ADRENAL GLAND - Anti-diuretic hormone is released by the

posterior pituitary gland. This will order the

renal tubules to reabsorb water decreasing
fluid output.
- Aldosterone will reabsorb sodium which will
>Norepinephrine >Cortisol attract water.
->vasoconstriction ->stimulates liver to Adrenal Medulla
perform - Releases two catecholamines:
gluconeogenesis and Norepinephrine and Epinephrine
glycogenolysis - Epinephrine increases cardiac rate because
patient is bleeding due to surgery > the
>Epinephrine >Aldosterone heart has to pump rapidly in order to give
-> Increase HR -> orders renal tubules more blood to the other systems of the body
to reabsorb SODIUM ; (blood contains oxygen and nutrients)
where sodium goes - Norepinephrine causes vasoconstriction
water follows. (compensatory mechanism): Blood pressure
>Testosterone goes down (hypotension) due to bleeding
->Sex hormone ➡️decreasing blood supply to the brain ➡️
vasoconstriction ➡️arteries constricted ➡️no
Adrenal cortex perfused bleeding developed ➡️therefore
- Cortisol will order the liver to peform increasing blood pressure ➡️giving more
glycogenolysis and gluconeogenesis blood to the brain
because patient is in NPO > when there is
increased stress > hypermetabolism occurs > MECHANISM OF INFLAMMATION
more glucose is needed because cells will Undergoes surgery > incision > tissue injury > SNS
become hungry. triggered > Adrenal Medulla release NE causing
- Glycogenolysis (glycogen-glucose) > Vasoconstriction > injured tissue release chemical
glucose is released because patient is mediators (Ex. Histamine, Bradikinin, Prostaglandin)
undergoing surgery > under stress > causing Vasodilation > more blood will go to the
increased metabolism > increasing activity injured site causing Redness and Warmth to touch
of cells, needing more food > cortisol orders because of increase blood supply. > d/t release of
the liver to produce more glucose > if the Histamine > increase capillary permeability >
liver runs out of glycogen, it will convert fats albumin goes out intravascularly to interstitial space
and proteins to glucose (gluconeogenesis), thus Swelling happens. > d/t increase blood suppy
which is not good. there is pressure on the nerve endings beneath the
- patient is receiving IV fluids because of this skin causing Pain and there is Loss of Function.
to counteract loss of glucose - You have to clean the site very well
- aldosterone is a glucocorticoid produced because they are going to create an
by the adrenal cortex. It will reabsorb more incision, if it is not clean bacteria will go in.
Na (sodium), where sodium goes water - Pain is localized
follows. - WBCs phagocytize (a process called
- Patient will be bleeding > needing endocytosis) > it will ingest bacteria in the
increased volume > aside from bleeding form of lysosomes
client is in NPO, client also loses fluids - Albumin (maintains osmotic pressure) will be
through respiration > no fluids are coming in allowed to go out from the intravascular
to the client’s body > sodium attracts water space to the third space > accumulation of
to keep fluid balance albumin in the 3rd space > osmosis
Difference of aldosterone from ADH (anti-diuretic (movement of water from higher to lower
hormone) area of concentrations) > water will go out
 - Hypertonic solution due to the release of o Hypotonic: albumin inside the
albumin to the 3rd space. capillary
Blood vessel dysfunction o Hypertonic: albumin outside the
- The capillaries connect the arterioles and capillary
venules o Oncotic: fluid retained in blood
o This is where exchange of gases vessels because of pressure
occurs
Functions of the inflammatory GENERAL MANIFESTATION OF INFLAMMATION
- Prevents spread of the damaging agents >Body weakness
- Disposes of cell debris and pathogen >Loss of Appetite
- Sets the stage for repair >Fever
- Inflammation sets the stage for healing >
vasodilation > good amount of blood will go Purposes of surgery
to the damaged area > good amount of Diagnostics – confirmation of the suspected
nutrients, oxygen, and WBCs will also go to diagnosis (ex. Biopsy, Endoscopy, Culture)
the area > flow in the blood in the wound is - To determine whether disease is benign or
already preparing the site for healing. malignant.
- WBCs are activated during inflammation - Determines the cause
- There is increase in heat during inflammation Explorative – confirms the type of and extent of the
because heat will make it hard for the disease (ex. Laboratory)
bacteria to survive. Reconstructive – repair of physical deformities,
o Prevent the spread of damaging improves appearance. (Ex. Rhinoplasty,
agents Mammoplasty, skin grafting)
o Forms a barrier to prevent the Currative – diseased or damaged body organ or
bacteria from metastasizing structure is removed or repaired. (Ex.
Histamine – produced by circulating basophils, Appendectomy, Amputation, hysterectomy,
platelets and mast cells adjacent to vessels fixation of fractures)
- (vasodilation, increased vascular Palliative – alleviates pain or other disease
permeability, endothelial activation) symptoms; slows progression of disease but does
Serotonin – produced mainly within platelets dense not cure (Ex. Nerve blocks placement of feeding
body granules (vasodilation, increased vascular tubes)
permeability) - Patient is healthy but there is a problem

Blood vessel dysfunction Surgery based on urgency

- Capillaries leak out their walls CLASSIFICATIO INDICATIONS EXAMPLES
- Caused by severe infection (sepsis) and N
certain diseases Emergent – Px Preserved the -Severe
requires function of bleeding
Capillary permeability immediate body parts or -Gunshot
- Due to release of histamine of the injured attention. ; it life of the -Fracture
tissue it will alter capillary permeability and may be life patient. skull
enlarge the pores of the blood vessels. threatening c/o within 1-2
Because of the enlargement of pores this hours ; w/o
will cause the protein albumin to go out delay
(albumin is the protein that controls the Urgent – px c/o within -Repair of
oncotic pressure inside the vessel) this will requires 24-48 hours. incision
cause the water to go out as well, from the prompt -drainage of
intravascular space to the third space attention wound
causing swelling. infection
Required – px Planned -cataracts Preoperative interview
needs to have - Meet the patient at eye level & introduce
surgery yourself by name & role
Elective – px The patient is -repair of o The nurse should ask the patient to
should have in optimal scar tell her full name rather thin asking if
surgery. health, -vaginal she is a certain patient because
something repair there might be another patient by
wrong but that name on the schedule.
can wait, - Nurses should not start the physical
done before assessment or ask the patient’s name
the disease without first identifying themselves and their
affects of role
threatens the o To relieve the patient’s anxiety in the
quality of life. new environment of the surgical
(inguinal experience
hernia)
-satisfies Preoperative assessment
patient’s History of previous surgery
desires but - to avoid problems previously encountered
not needed o Ex: The patient has one lung left and
to preserve as a nurse, emphasize breathing and
life or coughing exercises because
function. respiratory complication is the
(cosmetic number one complication of surgery.
surgery) This is due to the anesthesia received
during surgery (exchange of gases
SURGICAL PROCEDURES CAN BE BROADLY will not be good).
CATEGORIZED AS: History of allergies
- ELECTIVE that which is planned - Patient might be allergic to seafood which
- EMERGENCY that which is unplanned contains iodine
Who is the most important part of the health care o Disinfectant used in hospitals
team? o Latex allergies
- The patient is the most important part of the
health care team. Chronic disease history
- With the patient, nothing will be done or - DM, HPN, Cancer, Asthma
procedure will not push through - To provide necessary medications
- To be alert for possible complications
Perioperative nursing
- The Preoperative Phase – decision to DM: patient is hyperglycemic (blood is filled with
proceed w/ surgical intervention and ends sugar), wound would not immediately heal
w/ entry in the Operating Room
- The Intraoperative Phase – entry in the HPN: patient might be taking aspirin which causes
Operating Room to admission of the patient bleeding. Should be stopped for five to seven days
to the Recovery Room or PACU before surgery
- The Postoperative Phase – admission of the
patient to the Recovery Room or PACU to Smoking history
discharge of the patient or follow-up - increase risk for postoperative complications
evaluation in clinical setting.
Smoking paralyzes cilia (found in the lining of the
Pre-operative phase trachea) resulting to pneumonia
 - The cilia contracts one thousand times per o review the risks, benefits, &
minute in an upward motion because alternatives to the planned
environment is not sterile. This mechanism procedure
would prevent particles to reach the lungs - If the patient verbalizes that he or
- Sneezing and coughing are protective she does not understand the
mechanisms procedure that is planned, it is the
nurse’s responsibility to notify the
Smoking produces carbon monoxide surgeon of this lack of understanding
- The hemoglobin inside the red blood cells right away
are carriers of oxygen and carbon dioxide - The nurse should not teach about the
but the presence of carbon monoxide procedure; the surgeon needs to do
makes the hemoglobin two hundred times this
attracted to carbon monoxide affecting
oxygenation - If the patient is a:
o Minor
- Nicotine causes vasoconstriction > less o Unconscious
blood supply > slow wound healing o Mentally incompetent
o The written permission may be given
Current height and weight by a responsible family member
- determine drug dosage calculations
- When immediate medical treatment is
Vital signs needed to preserve life and the patient is
- to detect abnormalities incapable of giving consent,
- provide baseline data The next of kin may give consent

Current medications - If reaching the next kin is not possible:

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

Check on the day of surgery 2. Ensuring a safe environment

- Jewelry, dental prosthesis and contact lenses - Proper positioning of the patient
removed (Circulating Nurse)
- Voided on call - Using safety straps, bed rails
- Indwelling catheter if ordered - Not leaving the sedated patient
- Tampon Removed unattended.
- ID Checked
- Vital Signs Common surgical positions
- Preoperative medications
- Side rails up - Supine: abdomen, thorax, face,
- Instruct the patient not to get out of the bed orthopedic, vascular surgeries
- Vital signs 30 minutes after pre-op o Patient lies back with arm
- Old chart sent to OR restraints and secured across the
- Time sent to surgery chest.
NOTE: The patient must have identification bracelet o Best position in administration of
properly secured on the wrist before being General Anesthesia
transported to the operating room to ensure correct o Transfer of patient from
identification. Operating Room – PACU
- Trendelenburg: allows greater access to
the lower abdominal cavity and pelvic
Intra-operative phase structures by allowing gravity to retract
Intraoperative phase organs
o Includes all those that occur from the time the o For lower abdominal surgeries
patient is transferred to the OR until he or she o Head tilt down
is transferred to the recovery facility. - Reverse trendelenburg: surgeon requires
unobstructed access to the upper
Nursing interventions peritoneal cavity and lower esophagus,
 allows clear view of the diaphragm, - Prevent distention during a long procedure.
cardiac sphincter and esophagus - Sterile technique must be maintained.
- Lithotomy: gynecological, obstetrical,
genitourinary procedures Anesthesia
o Supine position with legs raised in STAGE I Analgesia Stage
supporting poles or stirrups STAGE II Excitement Stage
- Sitting (fowler’s): facial, cranial, STAGE III Surgical Anesthesia
reconstructive breast surgery STAGE IV Medullary Paralysis
- Lateral (sims): hip, renal,and
cardiothoracic surgery Stage I: Analgesia stage
o Patient is turned to the side, - Loss of pain sensation with the patient still
surgical area exposed conscious and able to communicate
- Prone: spine, cranium, perianal region; - Warmth, dizziness and feeling of detachment
pressure on the abdomen restricts normal - May feel or have RINGING, ROARING,
ventilation BUZZING
o Patient lies on their stomach with - Noises are exaggerated; even low voices or
head turned to one side. minor sounds seem loud or unreal.
o For spinal or neuro surgery o Tone down voices and avoid
- Jackknife of kraske: anorectal surgery environmental noise
o Good visualization of the rectum - Hearing is the last sense to leave and the first
- Modified Dorsal Recumbent Position to come back
o Patient in supine, knees slightly
flexed, pillow under the leg. Stage II: Excitement stage
o For groin and lower extremities - Period of excitement and often combative
procedure. behavior
- Modified Semi-fowler’s Position – Beach - Characterized by struggling, shouting, talking,
chair laughing, crying
o For nose or throat procedure - Signs of sympathetic stimulation such as
- Right Kidney Position tachycardia, Increase RR and BP
o Left or Right side with both knees - Uncontrolled movements: restrain patient
flexed.
- Contraindicated: ages 60 and above. Stage III: Surgical anesthesia
Lithotomy, sims and lateral positions - Involves relaxation or skeletal muscles and
instead return of regular respiration
- Patient is unconscious
Urinary catheterization - Progressive loss of eye reflexes and pupil
- To prevent bladder distention during a long dilation
procedure or after the surgical procedure. - Surgery can be safely performed in Stage III.
- For bladder decompression to avoid trauma
during a lower abdominal or pelvic Stage IV: Medullary paralysis
procedure. - Very deep CNS depression with loss of
- To facilitate output and healing after a respiratory and vasomotor center stimuli to
surgical procedure on GUT structures which, death can occur rapidly
- Catheterization is performed after anesthesia - Happens when too much anesthesia has
is administered been administered.
- Before the patient is positioned for the surgical - Cyanosis develops and death may follow
procedure. - Overdose of anesthesia
- It should be inserted before the vaginal or
abdominal skin preparation to prevent General anesthesia
perineal splash to the surgical site.
 - Drugs that produce unconsciousness and - A potent muscle relaxant and protects the
lack of responsiveness to all painful stimulation heart against cathecolamine-induced
- Basic elements include: dysrhythmias > CO is not decreased
- Loss of consciousness - It depresses bronchoconstriction. May be
- Analgesia used in Asthma and COPD.
- Muscle relaxation - Does not cause renal and hepatic toxicity but
- Interference with undesirable reflexes is expensive.
- Amnesia: inability to recall what took
place. Adverse effects
- Respiratory depression
Two methods of administering general anesthesia - Hypotension
- Inhalation - Expensive
- Intravenous It is not associated with renal or hepatic
toxicity
Inahalation anesthetics
- Halothane Enflurane (endurane, ethrane)
- Isoflurane o Induction of anesthesia is smooth and rapid
- Enlurane o Salivation is not stimulated
- Nitrous Oxide o Muscle relaxation is greater than with
- Cyclopropane halothane. However despite the action, a
- Ethylene Neuromuscular Blocker is employed to permit
a reduction of Enflurane dosage
Halothane (fluothane) o Suppress uterine contraction
o Induction of anesthesia is smooth and rapid
o Weam analgesic. Co-administration of a Adverse effects
STRONG ANALGESIC (morphine, nitrous oxide) o High dosage can induce seizure
is usually required. o Substantial depression of respiration
▪ Counteract with atropine sulfate
o Relaxation of skeletal muscle is only Nitrous oxide (blue cylinder)
moderate. Concurrent use of neuromuscular o “Laughing Gas”
blocking agent is required (Pancuronium) o It has a very high analgesic potency and very
o Can cause liver damage low anesthetic potency
o Promote significant relaxation of the uterine
smooth muscles > inhibit uterine contractions Analgesia: Loss of sensibility to pain
> delaying delivery Anesthesia: refers not only to loss of pain but to loss of
all other sensations as well. Touch, Temperature, Taste
Adverse effects
- Hypotension: - Never employed as a primary anesthesia. It is
o Dec myocardial contractility > frequently combined w/other inhalational
decreases CO by 20%- 50%. agents to enhance analgesia
o Stimulate vagal tone > decrease HR -> - Most widely used inhalation agent
decrease CO - Almost all patients undergoing general
- Respiratory depression anesthesia receive nitrous oxide to
- Vomiting supplement the analgesic effect of the
- Hepatic toxicity primary anesthetic
- Major concern is postop Nausea and
Isoflurane (forane) Vomiting
- Most widely used inhalational anesthetic - Can cause bowel distention
- There is no muscle relaxation
Cyclopropane(orange)and Ethylene(red cylinder)
- Obsolete inhalational anesthetics because: Balanced anesthesia
o They are explosives Use of a combination of drugs each with a specific
o They offer no advantage over newer effect to achieve:
less hazardous anesthetics - Analgesia
- Muscle relaxation
Intravenous anesthetics - Unconsciousness
- Injected directly into the circulation usually - Amnesia
via a PERIPHERAL VEIN in the arm. The agents most commonly used to achieve these
- May be used alone or to supplement the agents are:
effects of inhalational agents Short-acting Neuromuscular blocking
barbiturates agents
Thiopental (Penthonal) For induction For muscle relaxation
- Acts rapidly to produce unconsciousness in of anesthesia
10-20 seconds after IV injection - Thiopental - Vecuronium
- Analgesic and muscle relaxant effects are - Methohexital (Norcuron)
weak. - Rocuronium
- Supplement to regional anesthesia (Dameron)
- Used as a safe adjunct for intubation in head
injuries Opioids and nitrous Preoperative medications
oxide
Adverse effects
- Cardiovascular and respiratory depression For Induction of Use of anticholinergics that
- Apnea, if given rapidly Analgesia decrease secretions to
facilitate intubation and
Propofol (diprivan, diprifol) prevent bradycardia
- Used for rapid induction and maintenance of
- Morphine
anesthesia for non invasive procedures
- Demerol
o Endoscopy
o MRI
Nerve block
o Radiation Therapy
- Injecting the anesthetic at some point along
- Unconsciousness develops w/in 60 secs and
the nerve/nerves that run to and from the
lasts for 3-5mins following a single injection.
region in which the loss of pain sensation or
- Causes death rapidly
muscle paralysis is desired
- Moderate to severe may be felt at the
injection site
Intravenous regional anesthesia
o Larger antecubital vein should be use
- Employed to the anesthesia the extremities
o Site should be injected with lidocaine
Anesthesia is produced by injection into the distal
vein of an arm or leg
Adverse effects
- Profound respiratory depression
Topical anesthetics
- Bradycardia

Bnzocane (Auralgan)
Ketamine(ketamax, ketazol)
- For ear pain
- Dissociative anesthesia, dissociated from the
environment
Lidocaine(xylocaine,epicene, enducaine, emla,
- Patient may be awake but:
emlocaine)
Adverse effects
- For dermatological procedures
- Hallucinations
- For painless IV insertion
- Disturbing dreams
 - Most widely used local anesthetics - Elevate legs
- Preparations: Cream ointment jelly patch soln - Closely Monitor BP
aerosol - IV fluids and ephedrine, alpha 1 agonist that
increases BP by stimulating norepinephrine
Tetracaine (pontocaine and niphanoid) release.
- For surgical, dental and obstetric procedures.
- Eye drop to numb the eye for various Spinal headache
ophthalmic procedures. - Indicating leak of CSF thru the opening in the
dural sheath.
Avoid application to skin that is abraded or injured. - Injected lumbar area > leak of CSF (shock
To prevent systemic toxicity, bradycardia, and absorber) > increasing pressure
convulsions - May occur from 6-12hrs after spinal
- Wear gloves when applying the anesthetic anesthesia to the 2nd postop day
- Signs and symptoms:
Spinal anesthesia (lumbar) o Frontal/occipital headache
- Injecting local anesthetic into the o Tinnitus
subarachnoid space (Intrathecal) o Double vision
- To create sensory, motor and autonomic o Nausea
blockage of the nerve roots and spinal cord. o Photophobia
- Indicated for surgical procedures below the
diaphragm such as: Intervention
o Prostectomy - Supine position (6-8 hours): good distribution
o Knee Arthoscopy of CSF
o Total Joint Replacement - Large amount of IV fluids. (Well regulated to
o Urologic Procedures replace lost CSF)
- Systemic analgesia
Anethetics most commonly employed
- Bupivacaine Sterile technique
- Lidocaine - Sterile means absence of all microorganisms
- Tetracaine
Maintaining surgical asepsis
Complications and interventions - Maintaining asepsis to avoid contamination
- Hypotension of the surgical site by microorganisms is the
- Spinal headache responsibility of all other members of the
- Urinary retention surgical team.
- All materials in contact with the surgical
The patient will feel sensation to the toes before the wound and used w/in the sterile field must be
perineal area sterile.
A spinal headache due to the loss of fluid is a severe
headache that occurs while in the upright position Principle of sterile technique
but is relieved in the lying position. - The edge of a sterile field and 1-2 inches
inward is unsterile.
Hypotension - Sterile packages are labelled as sterile. If a
- BP is decreased by venous dilation secondary package is not labelled sterile, it should be
to blockade of sympathetic nerves. considered an unsterile item
- Loss of venous tone decreases the rerun of - Sterile objects that comes in contact with
blood to the heart casing a reduction in unsterile objects are considered
cardiac output and corresponding fall in BP contaminated
- Any part of sterile field that falls of hands
Intervention below the top of the table is unsterile.
 - A sterile field that becomes wet will draw - The sterile gown is worn immediately after the
microorganisms from the surface underneath surgical scrub
and contaminate the field. - The sterile gloves are worn immediately after
- Items in a sterile package must be used gowning
immediately once it has been opened or it - Sterile drapes to create sterile field
considered contaminated - The movements of the surgical team are from
- Gowns of the surgical team are considered are from sterile to sterile areas and from
sterile in front from the chest to the level of the unsterile to unsterile areas
sterile field - Have unscrubbed personnel stay at least one
- The sleeves are considered sterile from two foot away from the sterile field
inches above the elbow to the stockinet cuff Whenever a sterile barrier is breached, the area must
be considered contaminated
Surgical mask
- Remove all jewelry, hair covered by Preoperative responsibilities
headgear Scrub nurse Circulating nurse
- Disposable mask must fit snugly and Read card file to verify Help in preparing
comfortable over the nose and mouth surgeons special needed supplies
- Contains nasal and oral droplets, which are requirements
easily transmitted to the hands as the mask Assemble all supplies Help scrub nurse and
dangles when left hanging around the neck. needed in the surgeon in gowning
- When a face mask is not worn over the mouth procedure
and nose, it should be discarded Wear mask and scrub Opens sterile packs
hands, put gown and
Surgical scrub gloves in preparation
- A study revealed that microorganisms for the procedure
decrease to an estimated 50% with each Prepare sterile field Perform and record
six-minute scrub counts and admit
- Other studies have shown that a vigorous patient top operative
five-minute scrub with a reliable antiseptic suite
agent is as effective as a ten-minute scrub. Make sure all
- During and after scrubbing keep the hands instruments are working
higher than the elbows to allow water flow properly
from the cleanest area the hands, to the
- The scrub nurse counts sponges and
marginal areas of the upper arms
instruments with the circulating nurse
Drying of hands and arms
- Hold the towel away from the body, dry only
During the procedure
scrubbed areas, starting with the hands.
Scrub nurse Circulating nurse
- Avoid contaminating the hands or areas
Assist the surgeon in Anticipates the
distal to the elbows
draping the patient anesthetist’s needs
during induction of
Hand rub
anesthesia
- Chlorhexidine gluconate or
Pass off suction cautery Assist with drapes and
- Betadine soap 7%
lines connect suction and
o Rub 3-5 minutes
cautery lines
- Sterilium
Keep an orderly sterile Anticipate the needs of
o Continuous rubbing 2-5 minutes, then
field the team
air dry
Anticipate the surgeons Record all supplies
needs
Maintaining surgical asepsis
Hands supplies and Monitor asepsis -Increase production of mucus if patient is
equipment required by technique semiconscious increase IV fluids
the surgeon -Administer pain medications ex.Demerol before
Conduct internal count Charge supplies and coughing.
of sponges, sutures, and material used -Use of incentive spirometry Q2-Q4
needles, and -Monitor patients breath sounds and temperature
instruments to detect early signs of infection
-Assist on early ambulation
Closing phase -Side-lying position if patient is unconscious to allow
Scrub nurse Circulating nurse the secretion to mobilize and secreted.
Count with the make a tally of sponges -Once conscious, patients head may be down
circulating nurse at and counted together 30degrees to allow by gravity to pull down the
frequent intervals with the scrub nurse abdominal contents.
Assist surgeon in sutures Apply tape to secure -Patient w/ spinal anesthesia (increase fluid intake ;
and dressing tubings and other if unconscious patient regulate IV fluid)
attachments -Oral airway shouldn’t be removed until gag reflex
has returned
Put on sterile dressings, Prepare patient for
-if patient is on ETT it shouldn’t be taken out until
clean used instruments transfer to recovery
patient is able to cough and swallow.
and supplies room
-Breathing exercises after patient regains the gag
Transfer patient to the
and cough reflex to help the patient cough.
recovery room and
-Why do breathing exercise?
endorse significant
-To expand lungs
details to RR nurse
-To promote gas exchange
Cleans up the room
-to eliminate inhalation of anesthetic agents
after the procedure
- Turn patient at least Q2
- In splinting used:
Time-out
- Hand
When a “time-out” is called prior to surgery, the
- Pillow
surgical team must:
- Abdominal Binders
o Read back all prescriptions
-Coughing is contraindicated:
o Verify the correct site
- If patient is having craniotomy
o Identify the patient again
- Head Injury
o Double check the echocardiogram
- If Patient will go eye surgery

POST-OPERATIVE PHASE
Involves the period after the client is discharged
from the recovery room and ends with the
resolution of all surgical consequences.
- most important assessment is respiratory
assessment
- Assess patent airway and adequate gas
exchange
- Check O2 Saturation (95%-100% Normal Range)
``
- Respiratory assessment
-Airflow
-O2 Saturation
-Respiratory Rate
-Auscultation of Breath Sounds
-If patient will undergo cosmetic surgery it
-Patient should drink a minimum of 2500ml of fluid
will increase tension on delicate tissues.
 minute 5-8L) less blood will go to the wound
Cardiovascular complications site.
- Tachycardia and hypertension Mild Elevation
-Increase peripheral resistance causing the blood - 38*C
to be sluggish resulting to decrease amount of - 24-48 hours of this temperature is
blood going to the wound thus slow healing of considered normal due to inflammatory
wound and poor oxygenation. response to surgical stress.
-Post Operative Pain Above 38.*C
-Hypothermia - Third day or later is due to infection
- d/t cold environment it will cause - Wound infection, UTI, or Atelectasis
vasoconstriction (collapse of the lungs).
- so give additional blanket and lower down Temperature above 37.7*C
the AC - Third day or later
- Due to infection
Tachycardia and hypotension - Wound infection
- Adverse effect of Anesthesia >UTI
- Dehydration d/t bleeding >Phlebitis
- Hypoglycemia >UTI
- NPO for 6-8 Hours
- Blood loss during surgery
- Persistent Pain

Nursing interventions
O2 Therapy and IV Fluid Bolus
- Breathe more deeply and move legs to
increase venous return.
- Use of elastic bandages for antiembolism
stockings (Squeezes blood veins into the
heart)
- Use of analgesics
- Rewarming will correct hypothermia – Deep Vein Thrombosis
Induce hypertension - Clinical Manifestations
- The PR,RR, and BP are recorded at least - Swelling (Unilateral)
Q15 for the 1st hour and Q30 for the next 2 - Warmth to touch
Hours. - Redness
- The temperature is monitored Q4 for the - Pain
first 24hours. - Tenderness
Hypothermia - Low-Grade Fever
- 36*C - Cyanosis
- Up to 12 hours duration post operatively -The Blood is viscous d/t bedridden patient
- d/t effect of anesthesia because of body thus patient is immobilize > no muscular
heat loss of surgical procedure. contraction > there is vein pooling > there is
- Vasoconstriction decreases blood going to thrombus > if it goes to the blood it will
the injured site so wound will not heal faster. become an embolus > contracting the
- Restrain/reduce action of WBC thus muscle will make the embolus go with the
patient becomes prone to infection. blood > vein have more blood than arteries
- Depress cardiac contractility therefore > arteries have no valves to prevent
there will be less cardiac output (amount of backflow > emboli enters the lungs thus
blood being ejected by heart for one PULMONARY EMBOLISM > if emboli is small it
 will travel and cross the blood brain barrier - Frequent repositioning.
thus resulting in STROKE or CVA. - Normal Peristalsis returns during the first
- Prevention of DVT 48-72 Hours Post-Operatively.
- Use of thrombo-embolic Stockings
- Elevating the foot of the bed(unless Diets
contraindicated). Clear Liquid Diet
- Never apply pillow under the knees - Broth
–> it will cause pressure in the - Clear Juice
popliteal vein -> thus blood - Gelatin
accumulation happens. - Tea and Coffee(w/o milk)
- compare Circumference, Color - Sodas (Sprite)
and Temperatire (CCT) - Beverages w/o milk
- Leg and Arm exercises. - Adequate fluid and water
- Recommended 3-5 Days
Gastrointestinal complications
Nausea and Vomiting Full Liquid Diet
- It can stress and irritate the abdominal and - With milk
GI wounds - Provide water, vitamins, calories, and minerals
- Don’t allow the patient to vomit because it - Dairy products
can increase ICP and IOP - Considered to be low in residue
- High risk to develop aspiration - For clients with difficulty in chewing and
pneumonia/pneumonia swallowing.
- Abdominal distention will happen because
of decrease peristalsis thus there will be no Soft Diet
movement of the intestine then there will be - Oatmeal
accumulation of gastric secretions in - Bananas
stomach + the swallowed air causing the - Boiled Eggs
abdomen to be distented and pain. - Milkshakes
- Place the patient in an upright position - Ice Cream
- Give anti-emetic drugs - Cream soup
- Metoclopramide (Plasil) - Pudding
- Ondasetron (Zofran) - Yogurt
- Insertion of NGT for Post-Operative patient
who undergo abdominal surgery.
- Auscultation of Bowel Sounds
- Auscultate the 4Quadrants/minute
(if you can’t hear bowel sounds for a Maintaining elimination
minute move to another quadrant Urinary Output
until you hear) - 1000-1500mL for 24 hours
- 5-25 bowel sounds/minute (Normal) - 30-50cc for an hour
- >3 bowel sounds/minute - Decrease urinary output – d/t loss of blood during
(Hypoactive) surgery > hypothalamus can feel that > Posterior
- Assess for swallowing reflex Pituitary Gland will release ADH – orders kidney to
- The best indicator for Peristalsis is the reabsorb fluids – Aldosterone is secondary to retain
Flatus/Stool sodium = PHYSIOLOGIC OLIGURIA.
- Slow Deep Breathing and avoid - 4th Post-Operative will give a Normal I&O
using straw - 2-3 days of Post-Operative will give you normal
- because of the air that a patient bowel sounds
can get when using a straw making - Dull if you percuss an organ and fluid
it distented.
- 6 to 8 hours is the expected for the patient to void
after removal of Foley Catheter. 4. Keep patient warm post operatively
- To prevent constipation - Provide warm IVF
- Early Ambulation - Have patient wear cap, booties and socks
- Increase Fluid Intake - Check temp pre op
- Fibers in Diet - Drink warm liquid
- Forced warm air blanket
Four evidence-based strategies for reducing
surgical site infection 5. Shower or bath using antiseptic soap to decrease
1. Giving antibiotic with 1 hour before surgical skin microbial colony counts
incision is made (for 24hrs only)
- To ensure bactericidal serum and tissue 6. Aseptic technique should be followed, cleaning
antibiotic levels and disinfecting the instrument
- Cephalosporin- first and second
generation 7. Cover incision site with sterile dressing 24-48 hours
- D/C within 24 hours of surgery
8. Meticolous Hand Hygiene
2. Removing hair appropriately - Before and after dressing change
- Done before the surgery - Sterile to sterile
- If necessary, remove with electric clippers
- Carried by surgeon’s order * Dehiscence - separation of the wound with
- Against the direction of hair growth when protrusion organ
using surgical clippers; razor is with the hair * Evisceration - total separation of wound layer and
growth protrusion of inter organ (cover with sterile dressing
and always splint)
3. Keep blood glucose control * 5- 10 – days to expect dehiscence and
- Patient will be under stress - then there will evisceration to occur
be increase metabolism in the body - SNS Causes of this two:
will be stimulated to stimulate adrenal 1. Obese
cortex to release cortisol - then cortisol will 2. Malnutrition (Insufficient protein and Vit. C)
go to the liver and undergo 3. Defective suturing (Incompetent suture)
gluconeogenesis wherein fats and protein 4. Not splinting
are being converted to glucose causing 5.Unusual strain of the incision
hyperglycemia
- Blood will be viscous – blood full of sugar – Signs and Symptoms:
will promote growth of bacteria - Something gave away stated by the
- Control starting first 48 hours patient
- Blood glucose should be below 200mg/dl - Clear pinkish drainage may appear
before surgery (Normal 80-120mg/dl of - Wound edges are partially/entirely
blood) separated
- Hyperglycemia hinders surgical recovery
and wound healing by: Nursing Intervention:
- Impairing immunity - Place patient in a position that puts least
- Inhibiting inflammatory response strain
- Interfering with collagen synthesis - Bend the knees and avoid coughing
(for wound healing and tissue - Notify the physician immediately
repair). - Patient will stay in recovery until fully
- Good medium for growth of recovered
bacteria
 - Patient can be transferred to private room o Gradually move the client
if: o Semi-fowler’s, fowler’s, let the feet
- Has patent airway dangle on the edge of the bed feet
- Conscious flat on the ground, assist the patient
- BP normal to stand first, then walk.
- Early ambulation – Most significant general o Do not leave the patient alone! At
nursing measure to Post-Operative patients risk for falls due to dizziness because
blood pressure will be dropping. 20
-Increases vital capacity and mmHg for the systole and 10 mmHg
maintains normal RR functions for the diastole.
-Stimulates circulation o Older clients are more at risk for this.
Because the tunica intima of the
-Increases muscle tone arteries have inadequate

-Improves GIT and Gut Function production of NO (nitric oxide) which

causes dilation of the arteries.
Additional notes from the lecture: o >60 years old decreased production
of NO
Post-operative Management
When to give food?
- Number 1 post-operative complication is
respiratory complications - Before giving the patient food, aside for
o Due to immobility, anesthesia side waiting for the doctor’s orders, assess!
effects, and pain (shallow breathing - Assess if protective reflexes are back:
may occur because of this) swallowing and gagging reflex
o Alveoli are not expanding enough - Auscultate for bowel sounds (5-25 bowel
sounds/ min- normoactive)
Complications
- If there is no bowel sound in one quadrant
- Deep vein thrombosis due to immobility auscultate the other quadrants for a full
o If patient is in bed for more than 3 minute.
days at risk for DVT - Ask if the patient has passed flatus. This
- Constipation- due to effect of anesthesia to indicates peristalsis.
the bowel muscles o Peristalsis comes back 3-5 post op
o Decreased peristalsis days
- Nausea and vomiting - Do not conclude patient has constipation,
o Do not wait for the patient to vomit client has been on NPO for more than 3
o This will cause the stimulation of the days. Wait till patient has eaten.
vasalva maneuver, causing tha
Why is there physiologic oliguria during the postop?
patient to hold breathe.
o This will increase ICP - Physilogic oliguria is normal especially for
o Very dangerous for patients who just patients who underwent surgery and has
had brain and eye surgeries lost a lot of blood.
o Give antiemetics when client - There will be decreased blood circulating
verbalizes being nauseated. the body and also because of lost of fluids
- Orthostatic hypotension through respiration > the body will always
o If client is more than 3 days in bed, compensate for its needs > the CNS will be
do not let the patient to stand up activated, hypothalamus will stimulate the
immediately. posterior pituitary gland to produce ADH > it
 will go to the blood and to the renal tubules Wound infection
> order tubules to reabsorb water due to
- This is not seen immediately postop. Seen in
compensation (negative feedback system)
the third day or later.
> decreased urine output > at the same
- Characterized by temperature above 38
time the zona fasciculate of the adrenal
degrees Celsius.
glands are stimulated releasing aldosterone
- Temperature is assessed q4 starting 1st
> aldosterone will be going to the blood
post-op day. Other VS are assessed q15,
and to the renal tubules and reabsorb
q30, and q1
sodium > where sodium goes water follows >
decreased urine output.
- The client will be able to have an equal
intake and output at the 3rd- 4th Acid-base balances
post-operative day. Respiratory alkalosis
- If it is already more than 3-4 days and
patient still does have scanty urine output - Doctors will not immediately give diuretics
the doctor will order for blood-urea nitrogen, - Due to hyperventilation more CO2 are
creatinine clearance both these tests eliminated causing alkalosis
determine the functioning of the kidneys - Hyperventilation- fast RR, rapid, deep
- It is important to provide IV fluids to restore breathing
lost fluids o Anxiety, severe pain, COPD,
- Always check for VS especially the BP, the high-grade fever)
patient may not present signs of bleeding - Tachypnea- Increased RR but depth can be
but there may be internal bleeding shallow.
- Decreased BP, decreased blood supply will - Not immediately give diuretics, if increased
be going to the brain. RR, give brown bag to recycle that CO2
o For pain- give Demerol or fentanyl
Infection o High-grade fever- acetaminophen,
- Patients are prone to urinary tract infections cool the room, tepid sponge bath,
due to catheter inserted to them and dressing patient lightly.
o Do perineal care to prevent this Compensatory mechanisms
- Usually the surgeon will ask the catheter to
be pulled out 2nd postop day - Lungs and the buffer systems compensate
- If it is removed expect the client to void very quickly within minutes, but cannot bring
independently after 6-8 hours. blood pH back to normal.
- If client has still not voided, stimulate them - The kidneys, on the other hand,
by letting them hear drips of water, placing compensates slowly (24-49 hours) but it is the
hands on basin with warm water, and assist only system that can bring the pH back to
the client to go to the bathroom. If client normal.
cannot stand and go to the bathroom - Extracellular- outside the cell (intravascular
provide a bedside commode for females and interstitial spaces)
and urinal for males, make sure to provide - For mixed acid-base problems can be seen
privacy. in chronic kidney disease
- Clitoral stimulation is another way to let the o Interventions are through medicines
patient void, drop warm water on the clitoris - If the body cannot compensate any more,
- Any tubes that are inserted to the patients the kidneys will work.
are good medium for bacterial growth o Produce H+ and secrete HCO3 for
alkalosis
 o Secrete H+ and reabsorb HCO3 for - pH is ↓7.35, PaCO2 ↑45 > respiratory acidosis
acidosis - pH is ↓7.35, HCO3 ↓22 > metabolic acidosis
o Damaged kidneys cannot produce - pH ↑7.45, PaCO2 ↓35 > respiratory alkalosis
HCO3 and H+ - pH ↑7.45, HCO3 ↑26 > metabolic alkalosis
- There is hypovolemia because: - sequence: compensation, respiratory or
o 98% of potassium is the main cation metabolic, acidosis or alkalosis.
inside the cell, while sodium is the
Asthma
main cation outside the cell.
o Increased K in the blood (3.5-5.5) - diminished breath sounds are an indication
<5.5 is hyperkalemia of severe obstruction and impending
o This causes cardiac dysrhythmia if respiratory failure
not treated, may lead to cardiac - a hereditary inflammatory disorder
arrest in hours. - Irritation of the goblet cells will cause
- pH acidity and alkalinity is measured by the secretion of mucus
H+ concentration in the blood
Three reasons for difficulty of breathing (DOB)
o H+ enters the cells > K will go out >
this will cause hyperkalemia > - Increased mucus in the lumen of the
Remove it by (1) diuretics: bronchi
furosemide (Lasix) this will increase - Decreased O2 in the lungs
urine output, (2) give base via IV like - Edema
sodium chloride, (3) dialysis (late
Consequences of asthma
management) (4) insulin, because
insulin does not only deliver glucose - Atelectasis- there will be a V/Q mismatch
into the cell but also potassium. (ventilation/perfusion mismatch), where in
o If treatment is diuretic, it will remove ventilation is not good but perfusion is
both extracellular and intracellular K. adequate > not all the blood is oxygenated
o Insulin- 2% of the K is only seen in the due to atelectasis (collapse of the alveoli) >
blood is carries inside the cell unoxygenated blood will go to the left side
o This causes hypokalemia > of the heart and will be pumped to the
dysrhythmia > arrest systemic circulation > hypoxemia
- Anaerobic metabolism means activity of the - Hyperinflation of the lungs > accumulation
cells, metabolism but there is less oxygen. of Co2 > the lungs will compensate by
o Pyruvic acid will be an end product increasing the RR to remove that Co2 > but
of the mitochondria > lactic acid > this further results to more accumulation of
metabolic acid Co2 due to the obstruction in the bronchi >
respiratory acidosis
Why do we give H2 receptor blockers for metabolic
- If you auscultate a patient with asthma and
alkalosis?
there is no lung sounds that is dangerous
- Action of H2 receptor blocker is to decrease
Manifestations of hypoxemia
gastric juice (by inhibiting conversion of
pepsinogen to pepsin created by the chief - Restlessness – braincells will be immediately
cells) and increasing the gastric pH (normal affected, it will not function well
pH of stomach is 1.2-2.4) to 3.5-4 > therefore, - Within 4 minutes brain cells will die without
only HCl exists (made by the parietal cells) O2

Interpretation of arterial blood gases risk factors

 - dust Ipratropium
- weather
- Side effects
- smoking
- Atrovent
- food choices
o Dryness of mouth and cough
o eggs
o Most commonly given due to lesser
- detergents
side effects than duavent
Drugs used to treat asthma - Duavent
o Dyspnea, cough, hypertension,
Short-acting bronchodilators
tremors and nervousness, and
- short-acting beta 2- agonists insomnia
- salbutamol (Ventolin/asmalin)
Combivent
- terbutaline sulfate (bricanyl)
- Usually given through MDI- metered-dose - The combination of ipratropium bromide
inhaler with albuterol
- Used to treat chronic bronchitis
Bronchodilators
- For patients who require more than a single
- Beta-adrenergic drugs bronchodilator
- Albuterol (ventolin)
MDI teaching points
- Metaproterenol (alupent)
- Bronchodilators with long duration of action - Wait 30 seconds between inhalation of
- Frequently administered by MDI same medication
- Wait 5-10 minutes between inhalations of
Metaproterenol
different medications
- Metaproterenol (alupent) is a - Inform the patient to start to breathe in
sympathomimetic bronchodilator slowly for 3-5 seconds to draw in the
- The client should take the last does few medicine
hours before bedtime so that the - Instruct the patient to hold his breathe for 10
medication does not produce insomnia seconds to allow the medicine to go deeply
into his lungs
Albuterol
- Use bronchodilators before corticosteroids
- Proventil o Bronchodilators should be given first
- Is a bronchodilator so that steroids will be easily
- Patient should avoid drinking large amounts absorbed because bronchi are not
of caffeine-containing drinks such as tea, constricted
cocoa, and cola drinks o Not all COPD patients are given
- Sprite and 7-Up do not contain caffeine steroids due to multiple adverse
- Should be given 2-3 hours before sleeping, effects
because this will keep the patient awake - Avoids repeating inhalations before the next
scheduled dose
Anticholinergics
Immediate adverse effects of steroids
- Acts on the parasympathetic nervous
system by inhibiting its stimulation - Patients become voracious eaters due to
- Ipratropium bromide (Atrovent, duavent) increased appetite. Results in gaining
- Used to treat asthmatic conditions by weight.
dilating the bronchioles o Educate patient to decrease sodium
- Administered by aerosol intake, because another effect of
 steroids is sodium retention and this stimulate breathing when there is less
will attract water oxygen or hypoxia, thus, the hypoxic drive.
o 3-4 teaspoons are the normal intake - We only give 1-2L of O2 to a COPD patient
of sodium because if too much O2 is given this hypoxic
- Prone to infection is steroids are taken for drive will be knocked off resulting to
more than two 233ks it will decrease the respiratory distress.
immune system and the action of the WBCs
Main causes
o > 3 months use it softens the bones >
osteoporosis (this is a late adverse - Smoking
effect) - Chronic bronchitis (blue bloaters)
o Asepsis is a must! o Obstructed airways resulting to
o Check all the tubes inserted cyanosis due to hypoxia
because this is good medium for - Emphysema (pink puffers)
bacterial growth o Can compensate even in the last
o Given via MDI prone to infection of stage of COPD
the mouth o Because we have 300 million alveoli
o If given orally make sure patient will and not all will be destroyed only a
gurgle, mouthwash can be used, or part
a spacer (use of tube to prevent o Barrel chest due to accumulation of
direct administration in the mouth) Co2 in the lungs
- Dyspnea and productive cough
Glucocorticoids
Cor pulmonale
- Beclomethasone (foster)- MDI
- It is only called cor pulmonale when there is
Chronic obstructive pulmonary disease (COPD)
right ventricular failure due to increased
- Rebamipide is used as a cytoprotective pressure in the pulmonary arteries and not
drug because majority of the drugs taken by for any other disease.
a COPD patient are gastric irritants - First cause of cor pulmonale- due to hypoxia
o Steroids are given as well this can arteries in the lungs will compensate by
cause gastric ulcers constricting in order to shunt that blood to
healthier alveoli > but with vasoconstriction
Hypoxic drive
there will be increased pressure on the
- The medulla oblongata and the pons of the pulmonary arteries > this will increase the
brain stem are the breathing centers of the workload of the right ventricle because it
body > this will immediately respond to the needs to push harder to overcome that high
presence of Co2 in the body (thus the body pressure in the lungs > this will cause the
will initiate breathing whether you like it or ventricular muscles to hypertrophy and fail >
not) > in COPD the alveoli are already this will decrease cardiac output of the
destroyed and the bronchi are constricted > heart
there will be accumulation of Co2 > this will - Second cause- due to hypoxia the vessels
narcotize the medulla and pons where the will constrict in order to supply oxygenated
central chemoreceptors are located it will blood to the primary organs of the body
not be sensitive anymore to Co2 > this is (brain, heart, and lungs) > this decrease in
where the peripheral chemoreceptors in the blood will be detected by the kidneys > and
carotid artery will start to work > it will as result is will compensate by releasing
erythropoietin > this will go to the bone
 marrow > create more RBCs > at the same - Back clapping, postural drainage
time renin will also be release due to
Auscultation
decrease in blood volume > it will go to the
liver and combine with angiotensinogen - Hyperresonance will be heard
and convert it to angiotensin I (a mild - Lungs sounds with the affected lungs will
vasoconstrictor) > will travel to the lungs and decrease
it will combine to the angiotensin-
The heart
converting enzyme > angiotensin II will be
produced (a potent vasoconstrictor) > with - Cardiac output- the amount of blood
the increase in RBCs and vasoconstriction > pumped by the heart every minute
this will cause the blood flow to be sluggish > - Stroke volume- the amount of blood
increase workload of the right ventricle > pumped by the heart per contraction of the
high pressure in the lungs due to ventricles
vasconstriction > prolonged increase in
Preload and afterload
pressure and workload > cor pulmonale

Alpha I- antitrypsin

- It is a disorder wherein the protein alpha-1

antitrypsin is defective or absent. This protein
is a protease which inactivate elastase that
breaks down elastin. But since there is a
deficiency, the elastase cannot be
prevented from breaking down too much
elastin. This primarily affects the lungs. If
there are bacteria or foreign matter that has
entered particularly in the alveoli, the
Neutrophils usually arrive to release
Neutrophil Elastase. This elastase is going to
break down the proteins of the bacteria - Preload- the amount of blood filling the
and as well as the elastin - which gives the chambers of the heart during diastole, Mitral
lung tissues elasticity and strength. But and tricuspid valves are open, atria
before this elastase could break down the contract > fill ventricles with blood
elastin in our lung tissue surface, the liver will - Afterload- the amount of resistance of
release the alpha-1 antitrypsin to inhibit the pressure the ventricles must overcome to
elastase. Without this alpha-1 antitrypsin circulate blood to the different organs of
protein, the neutrophil elastase goes the body
unchecked causing further breakdown of - Place patient in a semi-fowler’s position to
the elastin in the alveolar walls therefore decrease workload of the heart by
also resulting in the alveoli to lose its decreasing the preload
structural integrity and elasticity. If this - With hypertension when systolic BP is 160
happens, there would be loss of elastic and diastolic is 120, the ventricles need to
recoil resulting in decrease in ventilation and generate more pressure to exceed that 160
destruction of the alveolar wall and capillary mmHg to push that blood > increased
bed would result in decreased perfusion. workload of the left ventricle > ventricular
hypertrophy
Chest physiotherapy
Positions of auscultation
Coronary artery disease - Heart attach- myocardial infarction > due to
blocked artery
- As the ventricles contract, the ventricular BP
- Transient ischemic heart attack > may lead
builds until it exceeds the pressure in the
to CVA
pulmonary artery and the aorta.
- The left coronary artery is more affected
- Hear disease continues to be the number 1
killer in the country, accounting for almost Nitric oxide
25% of all deaths
- Produced by the intimal layer of the
- 9 filipinos dies of heart disease every hour
endothelial cells causing vasodilation
- 1 out of 4 pinoys is hypertensive while 1 out
of 5 pinots have pre-hypertension or at risk Etiology
of developing high blood pressure
- Obesity
Etiology and pathophysiology - Injure of the intimal layer
- This is a progressive disease that takes years
- Atherosclerosis the major cause of CAD
to show symptoms > easy fatigability,
o Characterized by focal deposit of
shortness of breath
cholesterol and lipid, primarily within
- Avoid eating too much red meat because
the intimal wall of the artery
there are too much fats there
o Endothelial lining altered as a result if
- Limit food intake > exercise so that fats will
the inflammation and injury
go to the muscles
- Large vessels (carotid and coronary artery)
are affected Development of collateral circulation
o As young as 2 y.o. can develop this
- growth of new blood vessels when there is
disease
obstruction the body will compensate.
o Young adults are the most affected
- Can easily rupture because it is new and
age group
can cause bleeding
- Arteriosclerosis- smaller vessels are affected
o 30-40 y.o. are at risk Risk factors of CAD
- The brain is supplied by 2 pairs of arteries:
- Divided into two factors: nonmodifiable and
the carotid artery anteriorly and the
modifiable
vertebral artery posteriorly
- Nonmodifiable- cannot be changed
- Fats are stored in adipose tissues
- Modifiable- can be changed
- Obstructions destroys the intimal later of the
endothelium due to inflammation, blockage Nonmodifiable factors
of RBCs and WBCs > the intimal layer will not
- Age
be able to produce nitric oxide (dilates the
- Gender
arteries) > (x) vasodilation > increase
o Has higher risk of developing CAD
pressure
o Smoke or drink when stressed
- The right coronary artery is larger than the
o Nicotine- constricts blood vessels
left coronary artery
o Alcohol decrease contractility of the
- If not in the heart, obstructions may go to
heart
the lower extremities and cause PAD
- Ethnicity
(peripheral arterial disease)
o African-Americans due to the nature
- Teach patient to not eat too much
of their jobs
carbohydrates > excess > obesity >
o Koreans and filipinos have high
diminished immune system > increase risk for
sodium intakes > hypertension
diseases
 - Family history usually between midnight and early
- Genetic predisposition morning
o These attacks can be very painful
Modifiable factor
- Unstable angina and NSTEMI result from
- Elevated serum lipids paritally or intermittently occluded coronary
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
artery
o It may not only be due to hereditary
- STEMI results from a fully occluded coronary
history but also the use of alcohol,
artery
drugs, and overeating
ECG durations
Angina pectoris
-
- Chest pain
o Heaviness, pressure, and squeezing
- Coronary artery is blocked by lipids or
cholesterol > decreased blood supply due
to blockage > will cause anaerobic - P wave- 0.08-0.10 s
metabolism > lactic acid will be produced < o < 0.11 second
this will irritate the nerve endings in the heart - PR interval- 0.12-0.20 s
> chest pain - QRS complex- 0.06-0.10
- T wave- 0.16 second
Classes of angina
Electroacardiography
- Prinzmetal
o Vasospasm occurs
o Narrowing of the coronaries
o No buildup of fatty deposits in the
artery walls
o Experienced at night, which can be
disruptive to sleep
o A medical condition in which there is
temporary spasm of the coronary
arteries causing pain and discomfort
o Unlike typical angina which is often
triggered by exertion or emotional
stress
o Prinzmetal’s angina almost always - Zone of ischemia- Myocardial ischemia
occurs when a person is at rest causes ST segment depression with or
 without T wave inversion as result of altered
repolarization
- Zone of injury- myocardial injury causes ST
segment elevation with or without loss of R
wave
- Zone of infarction- Myocardial infraction
causes deep Q waves as result of absence
of depolarization current from dead tissue
and receding currents from opposite side of
the heart

Revascularzation procedure

- Coronary angioplasty
- Place patient in left lateral decubitus
Pericardium
position especially if obese to displace heart
- Provides lubrication to decrease friction and move it closer to the thoracic cage for
during systolic and diastolic heart better palpation.
movements - Palpate apex beat or the point of maximal
- Normally it contains 10-15 mL of serous fluid impulse in the 5th ICS LMCL
- Assist in preventing in excessive dilation of - Auscultate
heart during diastole o The most common clinical
manifestation is creaky, scratchy, or
grating in quality of friction rub

ECG changes in pericarditis

- T wave initially upright and elevated but

then during recovery phase it inverts
- ST segment elevated and usually flat or
concave

Pericarditis
 - Sitting up and leaning forward positions the
stretched pericardium away from the pleura
which relieves discomfort

- The pain is generally worse with deep

inspiration and when lying supine or turning
- It is relieved by sitting up and leaning
forward
- 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
- 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
 ventricular filling > cardiac output
drops
o Signs and symptoms:
Pathophysiology of pericarditis o Confused, anxious, and restless

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

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

o Develops as pericardial effusion

increases in volume > compression of
the heart > restricts diastolic
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