FATHER SATURNINO URIOS UNIVERSITY

COLLEGE OF NURSING BATCH 2024

NCM 310 – Care of Clients with Problems of Oxygenation, Fluid & Electrolytes, Infectious, Inflammatory
& Immunologic Response, Cellular Aberration, Acute & Chronic
FIRST SEMESTER | PRELIMS
COURSE OUTLINE: Unit Examination 2 According to Urgency
Perioperative Nursing 1. Emergent  Without delay
a. Preoperative Phase Requires immediate  Severe Bleeding
b. Intraoperative Phase attention.  Bladder or
c. Postoperative Phase Intestinal
PERIOPERTATIVE NURSING Obstruction
The care of a client or patient  Fractured Skull
 BEFORE (Preoperative Phase)  Gunshot or Stab
 DURING (Intraoperative Phase) Wounds
 AFTER (Postoperative Phase) surgical operation.  Extensive Burns
 TYPES OF PATHOLOGIC PROCESS REQUIRING 2. Urgent  Within 24-30 hours
SURGERY Requires prompt  Acute Gallbladder
attention Infection
1. Obstruction: Impairment to the flow of vital fluids
 Kidney or ureteral
(blood, urine, CSF, bile)
stones
2. Perforation: Rupture of an organ
3. Erosion: Wearing-off of a surface or membrane 3. Required  Plan within a few
4. Tumors: Abnormal new growths Needs to have surgery weeks or month
 Prostatic
Examples:
Hyperplasia
Hydrocephalus Obstruction without obstruction
Burn Erosion
 Thyroid Disorders
Prostatic Hyperplasia Tumor
 Cataract
Cholelithiasis Obstruction
4. Elective  Failure to have
Intussusception Obstruction Should have surgery surgery not
Ruptured Aneurysm Perforation
catastrophic
 Repair of Scars
 CLASSIFICATION OF SURGERIES
 Simple Hernia
According to Purpose
 Vaginal Repair
1. Diagnostic  Determine the 5. Optional  Personal
presence and Decision rest with Preference
extent of a disease patient  Cosmetic Surgery
condition.
 Biopsy,
Exploratory PREOPERATIVE PHASE
Laparotomy Starts: Decision to proceed with Surgical Operation
2. Curative  Treat the disease Ends: Transfer of patient onto the Operating Table
condition. Goals of the Nurse
 “ectomy”; removal
● Assessing and correcting physiologic and psychologic
of an organ
problems that may increase surgical risk.
 Excision of Tumor,
Appendectomy, ● Giving the person and significant others complete
Cholecystectomy, learning / teaching guidelines regarding surgery.
Pancreatectomy ● Instructing and demonstrating exercises that will
3. Reparative  Repair damage benefits the person during post op period.
organ. ● Planning for discharge and any projected changes in
 “oorhapy, pexy”; lifestyle due to surgery.
repair of
congenitally  PREPATION FOR SURGERY
defective organ Informed Consent
 Multiple Wound The process in which patients are given important information,
Repair, including possible risk and benefits about medical procedure,
Episiorrhapy
treatment, genetic testing, or a clinical trial
(suturing),
Orchiopexy, Purpose of Consent
Herniation Repair ● To ensure that the client understand the nature of the
4. Reconstructive  Restore/ change treatment including the potential complications.
appearance ● To ensure that the client’s decision was made without
 Mammoplasty,
pressure.
Rhinoplasty
● To protect the client against unauthorized procedure.
5. Palliative  Relieve distressing
sign and ● To protect the surgeon and hospital against a client who
symptoms, not claims that an unauthorized procedure was performed.
necessarily to cure Circumstances Requiring Consent
the disease.
● Any invasive procedure where scalpel, scissors, suture,
 Gastrostomy Tube
Insertion, IJ and electrocoagulation may be used.
Catheter Insertion ● Procedures requiring sedation or anesthesia.
● Procedures involving radiation.
Examples:
● Non-surgical procedure that carries more than slight risk
Tonsilectomy Curative
to patient.
Pap Smear Diagnostic
Osteoplasty Reconstructive Who can sign the consent?
Perineorrhapy Reparative ● Patient who is legally aged and mentally capable
Trachelorrapy Reparative ● If minor or incompetent, a responsible family member
Colostomy creation Palliative (next of kin), power of attorney, or legal guardian.
● Emancipated Minor – Married minor

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 In an EMERGENCY situation  Cardiovascular Assessments
● No consent is necessary as long as every effort must be Assess for:
made to contact the patient’s family. ● Underlying cardiovascular conditions (Hypertension,
 ROLES OD MEDICAL TEAM IN CONSENT Myocardial Infarction, etc.)
● Maintenance drug (Blood Thinners,
● Surgeons: MUST OBTAIN THE CONSENT; explain the
Antihypertensives, etc.)
procedure.
Nursing Intervention:
● Nurses: Acts as a WITNESS; making sure patient
1. Surgery may be deferred until medical treatment can
willingly signs it.
be modified to meet cardiac tolerance. (Cardio-
 ASSESSMENT AND INTERVENTIONS Pulmonary Clearance.
 Basic Assessments 2. Blood thinners must be stopped 3 days before
 HEALTH HISTORY surgery to prevent bleeding.
 PHYSICAL EXAM
 Hepato-Renal Assessments
 Vital Signs
Assess for:
 Signs of Abuse:
● Underlying hepatic and renal conditions (Liver
> Bruises of different healing stage
Cirrhosis, Hepatitis, Chronic Kidney Disease, Oliguria,
> Broken bones
etc.)
> Changes in eating & eating habits
Nursing Intervention:
 LABORATORY EXAM
1. Hepato-renal conditions must be improved because
Complete Blood – RBC, Hemoglobin, and
Count liver and kidney metabolizes and excretes the
Hematocrit are important to the
oxygen carrying capacity anesthesia.
– WBC are indicator of immune 2. Have patient void prior to transport to Operating
function Room.
Blood Cross – To determine in case blood 3. Insert urinary catheter as prescribed (To monitor
Matching transfusion is elimination status)
required during or after surgery The exception is surgery that is performed as a life-
Serum ● To evaluate fluid and
saving measures or that is necessary to improve urinary
Electrolyte electrolyte status
PT, PPT ● Measure time required for function such as Obstructive Uropathy.
clotting to occur
Fasting Blood ● High level may indicate  Endocrine Assessments
Glucose undiagnosed DM Assess for:
BUN/ Creatinine ● To evaluate renal function ● Underlying endocrine conditions (Diabetes, Thyroid
ALT/AST ● To evaluate liver function
Disorders, etc.)
Urinalysis ● Determine urine composition
Nursing Intervention:
Assess for: 1. Endocrine conditions must be improved because:
● BMI > Hyperglycemia – Increases risk for surgical wound
● Deficiencies in specific nutrients infection.
● Metabolic abnormalities > Hypoglycemia – may develop intraop or post op due
● Hydration Status to px is under NPO prior to surgery.
Nursing Intervention: > Hyperthyroidism – Risk for Thyrotoxicosis
1. Review the surgeon’s prescription for NPO > Hypothyroidism – Risk for Respiratory Failure
2. Insert IV line per hospital policy
2. Use of Corticosteroids must be reported to the
 Dental Assessments anesthesiologist (Corticosteroids is Anti-inflammatory)
Assess for:  Hepato-Renal Assessments
● Dental Carries
Assess for:
● Dentures
● Underlying hepatic and renal conditions (Liver
● Dental Prosthesis
Cirrhosis, Hepatitis, Chronic Kidney Disease, Oliguria,
Nursing Intervention:
etc.)
1. Remove prior to procedure because it may cause
Nursing Intervention:
obstruction during intubation
Hepato-renal conditions must be improved because liver
2. Place dentures in a glass of water
 Psychological Assessments
 Drug and Alcohol Assessments
Assess for:
Assess for: ● Presence of fear and anxiety
● Alcohol Intoxication Nursing Intervention:
● Current drug use 1. Answer any questions or concerns that the client may
Nursing Intervention: have regarding surgery.
1. Patient frequently deny or attempt to hide it, nurse 2. Allow time for privacy for the client to prepare
must ask frank question, psychologically for surgery.
2. If emergency: local, regional, or spinal anesthesia 3. Provide supports and assistance as needed
may be used.
 Psychological Assessments
 Respiratory Assessments
Assess for:
Assess for:
● Any rituals and spiritual beliefs prior to procedure
● Underlying respiratory condition (Asthma, Pneumonia,
Nursing Intervention:
etc.)
1. Respect and support the rituals and any spiritual
● Smoking history (nicotine causes vasoconstriction) beliefs.
Nursing Intervention: 2. Refer to clergy and spiritual advisers as needed.
1. Patient is instructed smoking cessation at least 24 3. Therapeutic communication to allow ventilation of
hours prior to surgery. feelings.
2. Postpone surgery if with respiratory infection because
adequate ventilation may be compromised.

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 SPECIAL CONSIDERATIONS ● Instruct the client coughing techniques.
AMBULATORY SURGERY PATIENT
 ”Same day” surgery. (Patient is expected to go home
after surgery)
Nursing Intervention:
1. The nurse must quickly and comprehensively assess
and anticipate the patient’s need.
2. Be sure that the patient and family understand the flow
of operation.
3. Ensure any plans for follow-up home care are in place,
if needed.
ELDERLY PATIENTS
IMPORTANT NOTES:
- The older the person, the more it is risky to have
surgery.
- Elderly people frequently do not report symptoms
because they accept such symptoms as part of the
aging process.
OBSESE PATIENTS
IMPORTANT NOTES:
- Obesity increases the risk and severity of surgical
complications.
- Obesity increases the risk of technical and mechanical
problems during surgery (Wound Dehiscence).
- Patient tends to breathe poorly when supine (which is
the common position during surgery).
- Obese patient often to have difficulty in finding good site
for IV Insertion.
DISABLED PATIENTS
IMPORTANT NOTES:
- Individuals who are hearing-impaired may need a
translator or some alternative communication system ● Enemas are not commonly prescribed unless the patient
preoperatively. is undergoing abdominal or pelvic surgery.
- Patients’ needs must be identified as a factor in the
preoperative evaluation and clearly communicated to  IMMEDIATE PRE-OP NURSING INTERVENTIONS
personnel.
● Assist the patient in changing hospital gown
● Cover the head completely with cap
 PREOPERATIVE TEACHINGS ● Inspect the mouth, dentures and plates must be
removed
● Inform the client about what to expect postoperatively.
● Remove all jewelries and body piercing.
● Inform the client to notify the nurse if the client
● If the patient objects in removing wedding ring, secure it
experiences any pain postoperatively.
with tape.
● Inform the client that requesting an opioid after surgery
● Patient should void first before going to OR.
will not make the client a drug addict.
● All valuable articles are given to family members or
● Instruct the client how to use noninvasive pain relief
labelled it clearly and store it in a safe and secure place
techniques (relaxation, distraction, guided imagery).
according to hospital policy.
● Inform the client of any invasive devices that may be
● If preanesthetic medication is administered, the patient
needed after surgery (NGT, Urinary Catheter, IV
is kept in bed with the side rails raised.
Catheter).
● The completed chart (with the preoperative checklist
● Instruct not to pull any invasive devices
and verification form) accompanies the patient to the
● Demonstrate the use of patient controlled analgesia
OR with the surgical consent form attached.
(PCA) pump if prescribed and explain that the client is
● Transfer the patient to the holding area/presurgical suite
the sole person who should push the button to
30-60 minutes before anesthetic agent is administered.
administer medication.
● Instruct the client deep breathing techniques.
INTRA OPERATIVE PHASE
Starts: Transfer of patient onto the Operating Table
Ends: Admission to the Post Anesthetic Care Unit (PACU)
The Surgical Team
1. Surgeon • Performs the surgical procedure
sterile • Heads the surgical team
• Has the ultimate responsibility
for performing the surgery in an
effective and safe manner
2. • Assess the patient before
Anesthesiologist surgery, selects anesthesia, and
unsterile administers it.
• Intubate patients as necessary.
• Assesses and manages
condition throughout the
procedure.
3. Scrub nurse • Performs surgical hand scrub.
sterile • Setting up the sterile tables.
• Preparing sutures, ligatures, and
special equipment.
• Assisting the surgeon and
surgical assistant during the
procedure by anticipating the
instruments and supplies that
will be required.

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4. Circulating nurse • Main responsibilities Laser eye • Protects the eyes from the intense light
unsterile include: wear created by laser surgery
 Verifying consent Gloves • Non Sterile – Donned for clean
 Coordinating the procedures
team • Sterile – Donned for sterile procedures
 Ensuring
cleanliness  PRINCIPLES OF SURGICAL ASEPSIS
 Proper temperature ● All surgical supplies, instruments, sutures, dressings,
and humidity gloves, covers, and solutions that may come in contact
 Lighting and safe with the surgical wound or exposed tissue must be
function of sterilized before use.
equipment and the ● During surgery, only personnel who have scrubbed,
availability of gloved, and gowned touch sterilized objects.
supplies and ● The surgeon, surgical assistants, and nurses prepared
materials. themselves by scrubbing their hands and arms with
• Monitors aseptic practices antiseptic soap and water or alcohol-based product or
to avoid breaks in technique scrubless soap is used to prepare for surgery.
while coordinating the ● Requires meticulous cleaning and maintenance of the
movement of related OR environment.
personnel as well as ● An area of the patient’s skin larger than that requiring
implementing fire safety exposure during the surgery is meticulously cleansed,
precautions. and antiseptic solution is applied.
 BASIC GUIDELINES FOR MAINTAINING SURGICAL
SCRUB NURSE, together with CIRCULATING NURSE counts all ASEPSIS
sponges, instruments, and needles to be sure they are ● Only sterile surfaces/articles may touch other sterile
accounted for and not retained as a foreign body in the patient. surfaces/articles.
● Gowns of the surgical team are considered sterile in
 THE SURGICAL ENVIRONMENT front from the chest to the level of the sterile field.
● The surgical suite is behind double doors, and access is ● Only the top surface of a draped table is considered
limited to authorized personnel. sterile.
● External precautions include adherence to principles of ● Sterile supplies, including solutions, are delivered to a
surgical asepsis. sterile field or handed to a scrubbed person in such a
● Strict control of the OR environment is required, way that the sterility of the object or fluid remains intact.
including traffic pattern restriction. ● The movements of the surgical team are from sterile to
● To provide the best possible conditions for surgery, the sterile areas and from unsterile to unsterile areas.
● Movement around a sterile field must not cause
OR is situated in a location that is center to all
contamination of the field.
supporting services. ● Whenever a sterile barrier is breached, the area must
● To help decrease microbes, the surgical area is divided be considered contaminated.
into three zones: ● “When in doubt, throw it out!” Item of doubtful sterility
• Area in the operating room that are considered unsterile.
UNRESTRICTED interferes with other
ZONE departments.  INSTRUMENT DECONTAMINATION PROCESS
• Street clothes are allowed.
1. Cleaning Removal of foreign material from
• Ex: Patient reception area and
holding area. the instrument by a combination of
mechanical means (scrubbing) and
• Area in the operating room
SEMI- chemical means (detergents
where scrub attire is required.
RESTRICTED 2. Boiling Uses 100c boiling water to destroy
• Ex: Areas where surgical
ZONE most pathogens except pores.
instruments are processed.
3. Pasteurization Exposure to hot water with
• Scrub clothes, shoe cover,
temperature of 60-80c for 30
RESTRICTED caps, and mask are worn.
minutes
ZONE • Includes operating room and
sterile core area. 4. •
Chemical Items are soaked in a disinfectant.
Disinfection Used for heat labile instruments
that cannot be boiled or sterilized
 THE SURGICAL ATTIRE 5. Sterilization• Process in which all pathogens are
destroyed including spores.
Scrub suit • Two-piece pant suit
Types: Chemical Sterilization,
• Worn in the semi-restricted area
Autoclaving, and Dry Heat
• Must fit the body properly
Sterilization.
• Waistline drawstrings must be tucked in
• Wet or soiled garments should be
changed
 ANESTHESIA
Head • Should cover the hair completely.
 A state of narcosis (severe central nervous system
cover • Worn in semi-restricted area.
• Never comb your hair when wearing a depression produced by pharmacologic agents),
scrub suit. analgesia, relaxation, and loss of reflex.
• Disposable caps are preferred.
TYPES OF ANESTHEISA
• Bald head also causes contamination
by shedding squamous cells. 1. General Anesthesia: tulog si patient
Shoes and • Worn in semi-restricted area. • A reversible consisting of complete loss of
Shoe • Should be comfortable and puncture consciousness that provides analgesia, muscle
cover resistant. relaxation, and sedation.
• Shoe covers are worn during Route of Administration: INTRAVENOUS
procedures with expected Examples:
spills/splashes of blood or body fluids. - Barbiturates
Surgical • High infiltration masks decreases the - Benzodiazepines
mask risk of post wound infection - Non-barbiturate hypnotics
• Worn inside the restricted area at all - Dissociative Agents
times - Opiod Agents
• Should cover nose and mouth
completely
Eye wear/ • Protects the eyes from splashing of
Face blood and body fluids or from debris
shield when bone drilling is performed.
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Route of Administration: INHALATION – Inhaled anesthetics
include volatile liquid agents and gases. a. Supine Position
 Patient is flat on the back
Volatile Anesthetic agents - Halothane  Both arms are position at the side of the table.
Liquid produce anesthesia (Fluothane)  Used for procedures of anterior surface of the body
Agents when their vapors are - Enflurane such as abdominal operation.
inhaled (Ethrane) b. Tendelenburg’s Position
- Isoflurane  Used for surgery on the lower abdomen and pelvis to
(Forane) obtain good exposure by displacing the intestines into
- Sevoflurane the upper abdomen.
(Ultrane) c. Reverse Trendelenburg
 Used for thyroidectomy, laparoscopic
Gas Agents are  Nitrous Oxide cholecystectomy to displace the stomach contents
Anesthetic administered by into lower abdomen.
Agents inhalation and are d. Fowler’s Position
always combined with
 Used for shoulder, dental, nasopharyngeal, facial,
oxygen.
and breast reconstruction.
Stages of General Anesthesia e. Lithotomy Position
Stage 1 (BEGINNING ANESTHESIA / INDUCTION)  Used for perineal, vaginal, urologic, and rectal
- Feeling of detachment procedure.
- Drowsy/dizziness f. Prone Position
- Hallucination occurs  Used for perineal, vaginal, urologic, and rectal
- Ringing, roaring or buzzing in the ears procedure.
- Keep quiet because exaggerated noises are heard by g. Jack-Knife Position
the patient  Hips are positioned over the center break of the
Stage 2 (EXCITEMENT / DELIRIUM) operating table.
- Pupils are dilated, pulse rate are rapid, and may have  Done for rectal procedures
irregular respiration. h. Lateral Position
- Because of uncontrolled movement of the patient,  Used for renal surgery
restraints are necessary
Stage 3 (SURGICAL ANESTHESIA)  PREVENTING INTRA OP POSITION INJURIES
- Patient is unconscious and lies quietly
- Pupils are small but reactive to light Preventing Position Injury
- Respirations are regular, the pulse are normal ● The patient should be in as comfortable a position as
- Skin is pink or slightly flushed possible, whether conscious or unconscious.
Stage 4 (MEDULLARY DEPRESION / DANGER) ● The operative field must be adequately exposed.
- Too much anesthesia has been administered ● An awkward position, under pressure on body part, or
- Shallow respiration, weak and thread pulse use of stirrups should not obstruct the vascular supply.
- Widely dilated pupils ● Respirations should not be impeded by pressure of
- Death may occur
- If this stage develops, discontinue anesthesia and arms or chest or by a gown that constricts the neck or
initiate respiratory and circulatory support. chest.
● Precaution for patient safety must be observed,
particularly with thin, elderly, or obese patient and those
2. Regional Anesthesia: mata si px; unless given pampatulog
with a physical deformity.
• Anesthetic agents are injected around nerves so that
the region supplied by these nerves is anesthetized.  POTENTIAL INTRA OP COMPLICATIONS
Route of Administration:
NAUSEA AND VOMITING
EPIDURAL ANESTHESIA  Administer antiemetics preoperatively or
- Achieved by injecting a local anesthetic agent into the intraoperatively as ordered to counteract
epidural space that surrounds the dura mater of the possible aspiration.
spinal cord.  Turn patient’s head to side or lower the head
- Advantage: Absence of Headache of bed to prevent aspiration.
- Disadvantage: Greater technical challenge of  Suction saliva and vomitus.
introducing the anesthetic agents into the epidural rather RESPIRATORY COMPLICATIONS
than the subarachnoid space.  May lead to brain damage if not recognized.
 Monitor oxygen saturation all through-out
SPINAL ANESTHESIA
operation.
- Extensive conduction nerve block that is produced when
a local anesthetic agent is introduced into the  Administer oxygen as ordered.
subarachnoid space at the lumbar level. (L4-L5)  Check peripheral perfusion frequently.
- Produces anesthesia of the lower extremities, perineum, HYPOTHERMIA
and lower abdomen.  Patient’s temperature may fall during
anesthesia.
MODERATE SEDATION  May occur as a result of a low temperature
- Previously known as “Conscious Sedation” in the OR, infusions of cold fluids, inhalation
- Form of anesthesia that involves the IV administration of of cold gases, open body wounds, and
sedative or analgesic medications to reduce patient’s decreased muscle activity.
anxiety and to control pain during diagnostic or  Give warm IV and irrigating fluids as
therapeutic procedures. ordered.
 Wet gowns and drapes must be removed
MONITORED ANESTHESIA CARE (MAC) promptly.
- Previously known as “Monitored Sedation”
MALIGNANT HYPERTHERMIA
- Administered by an anesthesiologist who must be
prepared and qualified to convert to general anesthesia  Increase temperature
if necessary.  Identify meds that causes increase
temperature, and then stop the infusion.
LOCAL ANESTHESIA  Give antipyretics as ordered.
- Injection of a solution containing the anesthetic agent
into the tissues at the planned incision site.

 SURGICAL POSITIONS POSTOPERATIVE PHASE

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 Starts: Admission to the Post Anesthetic Care Unit (PACU - Assess for HYPOTENSION. It can result from blood
Ends: Follow-up evaluation in the clinical setting or at home loss, hypoventilation, position changes, pooling of the
 POST ANESTHETIC CARE UNIT blood extremities, or side effects of medication and
 Also called “Recovery Room” anesthetics.
 Located adjacent to the operating room suit. - Assess for SHOCK – one of the most serious
 PHASES OF POST ANESTHETIC CARE postoperative complications. WOF: HypoTachyTachy
PHASE 1 Care of surgical patients immediately after surgery  Give IV fluids and oxygen as ordered
and for the patient whose condition warrants close
monitoring and intensive care is provided. - Assess for HEMORRHAGE – Copious escape of blood
PHASE 2 • Patient is prepared for discharge. from blood vessels.
• Also known as step-down unit.  Signs: - Hypotachytachy
• Patient may remain in phase II unit for as long  Disorentation
as 4-6 hours.  Restlessness
 ADMITTING PATIENT TO THE PACU  Oliguria
Checkpoint Question:  Cold and pale skin
Who is responsible for transporting patient from operating  Frequent swallowing (for throat
room to the post anesthetic care unit? surgery)
a) Anesthesiologist
 Management:
b) Surgeon
c) Scrub Nurse
d) Circulating Nurse
 During transport, the anesthesia provider remains at
the head of the stretcher to maintain the airway.
 “The nurse who admits the patient to the PACU
reviews the following information with the
anesthesiologist”
 IMPORTANT INFORMATIONS TO REVIEW  Transfuse blood or blood products
 Medical diagnosis and type of surgery performed
 Determine the cause of bleeding
 Pertinent past medical history and allergies  Inspect surgical site and incision for
 Patient’s age and general condition, airway patency, bleeding
vital signs  Place patient in shock position
 Medical diagnosis and type of surgery performed
 Pertinent past medical history and allergies
 Patient’s age and general condition, airway patency, RELIEVING PAIN AND ENXIETY
vital signs - Monitor the patient’s psychological status, manage pain,
 Anesthetics and other medications used during the and provides psychological support to relieve the patient
procedure (ex: opioids and other analgesic agents, fears and concerns.
muscle relaxant, antibiotics). - Opioid analgesics are administered mostly in the IV to
 Any problem that occurred in the operating room (ex: provide immediate pain relief.
Extensive hemorrhage, shock, cardiac arrest)
 Pathology encountered (if malignancy is an issue PREVENTING RESPIRATORY COMPLICATIONS
during surgery, the nurse needs to know whether the - Patient is at risk for respiratory complications due to
patient and/or family have been informed). depressive effects of opioids medications, decreased
 Fluid administered, estimated blood loss and lung expansion secondary to pain, and decreased
replacement fluids. mobility.
 Any tubing, drains, catheters, or other devices.
 Specific information about which the surgeon, Common Respiratory Complications:
anesthesiologist, or anesthetist wishes to be notified
(ex: blood pressure or other vital signs anomalies). ATELECTASIS Alveolar  Decrease
collapse; breath sound
 NURSING MANAGEMENT IN THE PACU incomplete  Crackles
expansion of upon
ASSESSING THE PATIENT
lungs. auscultation
- Assess patient’s airway, respiratory function,
 Cough
cardiovascular function, skin color, level of
consciousness, and the ability to respond commands. PNEUMONIA  Fever and
- Check the surgical site for drainage or hemorrhage and chills
make sure that all drainage tubes and monitoring lines  Tachycardia
are connected and functioning.  Tachypnea
- Monitoring vital signs every 15 minutes
- Administer postoperative analgesics PULMONARY Accumulation of
- In patient with spinal anesthesia, maintain flat on bed CONGESTION fluid in the lungs
due to a
position for 6 hours to prevent spinal headache.
weakened
MAINTAINING PATENT AIRWAY cardiovascular
- Assess for hypopharyngeal obstruction, signs of system.
occlusion include choking, noisy, and irregular
respirations.
- Suction mucous or vomitus that is obstructing the
trachea (caution with patient who has had a
tonsillectomy or other oral and laryngeal surgery)

1. Encourage the patient to turn frequently, take deep

breaths, cough, and use the incentive spirometer at
MAINTAINING CARDIOVASCULAR ACTIVITY
least every 2 hours.
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 2. Careful splinting of abdominal or thoracic incisions sites
help the patient to overcome the fear that the exertion of
coughing might open the incisions.
3. Administer oxygen as ordered.
4. Coughing is contraindicated in patient with surgical
operations in the head due to risk for increase
intracranial pressure.

PREVENTING DEEP VEIN THROMBOSIS

 Signs and symptoms:
 Homan’s Sign – Calf pain upon
dorsiflexion
 Painful swelling of the entire leg
 Slight fever, chills, perspiration

- Nursing Intervention:
1. Hydrate patient adequately to prevent
hemoconcentration.
2. Encourage leg exercises and ambulate patient
as soon as permitted by the surgeon.
3. Avoid restricting devices such as tight straps
that can constrict and impair circulation.
4. Avoid rubbing or massaging calves and thighs.
5. Instruct to avoid standing or sitting in one place
for prolonged periods and crossing legs when
seated.
6. Assess distal peripheral pulses, capillary refill,
and sensation of lower extremities.
7. Initiate anticoagulation therapy as ordered.

PREVENTING WOUND INFECTION

 Signs and symptoms:
 Redness, excessive swelling,
tenderness, warmth.
 Red streaks in the skin near the
wound.
 Pus and foul smelling wound.
 Tender, enlarged lymph nodes closest
to the wound.
 Fever and chills
 Nursing Intervention:
1. Keep wound dressing intact
2. Used strict sterile technique when dressings
are changed.
3. Ensure all drains are working properly.
4. Wound irrigation may be done as ordered.
5. Administer antibiotics as ordered.
6. Assess for wound dehiscence and evisceration
 Wound dehiscence: disruption in
wound edges.
 Wound evisceration: protrusion of
viscera through an abnormal wound
opening.
 COVER WITH STERILE GAUZE
SOAKED IN NORMAL SALINE
SOLUTION!

7
[janinacncno]