6. • DIAGNOSTIC
e.g. BREAST BIOPSY, EXPLORATORY LAPAROTOMY
• ABLATIVE
e.g. MASTECTOMY, HYSTERECTOMY
• CONSTRUCTIVE
e.g. CHEILOPLASTY, PALATOPLASTY
• RECONSTRUCTIVE
e.g. ORIF
• PALLIATIVE
e.g. COLOSTOMY, NERVE ROOT RESECTION
• COSMETIC
e.g. REVISION OF SCARS, RHINOPLASTY
7. • EMERGENCY
e.g. GUNSHOT WOUND, SEVERE BLEEDING
• URGENT
e.g. KIDNEY OR URETHRAL STONES
• ELECTIVE
e.g. CATARACT REMOVAL, HERNIA REPAIR
• OPTIONAL
e.g. CIRCUMCISION
13. • NURSING HISTORY
e.g. BLEEDING DISORDERS, CARDIOVASCULAR DSE.,
RESPIRATORY DSE., LIVER DSE., RENAL DSE.,
DIABETES MELLITUS
• PAST SURGICAL HISTORY
• ALLERGIES
• SMOKING AND ALCOHOL HABITS
• OCCUPATION
• EMOTIONAL HEALTH
• SIGNIFICANT OTHER’S SUPPORT
• PATIENT’S AND SIGNIFICANT OTHER’S
UNDERSTANDING OF SURGERY
15. P 1. A NORMALLY HEALTHY PATIENT
P 2. A PATIENT WITH MILD SYSTEMIC DISEASE
P 3. A PATIENT WITH SEVERE SYSTEMIC DISEASE THAT
IS NOT INCAPACITATING
P 4. A PATIENT WITH AN INCAPACITATING SYSTEMIC
DISEASE THAT IS A CONSTANT THREAT TO LIFE
P 5. A MORIBUND PATIENT WHO IS NOT EXPECTED TO
SURVIVE FOR 24 HOURS WITH OR WITHOUT
OPERATION
16. • MUST BE BRIEF AND COMPLETE
• DETERMINE THE FOLLOWING:
NUTRITIONAL STATUS
HEIGHT AND WEIGHT
BODY MASS INDEX (BMI)
SERUM PROTEIN LEVEL
NITROGEN BALANCE
17. T• ASSESS FOR OBESITY, WEIGHT LOSS,
MALNUTRITION, METABOLIC ABNORMALITIES,
AND THE EFFECTS OF MEDICATIONS ON
NUTRITION
• OBTAIN BMI AND WAIST CIRCUMFERENCE
18. T
• ADVISE PATIENT TO STOP SMOKING 6 MONTHS
PRIOR TO SURGERY
• TEACH BREATHING AND COUGHING EXERCISES
• IF PATIENT HAS RESPIRATORY INFECTIONS,
POSTPONE THE SURGERY.
19. T
• IF PATIENT IS HYPERTENSIVE, POSTPONE THE
SURGERY.
• AVOID SUDDEN CHANGES IN POSITION,
PROLONGED IMMOBILIZATION, HYPOTENSION,
HYPOXIA AND OVERLOADING THE CV SYSTEM.
20. T
• OPTIMAL LIVER FUNCTION IS ESSENTIAL.
• SURGERY IS CONTRAINDICATED IN PATIENTS
WITH ACUTE
• NEPHRITIS, ACUTE RENAL INSUFFICIENCY AND
OLIGURIA OR ANURIA OR OTHER ACUTE RENAL
PROBLEMS.
21. T
• PATIENTS WITH DM ARE PRONE TO
HYPOGLYCEMIA AND HYPERGLYCEMIA.
• PERFORM CBG TEST BEFORE, DURING AND
AFTER SURGERY. MAINTAIN BLOOD GLUCOSE
BELOW 200 mg/dL.
• USE OF CORTICOSTERIODS PLACES THE
PATIENT AT RISK FOR ADRENAL INSUFFICIENCY.
• PATIENTS WITH THYROID DISORDERS ARE AT
RISK FOR THYROTOXICOSIS OR RESPIRATORY
FAILURE.
22. T• DETERMINE PRESENCE OF ALLERGIES
• DOCUMENT ANY SENSITIVITY TO MEDICATIONS
AND PAST ADVERS REACTIONS TO THESE
AGENTS.
• STRICT ASEPSIS ON IMMUNOSUPRESSED
SURGICAL PATIENTS.
23. T
ADRENAL
CORTICOSTERIODS
DO NOT DISCONTINUE ABRUPTLY, CV
COLLAPSE MAY OCCUR
DIURETICS THIAZIDE DIURETICS MAY CAUSE
EXCESSIVE RESPIRATORY DEPRESSION
CHLORPROMAZINE INCREASES HYPOTENSIVE EFFECTS
OF ANESTHETICS
DIAZEPAM MAY CAUSE ANXIETY, TENSION AND
SEIZURES IF WITHDRAWN SUDDENLY
ERYTHROMYCIN
IF COMBINED WITH CURARIFORM
MUSCLE RELAXANT,
RESPIRATORY PARALYSIS
24. TWARFARIN SHOULD BE DISCONTINUED, INCREASES
THE RISK OF BLEEDING
PHENELZINE
SULFATE
INCREASES HYPOTENSIVE EFFECTS
OF ANESTHETICS
LEVOTHYROXINE
SODIUM
ADMINISTER IV TO KEEP PATIENT
IN EUTHYROID
25. • LABORATORY SCREENING
e.g. CBC, SERUM ELECTROLYTES, COAGULATION STUDIES,
SERUM CREATININE, BUN, URINALYSIS, BLOOD TYPING
& CROSS MATCHING
• RADIOLOGIC SCREENING
e.g. X-RAY, MRI, CT SCAN
• OTHER DIAGNOSTIC SCREENING
e.g. ECG
28. WHAT DO YOU PLAN TO DO TO ME?
WHY DO YOU WANT TO DO THIS PROCEDURE?
WHAT ARE ALTERNATIVES TO THIS PLAN?
WHAT THINGS SHOULD I WORRY ABOUT?
WHAT ARE THE GREATEST RISKS OR WORST
THAT COULD HAPPEN?
AMERICAN COLLEGE OF SURGEONS (ACS)
29. If the patient is:
• A minor, a parent or legal guardian should sign.
• An emancipated minor, or independently earning
a living, he or she may sign.
• A minor who is the parent of infant or child who is
having the procedure, he or she may sign for the
child.
• Illiterate, he or she may sign with an X, after
which the patient‟s writes “patient‟s mark”.
30. If the patient is:
• Unconscious, a responsible relative or guardian
may sign.
• Mentally incapacitated by alcohol or other
chemical substance, a responsible relative or
guardian may sign when the urgency of the
procedure does not allow time for the patient to
regain mental competence.
31. T
• DIET ORDERS: NPO 6 – 12 HOURS PTOR
• MONITOR INPUT AND OUTPUT
• CATHETER INSERTION
• BOWEL PREPARATION (i.e. ENEMA, USE OF LAXATIVES)
32. T
• HYGIENE
• BATH
• REMOVE COSMETICS AND NAILPOLISH
• REMOVE ALL HAIRPINS AND CLIPS
• REMOVE DENTURES
• PROVIDE AN OR GOWN
33. T
• DISCONTINUE MEDICATIONS THAT ARE ADVISED
TO BE DISCONTINUED.
• ADMINISTER PREOPERATIVE MEDICATIONS
• INSERTION OF NGT
• SPECIAL SKIN PREPARATION
• TAKE CARE OF PT.’S BELONGINGS AND REMOVE
ALL BODY PROSTHESIS
34. • PROMOTE POSITIVE COPING STRATEGIES
IMAGERY
DISTRACTION
• PROVIDE PREOPERATIVE TEACHING
• PROVIDE OPPORTUNITY FOR VISITS
FROM FAMILY AND FRIENDS
40. • LEG EXERCISES
• TURNING-TO-SIDES EXERCISES
• GETTING-OUT-OF-BED EXERCISES
43. RESPECTING SPIRITUAL AND RELIGIOUS BELIEFS:
• PROVIDE TIME FOR PRAYER
• ARRANGE FOR VISIT FROM A SPIRITUAL
ADVISER / CLERGYMAN AS DESIRED
• TAKE INTO CONSIDERATION RELIGIOUS BELIEFS
IN THE OPERATIVE CARE
44. • ORAL LAXATIVES
e.g. CASTOR OIL, BISACODYL (DULCOLAX)
• CLEAR LIQUID DIET THE EVENING BEFORE
SURGERY
• NPO AFTER MIDNIGHT
• MULTIPLE-POSITION TAP-WATER ENEMAS THE
EVENING BEFORE SURGERY
• ORAL ANTIBIOTICS 24 HOURS BEFORE SURGERY
e.g., NEOMYCIN, ERYTHROMYCIN
45. • CLEANING THE SKIN OVER THE SURGICAL SITE
WITH ANTIMICROBIAL SOLUTION
e.g., POVIDONE-IODINE (BETADINE)
• REMOVING HAIR OVER THE SURGICAL SITE
e.g., SHAVING HAIR, CLIPPING HAIR
• APPLY ANTIMICROBIAL SOLUTION TO THE SKIN
OVER THE SURGICAL SITE
e.g., POVIDONE-IODINE (BETADINE)
46. REASONS FOR PREOPERATIVE MEDICATION:
REDUCE ANXIETY
PROMOTE RELAXATION
REDUCE PHARYNGEAL SECRETIONS
PREVENT LARYNGOSPASM
INHIBIT GASTRIC SECRETIONS
DECREASE THE AMOUNT OF ANESTHETIC
REQUIRED FOR INDUCTION AND MAINTENANCE
OF ANESTHESIA
50. 1. Morning bath and mouth care
2. Provide a clean gown
3. Remove hair pins, braid long hair, and cover hair with
cap.
4. Remove dentures, foreign materials, colored nail
polish, hearing aids, glasses and contact lens.
5. Take baseline vital signs before pre-op meds.
6. Check ID band
7. Check for special orders: enema , gastric tube, IV line
8. Have client void before pre-operative medications.
9. Continue to support emotionally
10.Accomplish the Pre-op Checklist
51. • Provision of a comfortable stretcher
• Provision of sufficient blankets
• Provision of safety measures
• Proper identification of surgical patient
• Proper greeting of patient
• Provision of a quiet environment
52. Informed consent
Surgeon / nurse conference
Laboratory tests
Skin preparation
Bowel preparation
Iv fluids
Preoperative medications, sedation and antibiotics
Removal of dentures, nail polish and jewelries
Npo status
55. 1. ONLY STERILE ITEMS ARE USED WITHIN THE STERILE
FIELD.
2. STERILE PERSONS ARE GOWNED AND GLOVED.
3. TABLES ARE STERILE ONLY AT TABLE LEVEL.
4. STERILE PERSONS TOUCH ONLY STERILE ITEMS OR
AREAS, WHILE UNSTERILE PERSONS TOUCH ONLY
UNSTERILE ITEMS OR AREAS.
5. UNSTERILE PERSONS AVOID REACHING OVER THE
STERILE FIELD, WHILE STERILE PERSONS AVOID LEANING
OVER AN UNSTERILE FIELD.
6. THE EDGES OF ANYTHING THAT ENCLOSES STERILE
CONTENTS ARE CONSIDERED UNSTERILE.
56. 7. THE STERILE FIELD IS CREATED AS CLOSE AS POSSIBLE
TO THE TIME OF USE.
8. STERILE AREAS ARE CONTINUOUSLY KEPT IN VIEW.
9. STERILE PERSONS KEEP WELL WITHIN THE STERILE
FIELD.
10. STERILE PERSONS KEEP CONTACT WITH STERILE
AREAS TO A MINIMUM.
11. UNSTERILE PERSONS AVOID STERILE AREAS.
12. DESTRUCTION OF THE INTEGRITY OF THE MICROBIAL
BARRIER LEADS TO CONTAMINATION.
13. MICROORGANISM MUST BE KEPT TO AN IRREDUCIBLE
MINIMUM.
57. THE OPERATING ROOM
• Should be free from contaminating particles, dusts,
pollutants, radiation and noise
THREE ZONES:
• UNRESTRICTED – street clothes are allowed
• SEMI-RESTRICTED – scrubs, shoe covers, caps and
masks
• RESTRICTED – scrubs, shoe covers, caps, masks, OR
gowns and gloves
58. OPERATING ROOM ATTIRE
• SCRUB SUIT
• STERILE GOWN
• HEAD COVER
• SHOES
PERSONAL PROTECTIVE DEVICES
• SURGICAL EYE PROTECTIVE
DEVICES
• SURGICAL FACE MASK
• STERILE GLOVES
59. 1. SURGEON
• Perform the operative procedure safely and correctly and
heads the surgical team.
• Assumes responsibility for all medical acts of judgement and
management.
2. ANESTHESIOLOGIST
• Assesses patient before surgery and an hour prior to induction
of anesthetics.
• Administers the anesthetic agent and monitors the patient„s
physical status throughout the surgery.
• Intubate the patient if necessary.
• Manage any technical problems related to administration of the
anesthetic agent.
• Supervise the patient condition throughout the surgical
procedure.
60. 3. CERTIFIED REGISTERED NURSE ANESTHETIST
• assist in the administration of anesthetic drugs to induce and
maintain anesthesia
• administers other medications as indicated to support the
patient's physical status during surgery
4. CIRCULATING NURSE
• sets up the operating room
• ensures that necessary supplies and equipment are readily
available, safe and functional
• makes up the operating room bed with gel and heating pads
• greets the patient
• assists the operating room team in transferring the client onto
the operating room bed
• positions the patient on the operating room bed
61. 4. CIRCULATING NURSE
• performs the surgical skin preparation
• drapes the surgical site with sterile drapes
• opens and dispenses sterile supplies during surgery
• manages catheters, tubes, drains and specimens
• administers medications and solutions to the sterile field
• assesses the amount of urine and blood loss and reports these
findings to the surgeon and anesthesia personnel
• reviews the results of any diagnostic tests or lab studies
• maintains a safe, aseptic environment
• monitors traffic in the operating room
• performs "sharps", sponge, and instrument count
• documents all care, events, findings, and patient's responses
62. 5. SCRUB NURSE
• helps set up the sterile field
• helps assist draping the client
• hand instruments to the surgeon
• performs "sharps", sponge, and instrument count
73. GENERAL ANESTHESIA
• produces total loss of consciousness by blocking awareness
centers in the brain, amnesia, analgesia, hypnosis, and relaxation
INDUCTION
Patient fells warmth, dizzy and feeling of detachment
Ringing, roaring or buzzing in the ears
Aware of being unable to move the extremities, noises are
exaggerated
EXCITEMENT
Pupil dilates but constricts in light
PR is rapid, RR is irregular
Restraints are applied
74. OPERATIVE OR SURGICAL ANESTHESIA
Pupils are small but reactive
Patient is unconscious
RR is irregular, PR is normal
MEDULLARY DEPRESSION / DANGER
Occurs when too much anesthesia is given
RR is shallow, pulse is weak and thready
Pupils are widely dilated and non reactive
Cyanosis occurs and eventually death
75. 1. Inhalation of gases and/or volatile agents through an
endotracheal tube or face mask
a. Gases e.g., nitrous oxide (N20)
b. Volatile agents
e.g., halothane (Fluothane), isoflurane (Forane)
2. Intravenous infusion of barbiturates or nonbarbiturates
a. Barbiturates e.g., thiopental sodium (Pentothal)
b. Non-barbiturates
e.g., ketamine (Ketalar), propolol (Diprivan), fentanyl citrate
with droperidol (Innovar)
79. A. MALIGNANT HYPERTHERMIA
Signs/Symptoms:
tachycardia, dysrthymias, muscle rigidity (especially jaw and
upper chest), hypotension, tachypnea, cola-colored urine,
extreme hyperthermia (late sign)
Treatment: DANTROLENE (DANTRIUM)
B. OVERDOSE
C. COMPLICATIONS TO ANESTHETIC AGENTS
e.g., hypotension, bradycardia, dysrthymias, respiratory
depression, decreased seizure threshold
D. COMPLICATIONS OF ET INTUBATION
e.g., broken caps, teeth, swollen lip, trauma to the vocal cords,
improper neck extension
80. • Injection of an anesthetic agent into or around a
specific nerve, nerve trunk, or several nerve trunks
supplying the tissue to be anesthetized
USES OF NERVE BLOCK ANESTHESIA:
a. prior to dental procedures
b. control of pain during plastic surgery
c. control of pain during surgery in an area supplied by
that specific nerve, nerve trunk, or nerve trunk(s)
d. to diagnose and treat chronic pain conditions
e. to increase circulation in some vascular disorders
81. • Injection of an anesthetic agent into the cerebrospinal
fluid in the subarachnoid space around the nerve roots
supplying the tissue to be anesthetized
USES OF SPINAL REGIONAL ANESTHESIA
• Control of pain during surgery of the lower abdomen
below the umbilicus, the groin, or the lower extremities
83. A. HYPOTENSION
INTERVENTIONS:
• administer O2 as ordered
• administer vasoactive drugs as ordered
• trendelenburg position if level of anesthesia is fixed
B. NAUSEA AND VOMITING
C. RESPIRATORY PARALYSIS
INTERVENTIONS:
• artificial respiration
D. NEUROLOGIC COMPLICATIONS
e.g., paraplegia, severe muscle weakness in legs
84. • Injection of an anesthetic agent into the epidural space
surrounding the dura mater around the nerve roots
supplying the tissue to be anesthetized.
USES OF EPIDURAL REGIONAL ANESTHESIA
• control of pain during surgery of the lower abdomen
below the umbilicus, the groin, or the lower extremities
• control of pain during labor and delivery
86. • Application of an anesthetic agent directly to the
surface of the tissue to be anesthetized
e.g. the skin or the mucosal surfaces of the mouth, throat, nose,
cornea
USES OF TOPICAL LOCAL ANESTHESIA
a. prior to injection of regional anesthesia
b. prior to endotracheal intubation
c. prior to various diagnostic procedures:
e.g. laryngoscopy, bonchoscopy, cystoscopy, endoscopy
87. • Injection of an anesthetic agent intracutaneously and
subcutaneously directly into the tissue to be
anesthetized
USES OF LOCAL INFILTRATION ANESTHESIA
• prior to injection of regional anesthesia
• prior to suturing of superficial lacerations at the end of
surgery into the incision for postoperative pain relief
• prior to dental procedures
• prior to minor surgical procedures
• excision of skin lesions or wound debridement
• repair of an episiotomy
88. • RETRACTING AND EXPOSING INSTRUMENTS
Handheld retractors
Self-retaining retractors
• CUTTING AND DISSECTING INSTRUMENTS
Scalpels
Knives
Scissors
Bone cutters
• Clamping and Occluding Instruments
Hemostatic forceps
Noncrushing vascular clamps
• Grasping and Holding Instruments
Forceps
Needle holders
Bone holders
89. TYPES OF SUTURE MATERIALS
1. ABSORBABLE SUTURES
a. Surgical Gut e.g. Plain, Chromic, Collagen Sutures
b. Synthetic Absorbable Polymers
e.g. Polydiaxanone Suture (PDS), Poliglecaprone 25
(Monocryl), Polyglyconate (Maxon), Polyglactin 910
(Vicryl) , Polyglycolic Acid (Dexon)
2. NONABSORBABLE SUTURES
a. Surgical Silk
b. Surgical Nylon
90. METHODS OF SUTURING
• Simple Continuous
• Simple Interrupted
• Continuous Interlocking
• Mattress
ASSESSMENT OF SUTURE LINE
• Stitched too tight or too loose
• Too many or too few stitches
• Suture holes are not equidistant from the edges so that
the bite is not even, or there is uneven spacing between
sutures
• There is inversion or eversion of tissue edges
• The edges of tissues are overlapping and heaped on
each other
93. A – Airway
B – Breathing
C – Circulatory
C – Consciousness
S – Safety/comfort
D – Dressing
D – Drainage
D – Drugs
E – Elimination
F – Fluids
F - Food
94. THE FIVE PHYSIOLOGICAL PARAMETERS:
1. ACTIVITY
2. RESPIRATION
3. CIRCULATION
4. CONSCIOUSNESS
5. COLOR
95. AREA OF ASSESSMENT Point
Score
1
hour
2
hours
3
hours
MUSCLE ACTIVITY
Ability to move all extremities
Ability to move 2 extremities
Unable to control any extremity
2
1
0
RESPIRATION
Ability to breath deeply and cough
Limited respiratory effort
No spontaneous effort
2
1
0
96. AREA OF ASSESSMENT Point
Score
1
hour
2
hours
3
hours
CIRCULATION
BP +/- 20% of pre-anesthetic level
BP +/- 20%-40% of pre-anesthetic level
BP +/- 50% pre-anesthetic level
2
1
0
CONSCIOUSNESS LEVEL
Fully awake
Arousal on calling
Not responding
2
1
0
97. AREA OF ASSESSMENT Point
Score
1
hour
2
hours
3
hours
O2 SATURATION
Unable to maintain O2 sat >92% on room air
Needs O2 inhalation to maintain O2 sat >90%
O2 sat <90% even with O2 supplement
2
1
0
REQUIRED FOR DISCHARGE FROM PACU: 7 - 8
98. ASSESSMENT:
respiratory rate, rhythm, depth
patency of airway
presence of oral airway
breath sounds
use of accessory muscles
skin color
ability to cough
ABG'S
O2 saturation
99. INTERVENTIONS:
position patient on side to prevent aspiration
suction artificial airways and oral cavity as
necessary
ask patient to perform respiratory exercises
administer O2 as needed
100. ASSESSMENT:
heart rate
blood pressure
skin color
heart sounds
peripheral pulses
capillary refill
edema
skin temperature
urine output
Homan's sign
changes in vital signs
symbolizing shock
type, amount, color, odor,
and character of
drainage from tubes,
drains, catheters or
incision
101. INTERVENTIONS:
check under patient for pooling of blood
check dressings, tubes, drains, and catheters for
blood
monitor changes in heart rate and blood pressure
103. ASSESSMENT:
LOC
mental status
movement and sensation in extremities
presence of gag and corneal reflexes
INTERVENTIONS:
orient patient to PACU environment
protect eyes if corneal reflex absent
protect airway if gag reflex absent
104. TYPES OF WOUND HEALING
• FIRST INTENTION
• SECONDARY INTENTION
• THIRD INTENTION
105. 1. CLEAN WOUND
• No break in sterile technique during the procedure
2. CLEAN – CONTAMINATED WOUND
• Minor break in sterile technique
• Alimentary, respiratory, genitourinary tract or oropharyngeal
cavity not entered
3. CONTAMINATED WOUND
• Open, fresh traumatic wound of less than 4 hours duration
• Gross contamination from GI tract
4. DIRTY AND INFECTED WOUND
• Old traumatic wound for more than 4 hours from dirty source
or with retrained necrotic tissue, foreign body or fecal
contamination
107. • DRY TO DRY – trap necrotic debris and exudates
• WET TO DRY – softens debris as it dries
• WET TO DAMP – wound debridement
• WET TO WET – moisture dilute exudates
108. warmth, swelling, tenderness or pain around incision
type, amount, color, odor, and character of drainage
on dressings
amount, consisency, color of drainage
dependent areas (e.g., underneath the patient)
drains and tubes and be sure they are intact, patent,
and properly connected to drainage systems
INTERVENTIONS:
• reinforce dressings as necessary
109. ASSESSMENT:
bladder distention
amount, color, odor, and character of urine from
foley catheter if present
INTERVENTIONS:
catheterize if necessary
notify MD if urinary output is less than 30 cc/hr
110. ASSESSMENT:
abdominal distention
N & V
bowel sounds
passage of flatus
type, amount, color, odor, and character of drainage
from nasogastric tube if present
111. ASSESSMENT:
I & O
color and appearance of mucus membranes
skin turgor, tenting, and texture
status of IV's
type, amount, color, odor, and character of drainage
from tubes, drains, catheters, and incision
type, amount of solultion, flow rate, tubing, infusion
site
112. PREDISPOSING FACTORS:
• diabetes, uremia, obesity, malnutrition, corticosteroid therapy
MAJOR CLINICAL MANIFESTATIONS:
• fever, foul-smelling, greenish-white drainage from wound,
persistent edema, redness
TREATMENT:
• antibiotics on basis of wound culture and sensitivity
• preventive nursing interventions:
• strict aseptic technique in the operating room and during
postoperative dressing changes
113. MAJOR CLINICAL MANIFESTATIONS:
• discharge of serosanguineous drainage from the wound
• sensation that something gave or let go
TREATMENT:
• lay patient down
• cover wound with sterile saline-soaked gauze or towels
• prepare to return patient to operating room for repair
• monitor for shock
PREVENTIVE NURSING INTERVENTIONS:
• splint wound when patient coughs
• medicate for nausea and vomiting
• highest risk during 5th to 8th postoperative days, so teach
patient s/s as they may already be discharged
115. PREDISPOSING FACTORS:
• infection
• dehydration
• response to stress and trauma
• prolonged hypotension
• transfusion reaction
• respiratory congestion
• thrombophlebitis
MAJOR CLINICAL MANIFESTATIONS:
• temperature elevated above 99.5° (37.5° C)
• elevated pulse and respiratory rates
• diaphoresis
• lethargy
117. MAJOR CLINICAL MANIFESTATIONS:
• little or no output or frequent small amounts
• palpably distended bladder
• restlessness
• discomfort
TREATMENT:
• measures to promote voiding (privacy, running water, sitting
patient up
• catheterization if above methods fail
PREVENTIVE NURSING INTERVENTIONS
• adequate hydration
• early ambulation
118. MAJOR CLINICAL MANIFESTATIONS:
• mild fever
• dysuria
• hematuria
• malaise
TREATMENT:
• adequate hydration
• maintenance of good bladder drainage
• antibiotics on basis of urine culture and sensitivity
PREVENTIVE NURSING INTERVENTIONS:
• encourage fluid intake
• early ambulation
• avoid catheterization or remove within 2 days
119. MAJOR CLINICAL MANIFESTATIONS:
• bowel obstruction
• pain
TREATMENT:
• surgery for lysis of adhesions
PREVENTIVE NURSING INTERVENTIONS:
• aseptic technique in operating room and during
dressing changes
120. MAJOR CLINICAL MANIFESTATIONS:
• increased temperature
• chills
• cough productive of purulent or rusty sputum
• crackles
• wheezes
• dyspnea
• chest pain
• tachypnea
• increased secretions
121. TREATMENT:
• promote full aeration of lungs by positioning in semi-
Fowlers or Fowlers
• administer O2 as ordered
• maintain fluid status
• administer antibiotics on basis of sputum culture and
sensitivity
• administer expectorants and analgesics as ordered
• chest physiotherapy
PREVENTIVE NURSING INTERVENTIONS:
• turn, coughing and deep breathing
• frequent position changes
• early ambulation
122. MAJOR CLINICAL MANIFESTATIONS:
• decreased lung sound over affected area
• dyspnea
• cyanosis
• crackles
• restlessness
• apprehension
• fever
• tachypnea
124. TREATMENT:
• position in semi-Fowler’s or Fowler’s
• administer O2 as ordered
• maintain hydration
• administer analgesics as ordered
• chest physiotherapy
• suctioning
• administer brochodilators and mucolytics via nebulizer
PREVENTIVE NURSING INTERVENTIONS:
• early ambulation
• turn, cough, and deep breathing
• incentive spirometry
125. MAJOR CLINICAL MANIFESTATIONS:
• absent bowel sounds
• no passage of flatus or feces
• abdominal distention
TREATMENT:
• nasogastric suction
• IV fluids
• rectal tube
• ambulate
PREVENTIVE NURSING INTERVENTIONS:
• early ambulation
• abdominal tightening exercises
• keep NPO if inactive bowel sounds
126. MAJOR CLINICAL MANIFESTATIONS:
• similar to paralytic ileus although bowel movement
may occur before obstruction
TREATMENT:
• bowel decompression with a Miller-Abbot tube
• surgical correction
127. MAJOR CLINICAL MANIFESTATIONS:
• dyspnea
• sudden severe chest pain or tightness
• cough
• pallor or cyanosis
• increased respirations
• tachycardia
• anxiety
• bradycardia
• hypotension
• restlessness
129. TREATMENT:
• contact physician stat
• maintain bedrest with HOB in semi-Fowler’s
• maintain fluid balance
• administer O2 as ordered
• administer anticoagulants as ordered
• administer analgesics as ordered
PREVENTIVE NURSING INTERVENTIONS:
• passive and active range of motion exercises to legs
• antiembolic stockings
• low-dose heparin administration if predisposing factors
present
• early ambulation
130. MAJOR CLINICAL MANIFESTATIONS:
• active bleeding
• elevation and discoloration of wound edges
TREATMENT:
• if small, may reabsorb; otherwise surgical evacuation
132. TREATMENT:
• position flat with legs elevated 45 degrees
• administer fluid resuscitation as well as whole blood
or its components as ordered
• administer O2 as ordered
• place extra covering to maintain warmth
• prepare for OR
133. MAJOR CLINICAL MANIFESTATIONS:
• pain and cramping in the calf of the involved
extremity
• redness, swelling in the affected area of the involved
extremity
• increased temperature of the involved extremity
• increased diameter of the involved extremity
135. TREATMENT:
• administer analgesics as ordered
• measure bilateral calf or thigh circumferences
• administer anticoagulants as ordered
• elevate affected extremity to heart level
• maintain bedrest
• apply moist heat on affected extremity as ordered
PREVENTIVE NURSING INTERVENTIONS:
• antiembolic stockings or sequential pneumatic
compressions stockings
• postoperative leg exercises
• early ambulation