventive measures for surgical-site infections. 22. Explain the preventive measures for vascular catheter infection. 23. List the steps for handwashing. 24, Explain the nurses’ responsibilities in infection control. 25, Whats inflammation? 26. What are the causes for inflammation? 27. List the types of inflammation. 28. Distinguish acute and chronic inflammation. 29. Explain the inflammatory responses. 30. List the common signs and symptoms of inflammation. 31, What is immunity? 32, State the types of immunity. 33, What is wound? 34, State the classifications of wound. 35, List the factors influencing wound healing. 36, Explain the stages of wound healing, 37. Distinguish primary and secondary wound healing 38, What is perioperative nursing? 39, State the types of surgeries, 40. List the purposes of surgeries, 41. Enlist the preoperative nursing assessment. 42, List the interoperative nurse responsibilities, 43, State the principles of basis aseptic technique in op theater. 44, List the types of anesthesia, 45. Explain the methods of anesthesia administration, 46, Describe the stages of general anesthesia, i 47. Discuss the common drugs used in anesthesia, 48. List the criteria for positioning the patient in operate room. 2 49. Enlist the factors influencing the development postoperative problems. 50, List the complications during intraoperative period. 51. Explain the postoperative complications and its n management. @ scanned with OKEN Scanner