ADRENAL GLAND developed ➡️therefore increasing blood pressure ➡️

giving more blood to the brain

MECHANISM OF INFLAMMATION
Undergoes surgery > incision > tissue injury > SNS triggered
> Adrenal Medulla release NE causing Vasoconstriction >
>Norepinephrine >Cortisol
Adrenal Medulla Adrenal Cortex injured tissue release chemical mediators (Ex. Histamine,
->vasoconstriction ->stimulates liver to
Bradikinin, Prostaglandin) causing Vasodilation > more blood
perform gluconeogenesis
will go to the injured site causing Redness and Warmth to
and glycogenolysis
touch because of increase blood supply. > d/t release of
Histamine > increase capillary permeability > albumin goes
>Epinephrine >Aldosterone
out intravascularly to interstitial space thus Swelling happens.
-> Increase HR -> orders renal tubules to
> d/t increase blood suppy there is pressure on the nerve
reabsorb SODIUM ;
endings beneath the skin causing Pain and there is Loss of
where sodium goes water
Function.
follows.
- You have to clean the site very well because they are
>Testosterone
going to create an incision, if it is not clean bacteria
->Sex hormone
will go in.
- Pain is localized
Adrenal cortex
- WBCs phagocytize (a process called endocytosis) > it
- Cortisol will order the liver to peform glycogenolysis
will ingest bacteria in the form of lysosomes
and gluconeogenesis because patient is in NPO >
- Albumin (maintains osmotic pressure) will be
when there is increased stress > hypermetabolism
allowed to go out from the intravascular space to the
occurs > more glucose is needed because cells will
third space > accumulation of albumin in the 3rd space
become hungry.
> osmosis (movement of water from higher to lower
- Glycogenolysis (glycogen-glucose) > glucose is
area of concentrations) > water will go out
released because patient is undergoing surgery >
- Hypertonic solution due to the release of albumin to
under stress > increased metabolism > increasing
the 3rd space.
activity of cells, needing more food > cortisol orders
Blood vessel dysfunction
the liver to produce more glucose > if the liver runs
- The capillaries connect the arterioles and venules
out of glycogen, it will convert fats and proteins to
o This is where exchange of gases occurs
glucose (gluconeogenesis), which is not good.
Functions of the inflammatory
- patient is receiving IV fluids because of this to
- Prevents spread of the damaging agents
counteract loss of glucose
- Disposes of cell debris and pathogen
- aldosterone is a glucocorticoid produced by the
- Sets the stage for repair
adrenal cortex. It will reabsorb more Na (sodium),
- Inflammation sets the stage for healing > vasodilation
where sodium goes water follows.
> good amount of blood will go to the damaged area
- Patient will be bleeding > needing increased volume
> good amount of nutrients, oxygen, and WBCs will
> aside from bleeding client is in NPO, client also
also go to the area > flow in the blood in the wound is
loses fluids through respiration > no fluids are
already preparing the site for healing.
coming in to the client’s body > sodium attracts water
- WBCs are activated during inflammation
to keep fluid balance
- There is increase in heat during inflammation
Difference of aldosterone from ADH (anti-diuretic
because heat will make it hard for the bacteria to
hormone)
survive.
- Anti-diuretic hormone is released by the posterior
o Prevent the spread of damaging agents
pituitary gland. This will order the renal tubules to
reabsorb water decreasing fluid output. o Forms a barrier to prevent the bacteria from
- Aldosterone will reabsorb sodium which will attract metastasizing
water. Histamine – produced by circulating basophils, platelets and
Adrenal Medulla mast cells adjacent to vessels
- Releases two catecholamines: Norepinephrine and - (vasodilation, increased vascular permeability,
Epinephrine endothelial activation)
- Epinephrine increases cardiac rate because patient is Serotonin – produced mainly within platelets dense body
bleeding due to surgery > the heart has to pump granules (vasodilation, increased vascular permeability)
rapidly in order to give more blood to the other
systems of the body (blood contains oxygen and Blood vessel dysfunction
nutrients) - Capillaries leak out their walls
- Norepinephrine causes vasoconstriction - Caused by severe infection (sepsis) and certain
(compensatory mechanism): Blood pressure goes diseases
down (hypotension) due to bleeding ➡️decreasing
Capillary permeability
blood supply to the brain ➡️vasoconstriction ➡️
arteries constricted ➡️no perfused bleeding
 - Due to release of histamine of the injured tissue it (inguinal hernia)
will alter capillary permeability and enlarge the pores -satisfies
of the blood vessels. Because of the enlargement of patient’s desires
pores this will cause the protein albumin to go out but not needed to
(albumin is the protein that controls the oncotic preserve life or
pressure inside the vessel) this will cause the water to function.
go out as well, from the intravascular space to the (cosmetic
third space causing swelling. surgery)
o Hypotonic: albumin inside the capillary
o Hypertonic: albumin outside the capillary SURGICAL PROCEDURES CAN BE BROADLY
o Oncotic: fluid retained in blood vessels CATEGORIZED AS:
because of pressure - ELECTIVE that which is planned
- EMERGENCY that which is unplanned
GENERAL MANIFESTATION OF INFLAMMATION Who is the most important part of the health care team?
>Body weakness - The patient is the most important part of the health
>Loss of Appetite care team.
>Fever - With the patient, nothing will be done or procedure
will not push through
Purposes of surgery
Diagnostics – confirmation of the suspected diagnosis (ex. Perioperative nursing
Biopsy, Endoscopy, Culture) - The Preoperative Phase – decision to proceed w/
- To determine whether disease is benign or malignant. surgical intervention and ends w/ entry in the
- Determines the cause Operating Room
Explorative – confirms the type of and extent of the disease - The Intraoperative Phase – entry in the Operating
(ex. Laboratory) Room to admission of the patient to the Recovery
Reconstructive – repair of physical deformities, improves Room or PACU
appearance. (Ex. Rhinoplasty, Mammoplasty, skin grafting) - The Postoperative Phase – admission of the patient to
Currative – diseased or damaged body organ or structure is the Recovery Room or PACU to discharge of the
removed or repaired. (Ex. Appendectomy, Amputation, patient or follow-up evaluation in clinical setting.
hysterectomy, fixation of fractures)
Palliative – alleviates pain or other disease symptoms; slows Pre-operative phase
progression of disease but does not cure (Ex. Nerve blocks Preoperative interview
placement of feeding tubes) - Meet the patient at eye level & introduce yourself by
- Patient is healthy but there is a problem name & role
o The nurse should ask the patient to tell her
Surgery based on urgency full name rather thin asking if she is a
CLASSIFICATIO INDICATIONS EXAMPLES certain patient because there might be
N another patient by that name on the
Emergent – Px Preserved the -Severe schedule.
requires immediate function of body bleeding - Nurses should not start the physical assessment or ask
attention. ; it may parts or life of -Gunshot the patient’s name without first identifying
be life threatening the patient. -Fracture skull themselves and their role
c/o within 1-2 o To relieve the patient’s anxiety in the new
hours ; w/o delay environment of the surgical experience
Urgent – px c/o within 24-48 -Repair of
requires prompt hours. incision Preoperative assessment
attention -drainage of History of previous surgery
wound - to avoid problems previously encountered
infection o Ex: The patient has one lung left and as a
Required – px Planned -cataracts nurse, emphasize breathing and coughing
needs to have exercises because respiratory complication
surgery is the number one complication of surgery.
This is due to the anesthesia received during
Elective – px The patient is in -repair of scar surgery (exchange of gases will not be
should have optimal health, -vaginal repair good).
surgery. something History of allergies
wrong but can - Patient might be allergic to seafood which contains
wait, done iodine
before the o Disinfectant used in hospitals
disease affects of o Latex allergies
threatens the
quality of life.
Chronic disease history o review the risks, benefits, &
- DM, HPN, Cancer, Asthma alternatives to the planned
- To provide necessary medications procedure
- To be alert for possible complications - If the patient verbalizes that he or she does
not understand the procedure that is planned,
DM: patient is hyperglycemic (blood is filled with sugar), it is the nurse’s responsibility to notify the
wound would not immediately heal surgeon of this lack of understanding
right away
HPN: patient might be taking aspirin which causes bleeding. - The nurse should not teach about the
Should be stopped for five to seven days before surgery procedure; the surgeon needs to do this

Smoking history - If the patient is a:

- increase risk for postoperative complications o Minor
o Unconscious
Smoking paralyzes cilia (found in the lining of the trachea) o Mentally incompetent
resulting to pneumonia o The written permission may be given by a
- The cilia contracts one thousand times per minute in responsible family member
an upward motion because environment is not sterile.
This mechanism would prevent particles to reach the - When immediate medical treatment is needed to
lungs preserve life and the patient is incapable of giving
- Sneezing and coughing are protective mechanisms consent,
The next of kin may give consent
Smoking produces carbon monoxide
- The hemoglobin inside the red blood cells are carriers - If reaching the next kin is not possible:
of oxygen and carbon dioxide but the presence of The physician may institute treatment without
carbon monoxide makes the hemoglobin two hundred written consent.
times attracted to carbon monoxide affecting o However, healthcare personnel must make
oxygenation every effort to obtain consent by phone
calls.
- Nicotine causes vasoconstriction > less blood supply - If it is a true lifesaving emergency, consent may be
> slow wound healing obtained over the telephone from the patient’s next
of kin or guardian
Current height and weight - The surgeon must obtain the telephone consent
- determine drug dosage calculations - If it is a true lifesaving emergency, the surgeon
often is already in surgery, the nurse makes the
Vital signs telephone call and another nurse will witness the call
- to detect abnormalities - Consent can be waived in situations in which no
- provide baseline data family is available
Current medications Muscles of respiration
- medications that can affect coagulation status - External intercostals
- Internal intercostals
Informed consent - Diaphragm – major muscle for respiration
- An active, share decision-making process between - Respiratory complication is the most common
the provider and the recipient of care adverse effect of anesthesia
- It protects the patient, the surgeon and the hospital o anesthesia also affects the medulla oblongata
and its employees.
which is the breathing center of the brain
When is it necessary?
Post-operative exercises (To be taught pre-op)
1. When it is invasive.
- Breathing exercises
2. When it requires anesthesia
- Coughing and Splinting
3. When it involves radiation
- Incentive Spirometry
4. When there is a risk of potential harm
- Leg exercises
- The operative consent must be signed before any
- Early Ambulation
preoperative medication is given.
- Range-of-Motion Exercises
- The surgeon is legally responsible for obtaining the
Deep breathing exercises
patient’s informed consent.
- Dilates the airways
- It is the surgeon's responsibility
- Stimulates surfactant production
o to discuss the planned procedure
- Expands the lung tissue surface thus improving
respiratory gas exchange
 - Dilated airways > increased lumen of bronchi > better - Immobility > no muscular contraction > no pushing
passing of oxygen and carbon dioxide > stimulates of blood going back to the heart > blood becomes
surfactant production > decreasing surface tension > viscous > clotted blood will be pushed > goes to the
decreased attraction of water molecules lungs thus pulmonary edema > goes to the brain,
o Surfactant: a phospholipid found in the type thus, CVA (cerebrovascular accident)
II alveolar cells
o Surfactant is present as early as 8 months Early ambulation
inside the womb - Ambulation will move secretions, increase peristalsis,
o If the surface tension is increased, it results prevent venous stasis (accumulation of blood in the
to the collapse of the alveoli lower extremities) that can develop venous
o Alveoli: Three million, one fifty each lung; thrombosis
comparable to a tennis court
- Pain after surgery > shallow breathing (inhaling Range of motion exercises
deeply = pain) - To prevent joint rigidity and muscle contractures
- Immobilized (bed ridden because of pain): tendency
of accumulation of goblet cells causing mucus to Preoperative teaching
partially obstruct airways - Do this close to the surgery date
- Reduces anxiety
Diaphragm - The timing of pre-op teaching is highly
- The diaphragm is the major muscle of respiration individualized.
- Deep breathing causes it to descend, thereby - Ideally there will be enough time for the nurse to give
increasing the ventilating surface instructions and answer questions
- Often the client is admitted on the day of surgery.
Coughing exercises It is imperative that the client receives instructions
- Loosens secretions and forces them into the brochus before this time so that the nurse can simply reinforce
to be expectorated or suctioned. instructions and answer questions
- Sitting upright shifts abdominal organs away, due to - But if the teaching is done too far in advance, the
gravity, from the lungs, enabling greater expansion. client will forget the information
o Mucus accumulates and can partially Client preparation
obstruct flow of oxygen and carbon dioxide
- Patients should be asked to perform deep breathing & NPO Status
incentive spirometry 10 times every hour holding - To prevent aspiration
each breath for three seconds during waking hours o 8-10 or 10-12 hours before surgery. Anesthesia >
to prevent: Decrease action of the smooth muscles in the
o atelectasis intestines, thus, decrease peristalsis > Increase
o pneumonia secretions > accumulation of gastric secretions in
- Contraindications the stomach > gag reflex not active > No
o Cranial surgeries because of increased ICP epiglottis > substances can regurgitate > vomit
may enter lungs > Thus aspiration and
o Eye surgeries because of increased
Pneumonia
intraocular pressure
Adults are advised to fast for:
Splinting
- 8 hours after eating fatty food
- Small pillow/rolled blanket or towel/hands (middle
- 4 hours after ingesting milk products
fingers should be touching)
- Clear liquids up to 2 hours before an elective
- For the suture not to break
procedure
- If patient has muscle weakness, use nurse’s hand
Intravenous access
Incentive spirometry
- For fluid and replacement
- Sitting is the best position
- Administering IV medications
- Promotes lung expansion and increases respiratory
- Providing a route for emergency medication
function
- Act as nutrition
- Promotes maximal inspiration and increased
- Administering blood products
cardiac output
o Profuse bleeding: route to give BT
- Patient is sited > exhale normally > put mouthpiece
to lips > seal with the lips ➡️breathe through the Oxygen
mouth > hold for three seconds > remove mouthpiece - Cannula- 2-6 L
> exhale normally through the mouth - Mask- 5L for it allows CO2 to be removed.
o Minimum of 5L
Leg exercises o Whenever a patient exhales, he/she is giving out
- Prevent venous stasis and help push blood to the right
carbon dioxide. The pressure inside is going to
side of the heart
push the carbon dioxide out of the pores so that
that patient won’t inhale it again
 - Venturi- best provider of oxygen because if mixes - For patients undergoing elective GIT surgery to ensure
room air with oxygen delivering it at a higher that the contents of the bowel are cleared. (Risk for
pressure but still the desired amount. Peritonitis)
o Still delivers desired FiO2 even changing o Due to the colon bacilli which is a normal
respiratory rates and tidal volumes. flora in the GIT.
- Rebreather o Colon Basili(e.coli) in the intestine is needed
- A common adverse effect of sedatives is respiratory for the production of VIT.K and 2,7,9,10
depression clotting factors.
- If alveoli is collapsed, exchange of gases will not be o Urobilinogen – gives brown color to the
good and also decreases hemoglobin stool
- For the wound to recover, there must be plenty of - Enemas are not commonly prescribed preoperatively
blood to the area (WBC, nutrients, antibodies) unless the patient is undergoing abdominal or pelvic
surgery.
Foley catheter - At 24-48 hours prior to surgery, the patient may be
- Muscle contract > Increase Urine > Bladder enlarge > allowed CLEAR LIQUIDS (no milk):
Catheter Inserted. o Water
- Prevent distention of urinary bladder especially if the o black tea
operation is quite long o coffee no cream
- Inserted at intraoperative phase o meat extracts
- An invasive procedure (any tube inserted) which is a o consommé
good medium for growth of bacteria
o glucose drinks
- 90% prone to UTI
*Full liquids contain milk like sherbet, ice cream,
- Should not last inside for two days. Removed on
creamy soup*
second postoperative day preventing UTI
- Less food intake
- Maintain close system of Foley catheter
- Laxatives/Enema: Used the evening before surgery to
- Empty bag regularly
clear the bowel of fecal matter. (Induce to move bowel)
- Prone to infection – Aseptic insertion –Perineal care
Examples:
- Meperidine
o Bisacodyl (Dulcolax)
Oral airway o Na Picosufate (Laxoberal)
- Gag reflex not good, insert o Klean-Prep (Picolax)
- To be removed if patient can swallow - Food and water are usually withheld at MIDNIGHT
- Do not let patient do deep breather/coughing (no midnight snacks) of the surgical day.
exercise. - Water may be given up to 4 hours before surgery.
(Depends on type of surgery)
Hair removal - Aspirin is withheld 7-10 days before surgery.
- The main purpose is to ease visualization of the Purposes of pre-anesthetic medications
surgical site and to provide a better skin surface for - Facilitation of anesthesia induction
wound closure. - Lowering of the dose of the anesthetic agent used.
- Shaving is done as close to the time of incision as - Reduction of pain and anxiety
possible to avoid contaminating the shave wound.
o If the wound occurred within 30 minutes Preoperative medications
before incision time, it is considered a clean - To reduce anxiety and induce sedation (strong
wound. sedatives)
o 5 – 8 hrs negative tayo dyan boss baka ma- o Diazepam (Valium)- 5-10 mg (DR); 2 mg
squeeze ang ating fucking neck. (insomnia)
- For surgery, appropriate preoperative skin preparation o Lorazepam (Ativan)
is key step to preventing SSIs. o Midazolam (Versed, Dormicum)
- Research studies show shaving cause multiple skin Note: MIDAZOLAM HYDROCHLORIDE
abrasions that later may become infected. Causes antegrade amnesia or decreased ability to
- Removing hair at the surgical site abrades the skin remember events that occurred around the time of
surface and enhances microbial growth. sedation.
o Destroy dermal layer of skin > opening pores The patient should be encouraged to take slow, deep
> injury to the skin > possible for breaths because midazolam is a respiratory depressant.
microorganisms to enter > infection to set in
- Hair at the surgical site should be left in place,
whenever possible. When hair removal is required, hair - To reduce/relieve discomfort during preoperative
should be clipped with an electric clipper. procedure
o Ex: cranial surgeries o Meperidine (Demerol)- acute pain
o Morphine- chronic pain
Bowel preparation
- Anticholinergics to decrease the risk of bradycardia
during surgery Preoperative medications
o Anticholinergics, especially antimuscarinic - Oral medications should be given 60-90 minutes
drugs inhibit bradycardia and by binding to before the patient goes to the OR. (Esophagus-stomach-
the muscarinic acetylcholine receptors, thus, intestine-absorbed blood-taken to liver-etc.)
blocking the activation of the parasympathetic o The patient should swallow these meds with
nervous system. minimal amount of water.
o Atropine + Demerol is always given - IM and SC injections should be given 30-60 minutes
o Risk of Bradycardia – Common before arrival at the OR
adverse effect of anesthesia - “On Call” from operating room
o Atropine counteracts bradycardia o OR nurse call when to give meds
o Atropine also decreases mucus - The patient is kept in bed with the side rails raised.
secretion and saliva - Identify yourself.
o Scopolamine - Identify the Before administration of the Drug
o Glycopyrolate (Robinul) o identify of the client by checking ID Band or
NOTE: Glycopyrolate an anticholinergic given for its asking the client to state his/her name
ability to reduce oral and respiratory secretions before - Ask the patient to void before pre-op meds
general anesthesia. - Inform patient of the effects of the drug to avoid
Adverse Effects: Increased CR and RR anxiousness because it can increase BP
- Do not let patient to get out of the bed once given with
- To increase gastric pH and decrease gastric volume pre-op meds (tendency to fall)
o Cimetidine (Tagamet) o Raise side rails
o Famotidine (Pepcid) o Do not leave the patient alone
o Ranitidine (Zantac) - The immediate surrounding are kept quiet to promote
Notes: relaxation. (no visitors)
- H2 BLOCKER: Hydrochloric Acid 60% ; - Cover the head completely with disposable paper cap
increase gastric PH, gastric volume ⬇ - All patients should void immediately before going to
- PPI: Gastric PH 90-95 ; potent but expensive the OR
- Not always given - The nurse should have the patient empty the bladder
- Gastric PH: hydrogen content low in the BEFORE the premedication is administered.
stomach for it to be acidic needed for Rationale for wearing a surgical cap
digestion of food. Acidity can kill - To prevent dissemination of microorganism
microorganisms found in food - To protect it from being soiled.
- Reason for increasing gastric PH or decrease - To prevent hair from falling into the sterile field.
gastric volume in surgery: - To prevent a static spark near the anesthesia machine.
- The stomach has three types of cells: mucous
mast cells, parietal cells (production of Preoperative checklist
hydrochloric acid), chief cells (pepsinogen = Night before the surgery
neutralize acidity) > 2400 gastric secretions in - Allergies
24 hours > production of acid is continuous - Consent
but protected by mucous mast cells or eating - History/PE
on time is another > patient is going to bleed - Weight
decreasing circulation > stomach is a - NPO
secondary organ and is receiving less blood > - Pre anesthetic evaluation
mucous mast cells won’t be able to produce - Exercises Performed
enough mucus to neutralize acid > plenty of - PM Care
acid > acid can eat mucosa of stomach > - Polish/Denture/Make up removed
Gastric ulcers - Sedatives as ordered. If not, ordered call the physician
- Drugs can diminish acidity of gastric - Signature of RN
secretions (Gastric PH of 3.5 or 4 ⬆) - Lab/Diagnostic
- Less acid for not cause auto digestion - BT/Consent for BT. Ask religion

- Anti Emetics Check on the day of surgery

o Metoclopramide - Jewelry, dental prosthesis and contact lenses removed
- Voided on call
o Droperidol
- Indwelling catheter if ordered
o Stop nausea
- Tampon Removed
 Can open wound when vomiting - ID Checked
causing dehiscence - Vital Signs
NOTE: Eye/brain surgery. Vomiting increase pressure. - Preoperative medications
Anti Emetics given preop (Depends on anesthesia, if - Side rails up
major adverse effect is vomiting) or postoperatively.
 - Instruct the patient not to get out of the bed and lower esophagus, allows clear view of the
- Vital signs 30 minutes after pre-op diaphragm, cardiac sphincter and esophagus
- Old chart sent to OR - Lithotomy: gynecological, obstetrical,
- Time sent to surgery genitourinary procedures
NOTE: The patient must have identification bracelet properly o Supine position with legs raised in
secured on the wrist before being transported to the operating supporting poles or stirrups
room to ensure correct identification. - Sitting (fowler’s): facial, cranial, reconstructive
breast surgery
- Lateral (sims): hip, renal,and cardiothoracic
Intra-operative phase surgery
Intraoperative phase o Patient is turned to the side, surgical area
o Includes all those that occur from the time the patient is exposed
transferred to the OR until he or she is transferred to - Prone: spine, cranium, perianal region; pressure on
the recovery facility. the abdomen restricts normal ventilation
o Patient lies on their stomach with head
Nursing interventions turned to one side.
o For spinal or neuro surgery
1. Provide emotional support - Jackknife of kraske: anorectal surgery
- Introduce yourself, addressing the patient by name o Good visualization of the rectum
warmly and frequently - Modified Dorsal Recumbent Position
- Providing appropriate information and explanation, o Patient in supine, knees slightly flexed,
answering questions to help the patient feel secure pillow under the leg.
o Limit information as to not scare the o For groin and lower extremities
client more. procedure.
- Providing emotional support for the client’s family - Modified Semi-fowler’s Position – Beach chair
is equally important o For nose or throat procedure
- The purpose of separating the public from the - Right Kidney Position
restricted attire are is to: o Left or Right side with both knees
o Provide an aseptic environment
flexed.
o Prevent contamination of the environment - Contraindicated: ages 60 and above. Lithotomy,
by organisms sims and lateral positions instead
- The main purpose is infection control.
- Let the family know when the procedure is Urinary catheterization
completed. - To prevent bladder distention during a long
- How long the client will be in the OR procedure or after the surgical procedure.
- Where the client will go after discharge from the - For bladder decompression to avoid trauma during a
recovery room. lower abdominal or pelvic procedure.
- To facilitate output and healing after a surgical
2. Ensuring a safe environment procedure on GUT structures
- Proper positioning of the patient (Circulating - Catheterization is performed after anesthesia is
Nurse) administered
- Using safety straps, bed rails - Before the patient is positioned for the surgical
- Not leaving the sedated patient unattended. procedure.
- It should be inserted before the vaginal or abdominal
Common surgical positions skin preparation to prevent perineal splash to the
surgical site.
- Supine: abdomen, thorax, face, orthopedic, - Prevent distention during a long procedure.
vascular surgeries - Sterile technique must be maintained.
o Patient lies back with arm restraints and
secured across the chest. Anesthesia
o Best position in administration of STAGE I Analgesia Stage
General Anesthesia STAGE II Excitement Stage
o Transfer of patient from Operating STAGE III Surgical Anesthesia
Room – PACU STAGE IV Medullary Paralysis
- Trendelenburg: allows greater access to the lower
abdominal cavity and pelvic structures by allowing Stage I: Analgesia stage
gravity to retract organs - Loss of pain sensation with the patient still conscious
o For lower abdominal surgeries and able to communicate
o Head tilt down - Warmth, dizziness and feeling of detachment
- Reverse trendelenburg: surgeon requires - May feel or have RINGING, ROARING, BUZZING
unobstructed access to the upper peritoneal cavity
 - Noises are exaggerated; even low voices or minor o Can cause liver damage
sounds seem loud or unreal. o Promote significant relaxation of the uterine smooth
o Tone down voices and avoid environmental muscles > inhibit uterine contractions > delaying
noise delivery
- Hearing is the last sense to leave and the first to come
back Adverse effects
- Hypotension:
Stage II: Excitement stage o Dec myocardial contractility > decreases CO
- Period of excitement and often combative behavior by 20%- 50%.
- Characterized by struggling, shouting, talking, o Stimulate vagal tone > decrease HR ->
laughing, crying decrease CO
- Signs of sympathetic stimulation such as tachycardia, - Respiratory depression
Increase RR and BP - Vomiting
- Uncontrolled movements: restrain patient - Hepatic toxicity

Stage III: Surgical anesthesia Isoflurane (forane)

- Involves relaxation or skeletal muscles and return of - Most widely used inhalational anesthetic
regular respiration - A potent muscle relaxant and protects the heart
- Patient is unconscious against cathecolamine-induced dysrhythmias > CO is
- Progressive loss of eye reflexes and pupil dilation not decreased
- Surgery can be safely performed in Stage III. - It depresses bronchoconstriction. May be used in
Asthma and COPD.
Stage IV: Medullary paralysis - Does not cause renal and hepatic toxicity but is
- Very deep CNS depression with loss of respiratory and expensive.
vasomotor center stimuli to which, death can occur
rapidly Adverse effects
- Happens when too much anesthesia has been - Respiratory depression
administered. - Hypotension
- Cyanosis develops and death may follow - Expensive
- Overdose of anesthesia It is not associated with renal or hepatic toxicity

General anesthesia Enflurane (endurane, ethrane)

- Drugs that produce unconsciousness and lack of o Induction of anesthesia is smooth and rapid
responsiveness to all painful stimulation o Salivation is not stimulated
- Basic elements include: o Muscle relaxation is greater than with halothane.
- Loss of consciousness However despite the action, a Neuromuscular Blocker
- Analgesia is employed to permit a reduction of Enflurane dosage
- Muscle relaxation o Suppress uterine contraction
- Interference with undesirable reflexes
- Amnesia: inability to recall what took place.
Adverse effects
o High dosage can induce seizure
Two methods of administering general anesthesia
o Substantial depression of respiration
- Inhalation
- Intravenous
Nitrous oxide (blue cylinder)
Inahalation anesthetics o “Laughing Gas”
- Halothane o It has a very high analgesic potency and very low
- Isoflurane anesthetic potency
- Enlurane
- Nitrous Oxide Analgesia: Loss of sensibility to pain
- Cyclopropane Anesthesia: refers not only to loss of pain but to loss of all other
- Ethylene sensations as well. Touch, Temperature, Taste

Halothane (fluothane) - Never employed as a primary anesthesia. It is

o Induction of anesthesia is smooth and rapid frequently combined w/other inhalational agents to
o Weam analgesic. Co-administration of a STRONG enhance analgesia
ANALGESIC (morphine, nitrous oxide) is usually - Most widely used inhalation agent
required. - Almost all patients undergoing general anesthesia
 Counteract with atropine sulfate receive nitrous oxide to supplement the analgesic effect
o Relaxation of skeletal muscle is only moderate. of the primary anesthetic
- Major concern is postop Nausea and Vomiting
Concurrent use of neuromuscular blocking agent is
- Can cause bowel distention
required (Pancuronium)
 - There is no muscle relaxation - Thiopental - Vecuronium
- Methohexital (Norcuron)
Cyclopropane(orange)and Ethylene(red cylinder) - Rocuronium
- Obsolete inhalational anesthetics because: (Dameron)
o They are explosives
o They offer no advantage over newer less Opioids and nitrous Preoperative medications
hazardous anesthetics oxide

Intravenous anesthetics For Induction of Use of anticholinergics that decrease

- Injected directly into the circulation usually via a Analgesia secretions to facilitate intubation and
PERIPHERAL VEIN in the arm. prevent bradycardia
- May be used alone or to supplement the effects of - Morphine
inhalational agents - Demerol

Thiopental (Penthonal) Nerve block

- Acts rapidly to produce unconsciousness in 10-20 - Injecting the anesthetic at some point along the
seconds after IV injection nerve/nerves that run to and from the region in which
- Analgesic and muscle relaxant effects are weak. the loss of pain sensation or muscle paralysis is desired
- Supplement to regional anesthesia
- Used as a safe adjunct for intubation in head injuries Intravenous regional anesthesia
- Employed to the anesthesia the extremities
Adverse effects Anesthesia is produced by injection into the distal vein of an
- Cardiovascular and respiratory depression arm or leg
- Apnea, if given rapidly
Topical anesthetics
Propofol (diprivan, diprifol)
- Used for rapid induction and maintenance of anesthesia Bnzocane (Auralgan)
for non invasive procedures - For ear pain
o Endoscopy
o MRI Lidocaine(xylocaine,epicene, enducaine, emla, emlocaine)
o Radiation Therapy - For dermatological procedures
- Unconsciousness develops w/in 60 secs and lasts for 3- - For painless IV insertion
5mins following a single injection. - Most widely used local anesthetics
- Causes death rapidly - Preparations: Cream ointment jelly patch soln aerosol
- Moderate to severe may be felt at the injection site
o Larger antecubital vein should be use Tetracaine (pontocaine and niphanoid)
o Site should be injected with lidocaine - For surgical, dental and obstetric procedures.
- Eye drop to numb the eye for various ophthalmic
Adverse effects procedures.
- Profound respiratory depression
- Bradycardia Avoid application to skin that is abraded or injured. To prevent
systemic toxicity, bradycardia, and convulsions
Ketamine(ketamax, ketazol) - Wear gloves when applying the anesthetic
- Dissociative anesthesia, dissociated from the
environment Spinal anesthesia (lumbar)
- Patient may be awake but: - Injecting local anesthetic into the subarachnoid space
Adverse effects (Intrathecal)
- Hallucinations - To create sensory, motor and autonomic blockage of
- Disturbing dreams the nerve roots and spinal cord.
- Indicated for surgical procedures below the diaphragm
Balanced anesthesia such as:
Use of a combination of drugs each with a specific effect to o Prostectomy
achieve: o Knee Arthoscopy
- Analgesia o Total Joint Replacement
- Muscle relaxation o Urologic Procedures
- Unconsciousness
- Amnesia Anethetics most commonly employed
The agents most commonly used to achieve these agents are: - Bupivacaine
Short-acting barbiturates Neuromuscular blocking agents - Lidocaine
For induction For muscle relaxation - Tetracaine
of anesthesia
Complications and interventions - Sterile objects that comes in contact with unsterile
- Hypotension objects are considered contaminated
- Spinal headache - Any part of sterile field that falls of hands below the
- Urinary retention top of the table is unsterile.
- A sterile field that becomes wet will draw
The patient will feel sensation to the toes before the perineal microorganisms from the surface underneath and
area contaminate the field.
A spinal headache due to the loss of fluid is a severe headache - Items in a sterile package must be used immediately
that occurs while in the upright position but is relieved in the once it has been opened or it considered contaminated
lying position. - Gowns of the surgical team are considered sterile in
front from the chest to the level of the sterile field
Hypotension - The sleeves are considered sterile from two inches
- BP is decreased by venous dilation secondary to above the elbow to the stockinet cuff
blockade of sympathetic nerves.
- Loss of venous tone decreases the rerun of blood to the Surgical mask
heart casing a reduction in cardiac output and - Remove all jewelry, hair covered by headgear
corresponding fall in BP - Disposable mask must fit snugly and comfortable over
the nose and mouth
Intervention - Contains nasal and oral droplets, which are easily
- Elevate legs transmitted to the hands as the mask dangles when left
- Closely Monitor BP hanging around the neck.
- IV fluids and ephedrine, alpha 1 agonist that increases - When a face mask is not worn over the mouth and
BP by stimulating norepinephrine release. nose, it should be discarded

Spinal headache Surgical scrub

- Indicating leak of CSF thru the opening in the dural - A study revealed that microorganisms decrease to an
sheath. estimated 50% with each six-minute scrub
- Injected lumbar area > leak of CSF (shock absorber) > - Other studies have shown that a vigorous five-minute
increasing pressure scrub with a reliable antiseptic agent is as effective as a
- May occur from 6-12hrs after spinal anesthesia to the ten-minute scrub.
2nd postop day - During and after scrubbing keep the hands higher than
- Signs and symptoms: the elbows to allow water flow from the cleanest area
o Frontal/occipital headache the hands, to the marginal areas of the upper arms
o Tinnitus Drying of hands and arms
o Double vision - Hold the towel away from the body, dry only scrubbed
o Nausea areas, starting with the hands.
o Photophobia - Avoid contaminating the hands or areas distal to the
elbows
Intervention
- Supine position (6-8 hours): good distribution of CSF Hand rub
- Large amount of IV fluids. (Well regulated to replace - Chlorhexidine gluconate or
lost CSF) - Betadine soap 7%
- Systemic analgesia o Rub 3-5 minutes
- Sterilium
Sterile technique o Continuous rubbing 2-5 minutes, then air dry
- Sterile means absence of all microorganisms
Maintaining surgical asepsis
Maintaining surgical asepsis - The sterile gown is worn immediately after the
- Maintaining asepsis to avoid contamination of the surgical scrub
surgical site by microorganisms is the responsibility of - The sterile gloves are worn immediately after
all other members of the surgical team. gowning
- All materials in contact with the surgical wound and - Sterile drapes to create sterile field
used w/in the sterile field must be sterile. - The movements of the surgical team are from are from
sterile to sterile areas and from unsterile to unsterile
Principle of sterile technique areas
- The edge of a sterile field and 1-2 inches inward is - Have unscrubbed personnel stay at least one foot away
unsterile. from the sterile field
- Sterile packages are labelled as sterile. If a package Whenever a sterile barrier is breached, the area must be
is not labelled sterile, it should be considered an considered contaminated
unsterile item
Preoperative responsibilities
Scrub nurse Circulating nurse
 Read card file to verify Help in preparing needed Involves the period after the client is discharged from the
surgeons special supplies recovery room and ends with the resolution of all surgical
requirements consequences.
Assemble all supplies needed Help scrub nurse and - most important assessment is respiratory assessment
in the procedure surgeon in gowning - Assess patent airway and adequate gas exchange
Wear mask and scrub hands, Opens sterile packs - Check O2 Saturation (95%-100% Normal Range)
put gown and gloves in - Respiratory assessment
preparation for the procedure -Airflow
Prepare sterile field Perform and record counts -O2 Saturation
and admit patient top -Respiratory Rate
operative suite -Auscultation of Breath Sounds
Make sure all instruments are -Patient should drink a minimum of 2500ml of fluid
working properly -Increase production of mucus if patient is semiconscious
- The scrub nurse counts sponges and instruments with increase IV fluids
the circulating nurse -Administer pain medications ex.Demerol before coughing.
-Use of incentive spirometry Q2-Q4
During the procedure -Monitor patients breath sounds and temperature to detect
Scrub nurse Circulating nurse early signs of infection
Assist the surgeon in draping Anticipates the anesthetist’s -Assist on early ambulation
the patient needs during induction of -Side-lying position if patient is unconscious to allow the
anesthesia secretion to mobilize and secreted.
Pass off suction cautery lines Assist with drapes and -Once conscious, patients head may be down 30degrees to
connect suction and cautery allow by gravity to pull down the abdominal contents.
lines -Patient w/ spinal anesthesia (increase fluid intake ; if
unconscious patient regulate IV fluid)
Keep an orderly sterile field Anticipate the needs of the
-Oral airway shouldn’t be removed until gag reflex has
team
returned
Anticipate the surgeons Record all supplies
-if patient is on ETT it shouldn’t be taken out until patient is
needs
able to cough and swallow.
Hands supplies and Monitor asepsis technique
-Breathing exercises after patient regains the gag and cough
equipment required by the
reflex to help the patient cough.
surgeon
-Why do breathing exercise?
Conduct internal count of Charge supplies and material
-To expand lungs
sponges, sutures, and used -To promote gas exchange
needles, and instruments
-to eliminate inhalation of anesthetic agents
- Turn patient at least Q2
Closing phase - In splinting used:
Scrub nurse Circulating nurse - Hand
Count with the circulating make a tally of sponges and - Pillow
nurse at frequent intervals counted together with the - Abdominal Binders
scrub nurse -Coughing is contraindicated:
Assist surgeon in sutures and Apply tape to secure tubings - If patient is having craniotomy
dressing and other attachments - Head Injury
Put on sterile dressings, Prepare patient for transfer to - If Patient will go eye surgery
clean used instruments and recovery room
supplies >>>Do not allow patient to vomit for it
Transfer patient to the
increases ICP. If ICP increases -> there
recovery room and endorse
significant details to RR will be pressure on the healthy neurons
nurse -> d/t pressure death of brain cells.
Cleans up the room after the
procedure

Time-out ``
When a “time-out” is called prior to surgery, the surgical team >>>If there will be edema in the eyes -> it will
must:
increase the intraocular pressure -> pressure on
o Read back all prescriptions
the optic nerve happens -> possible the patient to
o Verify the correct site
o Identify the patient again be blind.
o Double check the echocardiogram -If patient will undergo cosmetic surgery it will
increase tension on delicate tissues.
POST-OPERATIVE PHASE
Cardiovascular complications
- Tachycardia and hypertension
-Increase peripheral resistance causing the blood to be
sluggish resulting to decrease amount of blood going to the
wound thus slow healing of wound and poor oxygenation.
-Post Operative Pain
-Hypothermia
- d/t cold environment it will cause vasoconstriction
- so give additional blanket and lower down the AC
Deep Vein Thrombosis
Tachycardia and hypotension - Clinical Manifestations
- Adverse effect of Anesthesia - Swelling (Unilateral)
- Dehydration d/t bleeding - Warmth to touch
- Hypoglycemia - Redness
- NPO for 6-8 Hours Keep IV Fluids - Pain
- Blood loss during surgery Regulated - Tenderness
- Persistent Pain - Low-Grade Fever
- Cyanosis
Nursing interventions -The Blood is viscous d/t bedridden patient thus
O2 Therapy and IV Fluid Bolus patient is immobilize > no muscular contraction >
- Breathe more deeply and move legs to increase there is vein pooling > there is thrombus > if it goes
venous return. to the blood it will become an embolus > contracting
- Use of elastic bandages for antiembolism stockings the muscle will make the embolus go with the blood
(Squeezes blood veins into the heart) > vein have more blood than arteries > arteries have
- Use of analgesics no valves to prevent backflow > emboli enters the
- Rewarming will correct hypothermia – Induce lungs thus PULMONARY EMBOLISM > if emboli
hypertension is small it will travel and cross the blood brain barrier
- The PR,RR, and BP are recorded at least Q15 for thus resulting in STROKE or CVA.
the 1st hour and Q30 for the next 2 Hours. - Prevention of DVT
- The temperature is monitored Q4 for the first - Use of thrombo-embolic Stockings
24hours. - Elevating the foot of the bed(unless
Hypothermia contraindicated).
- 36*C - Never apply pillow under the knees –> it
- Up to 12 hours duration post operatively will cause pressure in the popliteal vein ->
- d/t effect of anesthesia because of body heat loss of thus blood accumulation happens.
surgical procedure. - compare Circumference, Color and
- Vasoconstriction decreases blood going to the Temperatire (CCT)
injured site so wound will not heal faster. - Leg and Arm exercises.
- Restrain/reduce action of WBC thus patient
becomes prone to infection. Gastrointestinal complications
- Depress cardiac contractility therefore there will be Nausea and Vomiting
less cardiac output (amount of blood being ejected by - It can stress and irritate the abdominal and GI
heart for one minute 5-8L) less blood will go to the wounds
wound site. - Don’t allow the patient to vomit because it can
Mild Elevation increase ICP and IOP
- 38*C - High risk to develop aspiration
- 24-48 hours of this temperature is considered pneumonia/pneumonia
normal due to inflammatory response to surgical stress. - Abdominal distention will happen because of
Above 38.*C decrease peristalsis thus there will be no movement
- Third day or later is due to infection of the intestine then there will be accumulation of
- Wound infection, UTI, or Atelectasis (collapse of gastric secretions in stomach + the swallowed air
the lungs). causing the abdomen to be distented and pain.
Temperature above 37.7*C - Place the patient in an upright position
- Third day or later - Give anti-emetic drugs
- Due to infection - Metoclopramide (Plasil)
- Wound infection - Ondasetron (Zofran)
>UTI - Insertion of NGT for Post-Operative patient who
>Phlebitis undergo abdominal surgery.
>UTI - Auscultation of Bowel Sounds
- Auscultate the 4Quadrants/minute (if you
can’t hear bowel sounds for a minute move
Patient is
Give to another quadrant until you hear)
Perineal Increase Vit.C to
with Care Fluid acidify
catheter given 2x intake to the urine
(Invasive)
 - 5-25 bowel sounds/minute (Normal) Four evidence-based strategies for reducing surgical site
- >3 bowel sounds/minute (Hypoactive) infection
- Assess for swallowing reflex 1. Giving antibiotic with 1 hour before surgical incision is
- The best indicator for Peristalsis is the Flatus/Stool made (for 24hrs only)
- Slow Deep Breathing and avoid using - To ensure bactericidal serum and tissue antibiotic
straw levels
- because of the air that a patient can get - Cephalosporin- first and second generation
when using a straw making it distented. - D/C within 24 hours of surgery
- Frequent repositioning.
- Normal Peristalsis returns during the first 48-72 2. Removing hair appropriately
Hours Post-Operatively. - Done before the surgery
- If necessary, remove with electric clippers
Diets - Carried by surgeon’s order
Clear Liquid Diet - Against the direction of hair growth when using
- Broth surgical clippers; razor is with the hair growth
- Clear Juice
- Gelatin 3. Keep blood glucose control
- Tea and Coffee(w/o milk) - Patient will be under stress - then there will be
- Sodas (Sprite) increase metabolism in the body - SNS will be
- Beverages w/o milk stimulated to stimulate adrenal cortex to release
- Adequate fluid and water cortisol - then cortisol will go to the liver and
- Recommended 3-5 Days undergo gluconeogenesis wherein fats and protein are
being converted to glucose causing hyperglycemia
Full Liquid Diet - Blood will be viscous – blood full of sugar – will
- With milk promote growth of bacteria
- Provide water, vitamins, calories, and minerals
- Control starting first 48 hours
- Dairy products
- Blood glucose should be below 200mg/dl before
- Considered to be low in residue
surgery (Normal 80-120mg/dl of blood)
- For clients with difficulty in chewing and swallowing.
- Hyperglycemia hinders surgical recovery and
Soft Diet wound healing by:
- Oatmeal - Impairing immunity
- Bananas - Inhibiting inflammatory response
- Boiled Eggs - Interfering with collagen synthesis (for
- Milkshakes wound healing and tissue repair).
- Ice Cream - Good medium for growth of bacteria
- Cream soup
- Pudding 4. Keep patient warm post operatively
- Yogurt - Provide warm IVF
- Have patient wear cap, booties and socks
- Check temp pre op
- Drink warm liquid
- Forced warm air blanket
Maintaining elimination
Urinary Output 5. Shower or bath using antiseptic soap to decrease skin
- 1000-1500mL for 24 hours NORMAL microbial colony counts
- 30-50cc for an hour
- Decrease urinary output – d/t loss of blood during surgery > 6. Aseptic technique should be followed, cleaning and
hypothalamus can feel that > Posterior Pituitary Gland will disinfecting the instrument
release ADH – orders kidney to reabsorb fluids – Aldosterone
is secondary to retain sodium = PHYSIOLOGIC OLIGURIA. 7. Cover incision site with sterile dressing 24-48 hours
- 4th Post-Operative will give a Normal I&O
- 2-3 days of Post-Operative will give you normal bowel 8. Meticolous Hand Hygiene
sounds - Before and after dressing change
- Dull if you percuss an organ and fluid - Sterile to sterile
- 6 to 8 hours is the expected for the patient to void after
removal of Foley Catheter. * Dehiscence - separation of the wound with protrusion organ
- To prevent constipation * Evisceration - total separation of wound layer and protrusion
- Early Ambulation of inter organ (cover with sterile dressing and always splint)
- Increase Fluid Intake * 5- 10 – days to expect dehiscence and evisceration to occur
- Fibers in Diet Causes of this two:
1. Obese o Give antiemetics when client verbalizes
2. Malnutrition (Insufficient protein and Vit. C) being nauseated.
3. Defective suturing (Incompetent suture) - Orthostatic hypotension
4. Not splinting o If client is more than 3 days in bed, do not
5.Unusual strain of the incision
let the patient to stand up immediately.
o Gradually move the client
Signs and Symptoms:
- Something gave away stated by the patient o Semi-fowler’s, fowler’s, let the feet dangle
- Clear pinkish drainage may appear on the edge of the bed feet flat on the
- Wound edges are partially/entirely separated ground, assist the patient to stand first, then
walk.
Nursing Intervention: o Do not leave the patient alone! At risk for
- Place patient in a position that puts least strain falls due to dizziness because blood pressure
- Bend the knees and avoid coughing will be dropping. 20 mmHg for the systole
- Notify the physician immediately and 10 mmHg for the diastole.
- Patient will stay in recovery until fully recovered o Older clients are more at risk for this.
- Patient can be transferred to private room if: Because the tunica intima of the arteries
- Has patent airway have inadequate production of NO (nitric
- Conscious oxide) which causes dilation of the arteries.
- BP normal o >60 years old decreased production of NO
- Early ambulation – Most significant general nursing When to give food?
measure to Post-Operative patients
- Before giving the patient food, aside for waiting for
-Increases vital capacity and maintains the doctor’s orders, assess!
normal RR functions - Assess if protective reflexes are back: swallowing
-Stimulates circulation and gagging reflex
- Auscultate for bowel sounds (5-25 bowel sounds/
-Increases muscle tone min- normoactive)
- If there is no bowel sound in one quadrant auscultate
-Improves GIT and Gut Function
the other quadrants for a full minute.
Additional notes from the lecture: - Ask if the patient has passed flatus. This indicates
peristalsis.
Post-operative Management o Peristalsis comes back 3-5 post op days
- Do not conclude patient has constipation, client has
- Number 1 post-operative complication is respiratory
been on NPO for more than 3 days. Wait till patient
complications
has eaten.
o Due to immobility, anesthesia side effects,
and pain (shallow breathing may occur Why is there physiologic oliguria during the postop?
because of this)
o Alveoli are not expanding enough - Physilogic oliguria is normal especially for patients
who underwent surgery and has lost a lot of blood.
Complications - There will be decreased blood circulating the body
and also because of lost of fluids through respiration
- Deep vein thrombosis due to immobility
> the body will always compensate for its needs > the
o If patient is in bed for more than 3 days at
CNS will be activated, hypothalamus will stimulate
risk for DVT the posterior pituitary gland to produce ADH > it will
- Constipation- due to effect of anesthesia to the bowel go to the blood and to the renal tubules > order
muscles tubules to reabsorb water due to compensation
o Decreased peristalsis (negative feedback system) > decreased urine output
- Nausea and vomiting > at the same time the zona fasciculate of the adrenal
o Do not wait for the patient to vomit glands are stimulated releasing aldosterone >
o This will cause the stimulation of the aldosterone will be going to the blood and to the renal
vasalva maneuver, causing tha patient to tubules and reabsorb sodium > where sodium goes
hold breathe. water follows > decreased urine output.
o This will increase ICP - The client will be able to have an equal intake and
o Very dangerous for patients who just had output at the 3rd- 4th post-operative day.
brain and eye surgeries - If it is already more than 3-4 days and patient still
does have scanty urine output the doctor will order
 for blood-urea nitrogen, creatinine clearance both - Lungs and the buffer systems compensate very
these tests determine the functioning of the kidneys quickly within minutes, but cannot bring blood pH
- It is important to provide IV fluids to restore lost back to normal.
fluids - The kidneys, on the other hand, compensates slowly
- Always check for VS especially the BP, the patient (24-49 hours) but it is the only system that can bring
may not present signs of bleeding but there may be the pH back to normal.
internal bleeding - Extracellular- outside the cell (intravascular and
- Decreased BP, decreased blood supply will be going interstitial spaces)
to the brain. - For mixed acid-base problems can be seen in chronic
kidney disease
Infection o Interventions are through medicines
- Patients are prone to urinary tract infections due to - If the body cannot compensate any more, the kidneys
catheter inserted to them will work.
o Do perineal care to prevent this o Produce H+ and secrete HCO3 for alkalosis
- Usually the surgeon will ask the catheter to be pulled o Secrete H+ and reabsorb HCO3 for acidosis
out 2nd postop day o Damaged kidneys cannot produce HCO3
- If it is removed expect the client to void and H+
independently after 6-8 hours. - There is hypovolemia because:
- If client has still not voided, stimulate them by letting o 98% of potassium is the main cation inside
them hear drips of water, placing hands on basin with the cell, while sodium is the main cation
warm water, and assist the client to go to the outside the cell.
bathroom. If client cannot stand and go to the o Increased K in the blood (3.5-5.5) <5.5 is
bathroom provide a bedside commode for females hyperkalemia
and urinal for males, make sure to provide privacy. o This causes cardiac dysrhythmia if not
- Clitoral stimulation is another way to let the patient treated, may lead to cardiac arrest in hours.
void, drop warm water on the clitoris - pH acidity and alkalinity is measured by the H+
- Any tubes that are inserted to the patients are good concentration in the blood
medium for bacterial growth o H+ enters the cells > K will go out > this
will cause hyperkalemia > Remove it by (1)
Wound infection
diuretics: furosemide (Lasix) this will
- This is not seen immediately postop. Seen in the third increase urine output, (2) give base via IV
day or later. like sodium chloride, (3) dialysis (late
- Characterized by temperature above 38 degrees management) (4) insulin, because insulin
Celsius. does not only deliver glucose into the cell
- Temperature is assessed q4 starting 1st post-op day. but also potassium.
Other VS are assessed q15, q30, and q1 o If treatment is diuretic, it will remove both
extracellular and intracellular K.
o Insulin- 2% of the K is only seen in the
blood is carries inside the cell
Acid-base balances
o This causes hypokalemia > dysrhythmia >
Respiratory alkalosis arrest
- Anaerobic metabolism means activity of the cells,
- Doctors will not immediately give diuretics metabolism but there is less oxygen.
- Due to hyperventilation more CO2 are eliminated o Pyruvic acid will be an end product of the
causing alkalosis mitochondria > lactic acid > metabolic acid
- Hyperventilation- fast RR, rapid, deep breathing
o Anxiety, severe pain, COPD, high-grade Why do we give H2 receptor blockers for metabolic
fever) alkalosis?
- Tachypnea- Increased RR but depth can be shallow.
- Action of H2 receptor blocker is to decrease gastric
- Not immediately give diuretics, if increased RR, give
juice (by inhibiting conversion of pepsinogen to
brown bag to recycle that CO2
pepsin created by the chief cells) and increasing the
o For pain- give Demerol or fentanyl
gastric pH (normal pH of stomach is 1.2-2.4) to 3.5-4
o High-grade fever- acetaminophen, cool the
> therefore, only HCl exists (made by the parietal
room, tepid sponge bath, and dressing
cells)
patient lightly.
Interpretation of arterial blood gases
Compensatory mechanisms
 - pH is ↓7.35, PaCO2 ↑45 > respiratory acidosis Bronchodilators
- pH is ↓7.35, HCO3 ↓22 > metabolic acidosis
- pH ↑7.45, PaCO2 ↓35 > respiratory alkalosis - Beta-adrenergic drugs
- pH ↑7.45, HCO3 ↑26 > metabolic alkalosis - Albuterol (ventolin)
- sequence: compensation, respiratory or metabolic, - Metaproterenol (alupent)
acidosis or alkalosis. - Bronchodilators with long duration of action
- Frequently administered by MDI
Asthma
Metaproterenol
- diminished breath sounds are an indication of severe
obstruction and impending respiratory failure - Metaproterenol (alupent) is a sympathomimetic
- a hereditary inflammatory disorder bronchodilator
- Irritation of the goblet cells will cause secretion of - The client should take the last does few hours before
mucus bedtime so that the medication does not produce
insomnia
Three reasons for difficulty of breathing (DOB)
Albuterol
- Increased mucus in the lumen of the bronchi
- Decreased O2 in the lungs - Proventil
- Edema - Is a bronchodilator
- Patient should avoid drinking large amounts of
Consequences of asthma caffeine-containing drinks such as tea, cocoa, and
cola drinks
- Atelectasis- there will be a V/Q mismatch - Sprite and 7-Up do not contain caffeine
(ventilation/perfusion mismatch), where in - Should be given 2-3 hours before sleeping, because
ventilation is not good but perfusion is adequate > not this will keep the patient awake
all the blood is oxygenated due to atelectasis
(collapse of the alveoli) > unoxygenated blood will Anticholinergics
go to the left side of the heart and will be pumped to
the systemic circulation > hypoxemia - Acts on the parasympathetic nervous system by
- Hyperinflation of the lungs > accumulation of Co2 > inhibiting its stimulation
the lungs will compensate by increasing the RR to - Ipratropium bromide (Atrovent, duavent)
remove that Co2 > but this further results to more - Used to treat asthmatic conditions by dilating the
accumulation of Co2 due to the obstruction in the bronchioles
bronchi > respiratory acidosis - Administered by aerosol
- If you auscultate a patient with asthma and there is no Ipratropium
lung sounds that is dangerous
- Side effects
Manifestations of hypoxemia - Atrovent
- Restlessness – braincells will be immediately o Dryness of mouth and cough
affected, it will not function well o Most commonly given due to lesser side
- Within 4 minutes brain cells will die without O2 effects than duavent
- Duavent
risk factors o Dyspnea, cough, hypertension, tremors and
nervousness, and insomnia
- dust
- weather Combivent
- smoking
- food choices - The combination of ipratropium bromide with
o eggs albuterol
- detergents - Used to treat chronic bronchitis
- For patients who require more than a single
Drugs used to treat asthma bronchodilator
Short-acting bronchodilators MDI teaching points
- short-acting beta 2- agonists - Wait 30 seconds between inhalation of same
- salbutamol (Ventolin/asmalin) medication
- terbutaline sulfate (bricanyl) - Wait 5-10 minutes between inhalations of different
- Usually given through MDI- metered-dose inhaler medications
 - Inform the patient to start to breathe in slowly for 3-5 this is where the peripheral chemoreceptors in the
seconds to draw in the medicine carotid artery will start to work > it will stimulate
- Instruct the patient to hold his breathe for 10 seconds breathing when there is less oxygen or hypoxia, thus,
to allow the medicine to go deeply into his lungs the hypoxic drive.
- Use bronchodilators before corticosteroids - We only give 1-2L of O2 to a COPD patient because
o Bronchodilators should be given first so that if too much O2 is given this hypoxic drive will be
steroids will be easily absorbed because knocked off resulting to respiratory distress.
bronchi are not constricted
Main causes
o Not all COPD patients are given steroids due
to multiple adverse effects - Smoking
- Avoids repeating inhalations before the next - Chronic bronchitis (blue bloaters)
scheduled dose o Obstructed airways resulting to cyanosis due
to hypoxia
Immediate adverse effects of steroids
- Emphysema (pink puffers)
- Patients become voracious eaters due to increased o Can compensate even in the last stage of
appetite. Results in gaining weight. COPD
o Educate patient to decrease sodium intake, o Because we have 300 million alveoli and not
because another effect of steroids is sodium all will be destroyed only a part
retention and this will attract water o Barrel chest due to accumulation of Co2 in
o 3-4 teaspoons are the normal intake of the lungs
sodium - Dyspnea and productive cough
- Prone to infection is steroids are taken for more than
two 233ks it will decrease the immune system and Cor pulmonale
the action of the WBCs - It is only called cor pulmonale when there is right
o > 3 months use it softens the bones > ventricular failure due to increased pressure in the
osteoporosis (this is a late adverse effect) pulmonary arteries and not for any other disease.
o Asepsis is a must! - First cause of cor pulmonale- due to hypoxia arteries
o Check all the tubes inserted because this is in the lungs will compensate by constricting in order
good medium for bacterial growth to shunt that blood to healthier alveoli > but with
o Given via MDI prone to infection of the vasoconstriction there will be increased pressure on
mouth the pulmonary arteries > this will increase the
o If given orally make sure patient will gurgle, workload of the right ventricle because it needs to
mouthwash can be used, or a spacer (use of push harder to overcome that high pressure in the
tube to prevent direct administration in the lungs > this will cause the ventricular muscles to
mouth) hypertrophy and fail > this will decrease cardiac
output of the heart
Glucocorticoids - Second cause- due to hypoxia the vessels will
- Beclomethasone (foster)- MDI constrict in order to supply oxygenated blood to the
primary organs of the body (brain, heart, and lungs) >
Chronic obstructive pulmonary disease (COPD) this decrease in blood will be detected by the kidneys
> and as result is will compensate by releasing
- Rebamipide is used as a cytoprotective drug because erythropoietin > this will go to the bone marrow >
majority of the drugs taken by a COPD patient are create more RBCs > at the same time renin will also
gastric irritants be release due to decrease in blood volume > it will
o Steroids are given as well this can cause go to the liver and combine with angiotensinogen and
gastric ulcers convert it to angiotensin I (a mild vasoconstrictor) >
Hypoxic drive will travel to the lungs and it will combine to the
angiotensin- converting enzyme > angiotensin II will
- The medulla oblongata and the pons of the brain stem be produced (a potent vasoconstrictor) > with the
are the breathing centers of the body > this will increase in RBCs and vasoconstriction > this will
immediately respond to the presence of Co2 in the cause the blood flow to be sluggish > increase
body (thus the body will initiate breathing whether workload of the right ventricle > high pressure in the
you like it or not) > in COPD the alveoli are already lungs due to vasconstriction > prolonged increase in
destroyed and the bronchi are constricted > there will pressure and workload > cor pulmonale
be accumulation of Co2 > this will narcotize the
medulla and pons where the central chemoreceptors Alpha I- antitrypsin
are located it will not be sensitive anymore to Co2 >
 - It is a disorder wherein the protein alpha-1 antitrypsin - Preload- the amount of blood filling the chambers of
is defective or absent. This protein is a protease the heart during diastole, Mitral and tricuspid valves
which inactivate elastase that breaks down elastin. are open, atria contract > fill ventricles with blood
But since there is a deficiency, the elastase cannot be - Afterload- the amount of resistance of pressure the
prevented from breaking down too much elastin. This ventricles must overcome to circulate blood to the
primarily affects the lungs. If there are bacteria or different organs of the body
foreign matter that has entered particularly in the - Place patient in a semi-fowler’s position to decrease
alveoli, the Neutrophils usually arrive to release workload of the heart by decreasing the preload
Neutrophil Elastase. This elastase is going to break - With hypertension when systolic BP is 160 and
down the proteins of the bacteria and as well as the diastolic is 120, the ventricles need to generate more
elastin - which gives the lung tissues elasticity and pressure to exceed that 160 mmHg to push that blood
strength. But before this elastase could break down > increased workload of the left ventricle >
the elastin in our lung tissue surface, the liver will ventricular hypertrophy
release the alpha-1 antitrypsin to inhibit the elastase.
Without this alpha-1 antitrypsin protein, the Positions of auscultation
neutrophil elastase goes unchecked causing further
breakdown of the elastin in the alveolar walls
therefore also resulting in the alveoli to lose its
structural integrity and elasticity. If this happens,
there would be loss of elastic recoil resulting in
decrease in ventilation and destruction of the alveolar
wall and capillary bed would result in decreased
perfusion.

Chest physiotherapy

- Back clapping, postural drainage

Auscultation

- Hyperresonance will be heard

- Lungs sounds with the affected lungs will decrease

The heart

- Cardiac output- the amount of blood pumped by the

heart every minute
- Stroke volume- the amount of blood pumped by the
heart per contraction of the ventricles

Preload and afterload

Coronary artery disease

- As the ventricles contract, the ventricular BP builds

until it exceeds the pressure in the pulmonary artery
and the aorta.
 - Hear disease continues to be the number 1 killer in Development of collateral circulation
the country, accounting for almost 25% of all deaths
- 9 filipinos dies of heart disease every hour
- 1 out of 4 pinoys is hypertensive while 1 out of 5
pinots have pre-hypertension or at risk of developing
high blood pressure

Etiology and pathophysiology

- Atherosclerosis the major cause of CAD

o Characterized by focal deposit of cholesterol
and lipid, primarily within the intimal wall
of the artery
o Endothelial lining altered as a result if the
inflammation and injury
- Large vessels (carotid and coronary artery) are
affected
o As young as 2 y.o. can develop this disease
o Young adults are the most affected age
group
- Arteriosclerosis- smaller vessels are affected
o 30-40 y.o. are at risk
- The brain is supplied by 2 pairs of arteries: the
carotid artery anteriorly and the vertebral artery
posteriorly
- Fats are stored in adipose tissues
- Obstructions destroys the intimal later of the
endothelium due to inflammation, blockage of RBCs
and WBCs > the intimal layer will not be able to
produce nitric oxide (dilates the arteries) > (x)
vasodilation > increase pressure
- The right coronary artery is larger than the left
coronary artery
- If not in the heart, obstructions may go to the lower
extremities and cause PAD (peripheral arterial
disease)
- Teach patient to not eat too much carbohydrates >
excess > obesity > diminished immune system >
increase risk for diseases
- Heart attach- myocardial infarction > due to blocked
artery
- Transient ischemic heart attack > may lead to CVA
- The left coronary artery is more affected

Nitric oxide

- Produced by the intimal layer of the endothelial cells

causing vasodilation

Etiology

- Obesity
- Injure of the intimal layer
- This is a progressive disease that takes years to show
symptoms > easy fatigability, shortness of breath
- Avoid eating too much red meat because there are too
much fats there
- Limit food intake > exercise so that fats will go to the
muscles
 - growth of new blood vessels when there is o No buildup of fatty deposits in the artery
obstruction the body will compensate. walls
- Can easily rupture because it is new and can cause o Experienced at night, which can be
bleeding disruptive to sleep
o A medical condition in which there is
Risk factors of CAD
temporary spasm of the coronary arteries
- Divided into two factors: nonmodifiable and causing pain and discomfort
modifiable o Unlike typical angina which is often
- Nonmodifiable- cannot be changed triggered by exertion or emotional stress
- Modifiable- can be changed o Prinzmetal’s angina almost always occurs
when a person is at rest usually between
Nonmodifiable factors midnight and early morning
- Age o These attacks can be very painful
- Gender - Unstable angina and NSTEMI result from paritally or
o Has higher risk of developing CAD intermittently occluded coronary artery
o Smoke or drink when stressed - STEMI results from a fully occluded coronary artery
o Nicotine- constricts blood vessels ECG durations
o Alcohol decrease contractility of the heart
- Ethnicity -
o African-Americans due to the nature of their
jobs
o Koreans and filipinos have high sodium
intakes > hypertension
- Family history - P wave- 0.08-0.10 s
- Genetic predisposition o < 0.11 second
- PR interval- 0.12-0.20 s
Modifiable factor - QRS complex- 0.06-0.10
- T wave- 0.16 second
- Elevated serum lipids
o Exercise, walking is the best, and lower food
intake
- Hypertension
o Smoking cessation and exercise to decrease
obesity
- Diabetes
o May be due to over eating > pancreas will
secrete insulin > it will eventually get tires >
diabetes
o Steroids may cause this
o It may not only be due to hereditary history
but also the use of alcohol, drugs, and
overeating

Angina pectoris

- Chest pain
o Heaviness, pressure, and squeezing
- Coronary artery is blocked by lipids or cholesterol > Electroacardiography
decreased blood supply due to blockage > will cause
anaerobic metabolism > lactic acid will be produced - Zone of ischemia- Myocardial ischemia causes ST
< this will irritate the nerve endings in the heart > segment depression with or without T wave inversion
chest pain as result of altered repolarization
- Zone of injury- myocardial injury causes ST segment
Classes of angina elevation with or without loss of R wave
- Zone of infarction- Myocardial infraction causes deep
- Prinzmetal
Q waves as result of absence of depolarization
o Vasospasm occurs
current from dead tissue and receding currents from
o Narrowing of the coronaries opposite side of the heart
Revascularzation procedure ECG changes in pericarditis

- Coronary angioplasty - T wave initially upright and elevated but then during
recovery phase it inverts
Pericardium - ST segment elevated and usually flat or concave
- Provides lubrication to decrease friction during
systolic and diastolic heart movements
- Normally it contains 10-15 mL of serous fluid
- Assist in preventing in excessive dilation of heart
during diastole

- The pain is generally worse with deep inspiration and

when lying supine or turning
- It is relieved by sitting up and leaning forward
Pericarditis - Dyspnea may be present
- Pain on inspiration associated with pericarditis is due
to contact between inflamed pericardium, which is
adjacent to the diaphragm and the trachea

- Place patient in left lateral decubitus position

especially if obese to displace heart and move it
closer to the thoracic cage for better palpation.
- Palpate apex beat or the point of maximal impulse in
the 5th ICS LMCL
- Auscultate
o The most common clinical manifestation is
creaky, scratchy, or grating in quality of
friction rub
 Causes of pericarditis

- Cardiac tamponade
o If accumulation is rapid, as little as 100-150
mL (100- 2L of fluid) of blood in the
pericardial sac can adversely affect the
cardiac output

- Sitting up and leaning forward positions the stretched

pericardium away from the pleura which relieves
discomfort

o Develops as pericardial effusion increases in

volume > compression of the heart >
restricts diastolic ventricular filling > cardiac
output drops

- Pericardial friction rub at the left sternal of the chest

- Fever and anxiety
- Increased EBC count
- Elevated ESR and C-reactive protein
- Nonproductive cough and hiccup

Pathophysiology of pericarditis
 o Signs and symptoms:
o Confused, anxious, and restless
o Tachypnea and tachycardia
o Distended neck veins
o Muffled heart sounds
o Although muffled heart sounds indicate
accumulation of fluid around the heart,
narrowing pulse pressure signals cardiac
tamponade

Diagnostic studies

- Widespread ST segment elevations

- Elevated CRP and ESR
- CT imaging- best diagnostic tool to determine size,
shape, and location
- MRI for visualization of the pericardium and
pericardial space

Medical management

- Aspirin, ibuprofen
- Colchicine or prednisone for severe pericarditis
- Pericardiocentesis- performed only for:
o Pericardial effusion wit cardiac tamponade
o Purulent pericarditis
o neoplasm