GENERAL CONCEPTS

in Medical-Surgical
Nursing

Earl Francis R. Sumile, RN

Instructor, College of Nursing
University of Santo Tomas
Erikson’s Psychosocial
Development and Havighurst’s
Developmental Tasks
• Adolescence (12-20) – Identity vs
Role Confusion
– Achieving new and more mature
relations with age-mates of both sexes
– Achieving a masculine or feminine social
role
– Accepting physique and using body
effectively
– Achieving emotional independence from
parents and other adults
Erikson’s Psychosocial
Development and Havighurst’s
Developmental Tasks
– Preparing for marriage and family life
– Preparing for an economic career
– Acquiring set of values and ethical
system as guide to behavior; developing
ideology
– Desiring and achieving socially
responsible behavior
Erikson’s Psychosocial
Development and Havighurst’s
Developmental Tasks
• Early Adulthood (21-39) –
Intimacy vs Isolation
– Selecting a mate
– Learning to live with marriage
partner
– Starting a family rearing children
– Managing a home
– Getting started in an occupation
Erikson’s Psychosocial
Development and Havighurst’s
Developmental Tasks
• Middle Age (40-60) – Generativituy vs
Stagnation
– Assisting teenage children to become
responsible and happy adults
– Achieving adult social and civic
responsibility
– Reaching and maintaining satisfactory
performance in one’s occupational
career
– Developing adult leisure-time activities
Erikson’s Psychosocial
Development and Havighurst’s
Developmental Tasks
– Relating oneself to one’s spouse as a
person
– Accepting and adjusting to the
physiologic changes of middle age
– Adjusting to aging parents
Erikson’s Psychosocial
Development and Havighurst’s
Developmental Tasks
• Later Maturity (>65) – Ego Integrity
vs Despair
– Adjusting to decreasing physical
strength and health
– Adjusting to retirement and reduced
income
– Adjusting to death of spouse
Erikson’s Psychosocial
Development and Havighurst’s
Developmental Tasks
– Establishing an explicit affiliation with
one’s age-group
– Adopting and adapting social roles in a
flexible way
– Establishing satisfactory physical living
arrangements
Terminologies

• Health
– (WHO) a state of complete physical,
mental and social well being and not
merely the absence of disease or
infirmity
– Absence or presence of symptoms of
illness or their ability to carry out their
normal activities
Terminologies

• Disease
– Presence of pathologic change in the
structure or function of the body or mind
• Illness
– Abnormal process in which the person’s
level of functioning is changed
compared with a previous level
Selye’s Types of Stress
Responses
• Localized Adaptation Syndrome (LAS)
– Short-lived stressor, signs and
symptoms seen in a certain part of the
body
• Generalized Adaptation Syndrome
(GAS)
– Stressor present for a long period; signs
and symptoms manifested by the entire
body
– Eg. Anorexia, body malaise, fever
Steps in the Inflammatory
Response
• Cell and tissue injury
• Vascular response
• Vasoconstriction – produces chemical
mediators (histamine, bradykinin,
serotonin, prostaglandins); produces
blanching of skin
• Vasodilation – causes stasis of blood
and margination of leukocytes;
produces redness of skin
• Fibrin clot formation – histamine,
kinins, prostaglandins causes opening
of venules
Steps in the Inflammatory
Response
• Fluid exudation - histamine, kinins,
protaglansdins causes opening of
venules
• Serous – clear and watery; protein or
albumin portion of the blood and from
serous membrane
• Sanguinous – large number of red
blood cells and looks like blood
Steps in the Inflammatory
Response
• Purulent – white blood cells, liquified
dead tissue debris and live or dead
bacteria; thick and foul smelling
• Edema – swelling of tissue from fluid in
the interstitial space
Steps in the Inflammatory
Response
• Cellular Exudation
• Leukocyte exudation – leukocytes
passes from blood to site of injury and
accumulates there
• Attack and engulfment of foreign
materials – removal and digestion of
bacteria, foreign particles and damaged
tissues
Steps in the Inflammatory
Response
• Healing
• Fibroblasts produce collagen fibers
leading to resolution of inflammation
• Regeneration – proliferation with same
type of cell;
• Labile cells – multiply constantly like the
gastro-intestinal tract
• Permanent cells – neurons
• Stable cells – latent regeneration: kidney,
liver
Cardinal Symptoms of
Inflammation
• Rubor (redness)
• caused by hyperemia
• Calor (heat)
• caused by vasodilation
• Tumor (swelling)
• caused by fluid exudation
• Dolor (pain)
• caused by pressure of fluid exudates and
chemical irritation of nerve endings
• Loss of function
• caused by swelling and pain
Systemic Reactions in
Inflammation
• Fever
• release of endogenous pyrogens,
prostaglandins, endotoxins and
leukotrienes; defense mechanism and
helps increase production of
antimicrobial agents like interferon
• Leukocytosis
• Increase number of leukocytes released
from bone marrow and lymph nodes into
blood
Systemic Reactions in
Inflammation
• Increased Erythrocyte Sedimentation
Rate
• Increase in fibrinogen; indicates that the
body’s defense mechanisms for the
repair of damaged tissues are operating
 Classification of
Inflammation
• According to characteristic type of
exudates:
• Serous – clear; easily reabsorbed
without damage
• Fibrinous – filled with large amount of
fibrinogen
• Sanguinous or hemorrhagic – large
amount of blood from vascular damage
Classification of
Inflammation
• Purulent or suppurative – results from
bacterial infection
• Catarrhal – mucinous secretion and
results from viral infection of respiratory
tract
Classification of
Inflammation
• According to position that inflamed
area occupies within involved tissue:
• Abscess – localized collection of pus
caused by suppuration in tissue, organ
and confined space
• Sinus – infection forming abscess
develops suppurating channel and
ruptures onto the surface or into a body
cavity
Classification of
Inflammation
• Fistula – infection forms a tube-like
passage from an epithelium-lined organ
or normal body cavity to the surface of
another organ or cavity
• Cellulitis – inflammatory process poorly
defined and diffused with tendency to
spread; involves cellular or connective
tissue
• Ulcer – superficial defect on surface of
organ or tissue caused by sloughing of
necrotic tissues
Classification of
Inflammation
• According to location (with suffix itis
– depends upon organ affected)
Classification of
Inflammation
• According to duration or length of
time
• Acute
• Lasts less than 2 weeks; response is
immediate; healing takes place with return
of normal structure and function
Classification of
Inflammation
• Chronic
• Lasts from several weeks to years;
debilitating and produces long lasting effect;
proliferative cell multiplication, cellular
filtration, necrosis, fibrosis or scarring; with
periods of
• Remission – disease is present but the
person does not experience symptoms
• Exacerbation – acute phase, signs and
symptoms are back
Objectives and Principles of
Care
• Conserving energy
• Enhancing inflammatory process
• Increasing fluid intake
• Diminishing effects of inflammation
• Isolating patient
Physiologic Responses to
Stress
• Neuroendocrine responses
• SAMR – Sympatho Adrenal Medullary
Response
• Fight or flight response
• Epinephrine
Physiologic Responses to
Increased Epinephrine
• Increased heart rate and blood
pressure
• Better perfusion of vital organs
• Increased cardiac output and cardiac
rate
• Increased myocardial contractility
• Increased venous return
• Peripheral vasoconstriction
• Increased blood glucose
• Increased energy
Physiologic Responses to
Increased Epinephrine
• Glycogenolysis or carboydrate
breakdown
• Increased mental activity
• alertness, dilated pupils
• Increased tension of skeletal muscles
• Preparedness for activity, decreased
fatigue
• Increased ventilation
• Provision of O2 for energy
Physiologic Responses to
Increased Epinephrine
• Increased coagulability of blood
• Prevents hemorrhage
• Increased perspiration
• Dissipation of heat
• Decreased urinary output
• Decreased gastrointestinal tract
activity; decreased urinary output;
decreased salivation
Physiologic Responses to
Stress
• Adreno-cortical response
• Glucocorticoids
• cortisol
• Mineralocorticoids
• aldosterone
Physiologic Effects of
Glucocorticoids
• Maintains blood glucose
• Increases gluconeogenesis
• Decreases glucose uptake by cells
• Protein and fat catabolism
• Depresses immune response
• Inhibits inflammatory process
• Destroys lymphocytes and decreases
antibody production
Physiologic Effects of
Glucocorticoids
• Augments effects of other hormones and
catecholamines
• Maintains cardiac output and blood
pressure
• Promotes Na and H2O water retention and
K excretion
• Maintains emotional stability
• Increases RBC and platelet formation
• Inhibits defensive acts (anti-inflammatory)
Physiologic Effects of
Mineralicorticoids
• Stimulate defensive acts (pro-
inflammatory)
• Acts on distal tubule of kidneys
• Reabsorption of Na and water
• Excretion of K and H ions
• Maintains vascular volume and BP
Physiologic Responses to
Stress
• Neurohypophyseal response
• Vasopressin or ADH
• Promote Na and water retention
• Adaptive mechanism in bleeding
Physiologic Responses to
Stress
• Antigen-antibody reaction
• Antigen/immunogens
• Substances which when introduced into an
animal causes formation of antibodies or
sensitized cell
• Antibody/immunoglobulins
• Produced when exposed to antigen;
produced in lymphoid tissues
Antibody Types
• IgG – immunoglobulin G
• Crosses placental barrier
• Predominant class (75-85%); major
antibody in primary and secondary
immune responses
• Present in blood plasma
• Plays major role in blood borne and
tissue infection
• Activates compliment system and
enhances phagocytosis
Antibody Types

• IgA – immunoglobulin A
• Present in all body fluids like tears,
saliva, [
• Protects against respiratory,
gastrointestinal and genitourinary
infection
• Prevents absorption of antigens from
food
• Passed on breast milk to protect
neonates
Antibody Types

• IgM – immunoglobulin M
• Confines in intravascular fluids; attached
to B-cells
• First produced in response to bacterial
or viral infection
• Mainstay or primary immune system
• Responsible for transfusion reactions in
ABO blood typing system
Antibody Types

• IgE – immunoglobulin E
• Produced by plasma cells in mucous
membranes and tonsils
• Mediate serum and hypersensitivity
reaction
• Defense against parasitism
Antibody Types

• IgD – immunoglobulin D
• Attached to B cells
• Unknown biologic function
• Activation of and suppression of
lymphocyte function
Antigen-antibody Reactions
• Agglutination
• Agglutinins; clump
• Precipitation
• Precipitins; clusters
• Opsonization
• Opsosins; coats
• Lysis
• Lysozyme; dissolves or liquifies
• Neutralization
• Antitoxin; neutralizes
Physiologic Responses to
Stress
• Immune Response
• Developed when the body recognized
the invading organism that cannot be
identified as part of itself
• Immunity – state of being resistant to
injury or disease
Functions of Immune
System
• Defense – resisting infection
• Homeostasis – removing”worn out”
self component
• Surveillance – identification and
destruction of mutant cells
Types of Immunity

• Active
• Antibodies are synthesized by the body
in response to antigenic stimulation
• Natural
• Contact with antigen eg. chickenpox,
measles
• Artificial
• Immunization with antigen (live or killed
vaccine or toxoid immunization)
Types of Immunity
• Passive
• Antibodies produced in one individual
transferred to another
• Natural
• Transplacental colostrum transfer from mom
to child
• Artificial
• Injection of serum from immune human or
animal
• e.g. human globulin, hyperimmune sera
Interactive Divisions of the
Immune System
• Humoral (antigen antibody reaction)
• Provides immunity against:
• Bacteria that produce acute infection
• Bacterial exotoxins (diphtheria, tetanus)
• Viruses that must enter the bloodstream to
reach their target tissues
• Organisms that enter the body from mucosal
tissues
Interactive Divisions of the
Immune System
• Cellular (cell mediated; lymphocytes)
• Offers protection from:
• Chronic bacterial infection (syphilis, leprosy,
TB)
• Many viral infections (measles, herpes,
chickenpox)
• Fungal infections (candidiasis)
• Parasitic infections (pneumocystis carinii)
• Transplanted or transformed cells
Comparison of Humoral and
Cellular Immunity
HUMORAL CELLULAR
Cells B-lymphocytes T-lymphocytes
Products Antibodies Sensitized T-
cells
Reaction Immediate Delayed
e.g. Anaphylactic TB, contact
shock, dermatitis,
transfusion AIDS
reaction
CARE OF PERI-OPERATIVE
CLIENTS
Conditions Requiring
Surgery
• Obstruction
• Perforation
• Erosion
• Tumor
• Foreign Body
Purposes of Surgery
• Diagnostic – e.g. biopsy
• Exploratory – e.g. exploratory
laparotomy
• Curative
– Ablative
• to remove a diseased organ (appendectomy)
– Reconstructive
• To restore (partially or completely) a
damaged organ or tissue to its normal
apprearance and function (rhinoplasty,
perineorrhapy)
Purposes of Surgery
– Constructive
• Repair of congenital defect (hypospadia)
• Palliative – e.g. colostomy
Types of Surgery

• According to Risk Involved

– Major
• High risk; prolonged in OR; large amount of
blood loss; removal of vital organs; post-
operative complications may develop
– Minor
• Little risk; not prolonged; fewer
complications
Types of Surgery

• According to Urgency
– Emergency - done immediately
– Imperative - performed within 24-48 hrs
– Planned or required - scheduled ahead
for patient’s well-being
– Elective - not absolutely necessary
– Optional - per request for aesthetic
purposes
Surgical Risks

• Physical and mental conditions

– Age
• extreme ages: less than 2 years or more
than 60 years have higher risks
– Nutritional status
• Debilitation and malnutrition
– Drugs taken regularly
• Antibiotics, aspirin
Surgical Risks
– Fluid and electrolyte balance
• Dehydration and hypovolemia
– General health and pre-existing
conditions
• Infection
• Cardiovascular (heart disease, hypertension)
• Pulmonary system (tuberculosis, COPD)
• Genitourinary (renal failure)
• Metabolic and liver function (diabetes,
cirrhosis)
• Neurologic (unconsciousness)
• Hematologic (anemia, hemophilia)
Surgical Risks

• Extent of disease
• Financial resources
• Preparation of surgical team
Pre-op Nursing Care
• Psychological preparations
– Fears and anxiety; patient expetations after
surgery
– Anesthesia
– Destruction of body image
– Pain
– Separation
– Death
– Worry about family, finances, employment and
future
– Unknown
Pre-op Nursing Care
• Informed Consent
– Client voluntarily agrees to undergo a
particular procedure or treatment after
having received these information:
• Description of the procedure or treatment
• Name and qualifications of person
performing the procedure or treatment
• Explanation of the risks involved, including
potential for damage, disfigurement or
death
• That the client has the right to refuse
treatment
Nursing Considerations
(Informed Consent)
• Surgeon explains everything
• Must be written in understandable
language
• Permission is repeated for each
procedure
• Signed at least 24 hours before
elective surgery
• Not to be forced into signing
Nursing Considerations
(Informed Consent)
• Patient signs own consent if he or
she is of age (18 yrs or older),
mentally capable, or is an
emancipated minor (<18 yrs but
independent from parents)
• In emergency where client is unable
to sign or there is immediate threat
to life, effort should be made to
contact family and 2 surgeons to sign
the consent
Pre-op Nursing Care
• Physiologic
– Cardiovascular – ECG for patient aged
40 yrs and above
– Hematologic – complete blood count
(CBC), hemoglobin and hematocrit
(H&H)
– Respiratory – chest x-ray, pulmonary
function test
– Genitourinary – routine urine analysis
(UA)
– Metabolic – fasting blood sugar (FBS)
Pre-op Nursing Care

• Physical
– Gi – NPO, laxatives, enema
– Rest and sleep
– AM care
– Pre-operative checklist
Pre-op Nursing Care
– Pre-operative medications
• Sedatives, hypnotics to decrease anxiety
and provide sedation (e.g. valium)
• Anticholinergics to decrease secretion of
saliva and gastric juices (e.g. atropine
sulfate)
• Narcotics and analgesics to relieve pain and
discomfort (e.g. nalbuphine hydrochloride)
Intra-Operative care
• Skin preparation
– Cranial – depends on surgeon
– Thyroid or neck surgery – chin to nipple
line plus shoulder and axilla
– Eye – cut eyelashes of affected eye
– Nasal – no shaving unless with
mustache
– Ear – 2 ½ inches around ear
– Chest – base of neck to waist, axilla and
under arm
Intra-Operative Care
– Abdominal and pelvic – nipple to symphysis
pubis, vulva, perineum, thigh
– Kidney (anterior) – nipple to perineum; (side to
side) suprascapular region to buttocks
– Vaginal, scrotal, rectal – waist to perineum plus
anterior and inner aspect of thigh and 6 inches
from groin; posterior – entire buttocks and
anus
– Lower extremities – digits 2 inches above knee,
entire extremity and groin
– Upper extremities – distal arm 2 inches above
elbow; elbow up to axilla
Positioning

• Putting patient in proper body

alignment ot expose the operative
site or area
Factors Influencing Position

• Site of operation
• Age and size of patient
• Pain upon moving
• Kind of anesthesia
– Regional – position patient first
– General – position patient last
Qualifications of Good
Position
• Free respiration
• Free circulation
• No pressure on nerve
• Hands or feet properly supported
• No undue postoperative discomfort
• Accessible operative site
Positions-Surgery
• Dorsal – laparotomy, appendectomy
• Dorsal recumbent – vaginal exam;
catheterization
• Fowler’s – craniotomy, tonsillectomy,
nsasal surgery
• Lithotomy
– cystoscopy, trans-urethral-resection of the
prostate, vaginal or perineal repair, vaginal
hysterectomy
Positions-Surgery

• Trendelenburg – urinary bladder,

colon, gynecologic surgery
• Reversed Trendelenburg –
thyroidectomy, gall bladder
• Kidney position with kidney rest –
kidney surgery
• Prone – laminectomy
Anesthesia

• Partial or total loss of sensation of

pain with or without loss of
consciousness
Effects of Anesthesia

• Analgesia – lessening or insensibility

to pain
• Amnesia – loss of memory
• Hypnosis – artificially induced sleep
• Muscle relaxation – part of the body
becomes less firm or rigid
Major Classification of
Anesthesia
• General
– causes total loss of sensation and
consciousness
– Advantages:
• Flexibility
• No discomfort in lengthy procedures
• Better patient monitoring
– Disadvantages:
• Causes respiratory or circulatory depression
• Explosion hazard
Methods of Administration
of General Anesthesia
• Inhalation
– giving gas (cyclopropane) or liquid (halothane)
in volatile form
– Open drop
– Mask or insufflation
– Endotracheal tube
• Intravenous – pentothal Na, ketalar,
innovar
• Rectal – used in minor procedures; does
not produce complete unconsciousness
Major Classification of
Anesthesia
• Regional
– Reduces all painful sensation in one
region of the body without inducing
unconsciousness
• Topical – lidocaine
• Local block
• Saddle block
• Nerve block
• Epidural block
• Caudal block
• Spinal – novocaine, nupercaine, pontocaine
Regional Anesthesia
• Advantages:
– Better airway control
– Fewer respiratory complications
• Disadvantages:
– Anxiety not allayed
– Not flexible
– Short time effect
– Causes systemic depression
– False security
Specialized Methods of
Producing Anesthesia
• Muscle Relaxants
– produces temporary paralysis of all
voluntary muscles: curare, anectin,
pavulon
• Hypothermia
– Deliberate reduction of patient’s body
temperature to 38-30o
• Purposeful Hypotension
– To reduce bleeding at the operative site
Stages of Anesthesia
• Analgesia
– from administration of anesthetics to loss of
consciousness
• Excitement or Delirium
– From loss of consciousness to loss of eyelid
reflexed
• Surgical
– From loss of eyelid reflexes to cessation of
respiratory effort
• Danger
Surgical Incisions

• Kocher’s – oblique, subcostal incision

– Right – gall bladder, biliary, liver surgery
– Left – spleen, gastric surgery
• Vertical
– Upper abdominal midline; epigastric
– Upper median incision – gastric
pancreatic, exploratory laparotomy,
transverse colostomy
Surgical Incisions

• Lower Abdominal Midline

– Pelvic laparotomy, suprapubic
prostatectomy, cesarian section, total
abdominal hysterectomy with bilateral
salphingo-oophorectomy (TAHBSO),
cystectomy, sigmoid colon,
cystolithotomy
– Suprapubic
– Median suprapubic
Surgical Incisions
• Paramedian
– Right upper – gall bladder, biliary, liver
surgery
– Left upper – spleen, gastric surgery
– Right lower – appendectomy, small
bowel resection
– Left lower – sigmoid colon,
hysterectomy
• Mc Burney’s or Rocky Davis –
appendectomy
Surgical Incisions
• Inguinal or Gridiron
– Herniorrhaphy, hydrocoele repair
– Right or left
• Horizontal Flank or midline
transverse
– Nephrectomy, lumbar sympathectomy,
ureterolithotomy
• Lumbotomy or simple flank
– Nephrostomy
Surgical Incisions

• Thoracotomy
– Anterior, lung, lateral anterospinal
fusion, mitral commisurotomy, patent
ductus arteriosus
– Right or left
• Thoraco-abdominal
– Esophago-gastrectomy, esophagostomy,
esophagocardiomyotomy
Surgical Incisions
• Pfannesteil or bikini
– cesarian section, pelvic
• Infraumbilical
– Umbilical hernia repair
• Collarline
– Thyroid, parathyroid
• Coronal or Butterfly
– Craniotomy
Surgical Incisions

• Limbal – cataract
• Elliptical or Halstead
– Radical mastectomy
• Posterior Aural – mastoidectomy
• Canine Fossa – caldwel luc
• Gibson – ureterolithotomy
Objectives of Post op Care

• Reestablishment of physiologic
equilibrium
• Prevention of pain and complications
Physiologic Parameters of
Recovery Room Discharge
• Activity
– Able to move 4 extremities voluntarily on
command
• Respiration
– Able to breath deeply and cough freely
• Circulation
– Blood pressure is +/- 20% of pre-anesthetic
level
• Consciousness
– Fully awake
• Color
– Pink
Goals of Care for Post-
operative Patients
• Promotion of respiratory function
– maintain open airway and prevention of
aspiration
Signs of Poor Respiration
• Early
– Restlessness, fast and thready pulse,
confusion, apprehension
• Late
– Cyanosis, air hunger, stridor
• Nursing Care
– Proper positioning
– Suctioning
– Oral airway
– Deep breathing, coughing exercises
Goals of Care for Post-
operative Patients
• Promote cardio-vascular function and
tissue perfusion

• Basis of good tissue perfusion –

satisfactory cardiac output
Signs of Poor Tissue
Perfusion
• Decreasing blood pressure
– May be due to muscle relaxants, spinal
anesthesia, overdose of pre-operative
medications, blood loss, position change
• Pulse
– Usually slightly rapid and irregular
Goals of Care for Post-
operative Patients
• Promotion of fluid and electrolyte
balance
– Causes of deficit
• Failure to replace fluid volume
• Inadequate replacement of normal losses
• Excessive postoperative losses
– Causes of excess
• Excessive fluid replacement
• Inadequate renal functions
 Goals of Care for Post-
operative Patients
• Promotion of nutrition and
elimination
– IVF, amino acids, blood
– Liquids if not contraindicated – diet
– BM on 2nd – 3rd post-operative day
• Promotion of comfort, rest and
freedom from pain
• Promotion of wound healing
Goals of Care for Post-
operative Patients
• Promotion of renal function
– Should void 6-10 hrs post-operatively
– Causes of Urinary Retention
• Anesthesia
• Clogged catheter
• Unfamiliar surroundings
• Pain, fear, tension
• Promotion of early movement and
ambulation
– Generally encouraged to ambulate 1-2 days
post-operatively
Goals of Care for Post-
operative Patients
• Prevention of post-operative
complications
– Fever
• Usually secondary to wind, water, wound,
inability to walk
– Shock
• Because of cardiovascular collapse;
management dependent upon cause
• Hypovolemic – IVF and blood transfusions
• Septic – antibiotic therapy
• Cardiogenic – treat primary problem
• Drug; transfusion – stop infusion and
Post-operative
Complications
• Pulmonary
– 48 hours post-operative
Pneumonia

• Inflammation of the alveoli as the

result of an infectious process or
presence of foreign material
Causes of Pneumonia

• Aspiration
• Infection
• Depressed cough reflex
• Increased secretions from anesthesia
• Dehydration
• Immobilization
Nursing Assessment for
Pneumonia
• Fever
• Chills
• Cough – productive of purulent or
rusty sputum
• Crackles or wheezes
• Dyspnea
• Chest pain
Nursing Interventions for
Pneumonia
• Promote full aeration of the lungs by
positioning the client in semi-fowler’s or
fowler’s position
• Administer oxygen as indicated
• Maintain nutritional and fluid status
• Administer antibiotic medications as
ordered
• Administer expectorants and analgesics as
ordered
Nursing Interventions for
Pneumonia
• Implement deep breathing and coughing
exercises every 2 hrs
• Maintain personal hygiene, including
frequent oral care
• Teach proper disposal of tissues and
sputum
• Ensure rest and comfort
• Provide emotional support to client and
family
Atelectasis

• The incomplete expansion or

collapse of alveoli with retained
mucous, involving portion of the lung
and resulting in poor gas exchange
Nursing Assessment for
Atelectasis
• Dyspnea
• Cyanosis
• Crackles
• Restlessness or apprehension
Nursing Intervention for
Atelectasis
• Position client in semi-fowler’s position
• Administer oxygen as needed
• Implement deep breathing, coughing and
incentive spirometry every 2 hours
• Implement leg exercises every 2 hrs and
ambulate as ordered
• Maintain hydration
• Administer analgesics for pain as ordered
• Provide emotional support to client and
family
Post-operative
Complications
• Cardiovascular
Hemorrhage

• Excessive blood loss, either internally

or externally (1 to 7 days p.o.)
Causes of Hemorrhage

• Slipped suture
• Dislodged clot in the wound
• Stress on the operative site
• Result of pathophysiologic conditions
• Effect of certain medications
Nursing Assessment for
Hemorrhage
• Restlessness, anxiety
• Frank bleeding
• Signs of hypovolemic shock
Nursing Interventions for
Hemorrhage
• Apply pressure dressing on bleeding
site
• Be prepared to have the client return
to the OR if bleeding cannot be
stopped or is massive
• Nursing care in shock
Shock

• Body’s reaction to peripheral

circulatory failure as a result of an
alteration in circulatory control or to
a loss of circulating fluid
• Hypovolemic – decrease in blood
volume
Nursing Assessment of
Shock
• Hypotension
• Cold clammy skin or diaphoresis
• Weak thready and rapid pulse
• Deep rapid respirations
• Decreased urinary output, thirst
Nursing Interventions for
Shock
• Maintain airway
• Place on flat position with leg elevated at
45o (shock position)
• Prepare to administer fluid or blood
• Administer oxygen as indicated
• Maintain warmth
• Administer medications as ordered
• Monitor vital signs and general condition
• Provide psychological support to client or
family
Thrombophlebitis

• 7 – 14 days post-op
• Inflammation of the vein associated
with blood clot formation
Nursing Assessment of
Thrombophlebitis
• Pain or cramping in the calf or thigh
• Redness and swelling of affected are
• Fever
• (+) Homan’s sign
– Pain on the calf or thigh upon
dorsiflexion of the foot
Nursing Interventions for
Thrombophlebitis
• Administer anticoagulant medications as
ordered
• Maintain on bed rest – don’t ambulate
• Use antiembolic stockings
• Elevate affected leg to heart level
• Do NOT massage or rub the legs
• Give analgesics and use external heat
applications as ordered
• Measure bilateral calf or thigh
circumference every shift
• Provide emotional support to the client or
Post-operative
Complications
• Wound Complications
Wound Infections
• Causes:
– Nosocomial
– Intrinsic to patient – diabetes, malnutrition
– Extrinsic – lack of aseptic technique
• Nursing Assessment:
– Lever
– Swelling
– Erythema
– Purulent discharge
– Leukocytosis
Wound Dehiscence

• Partial to complete separation of the

wound edges
Wound Evisceration

• Protrusion of abdominal viscera

through the incision and onto the
abdominal wall
Causes of Wound
Evisceration
• 1-3 days postop – suturing, abdominal
distention, vomiting, excessive coughing,
dehydration, infection
• Cachexia, hypoproteinemia, avitaminosis,
aging, decreased resistance to infection,
malignant tumor, multiple trauma,
hypothermia
• Corticosteroids, presence of foreign
bodies, irradiation, poor circulation
Nursing Assessment of
Wound Evisceration
• “giving” sensation at incision
• Feeling of wetness at post-operative site
• Evisceration with sever localized pain at
incision
• Dressing saturated with pink drainage
• Wound edges partially or entirely
separated
• Loops of intestine lying on abdominal wall
• Signs of shock may occur
Nursing Interventions for
Wound Evisceration
• Stay with patient and have someone notify
surgeon immediately
• If intestines are exposed, cover with sterile moist
dressings
• Keep patient on absolute bed rest – low fowler’s
• Instruct patient to bend his knees – relieves
tension on abdomen
• Instruct not to cough, sneeze, eat, drink and
remain quiet
• Assure patient that wound will be properly taken
cared for
• Prepare for surgery and repair of wound
Post-operative
Complications
• Urinary Retention
– Inability to void (voiding should return 6
to 8 hrs p.o.)
Causes of Urinary Retention
• Effect of anesthesia
• Local edema resulting from surgery
of the rectum, colon or gynecological
structures
• Temporary disturbance of the
bladder musculature
• Recumbent position
• Nervous tension
• Pain caused by movement on
surgical site
Nursing Assessment of
Urinary Retention
• Voiding of little or no ruing over 6-8
hrs period
• Palpation on abdomen elicits
discomfort
• Hypogastric distention
Nursing Interventions for
Urinary Retention
• Assist patient to sit or stand up (if
possible)
• Provide privacy
• Use psychological aid of running tap
water – relaxed bladder sphincter
spasm
• Catheterize when all measures are
unsuccessful
Post-operative
Complications
• Gastro-intestinal
Abdominal Distention or
Paralytic Ileus
• Accumulation of non-absorbable gas
in the intestines
Causes of Abdominal
Distention or Paralytic Ileus
• Resection and handling of the bowel
during surgery
• Swallowing of air during recovery
from anesthesia
• Passing gasses from the bloodstream
to bowel
Nursing Assessment of
Abdominal Distention or
Paralytic Ileus
• Diffuse abdominal pain
• High distention may cause dyspnea
• Increased abdominal girth
• Drumlike (tympanic) sound upon
percussion
• Acute dilation may produce shock
Nursing Interventions for
Abdominal Distention or
Paralytic Ileus
• Auscultate bowel sounds
• Assess client’s ability to pass flatus
or stool
• Instruct patient to refrain from
talking or moaning immediate post-
op
Nursing Interventions for
Abdominal Distention or
Paralytic Ileus
• Assist with movement in bed and
ambulation to help relieve gas pains
• Encourage good and fluid intake only
when ordered
• Administer NGT colon tubes,
suppositories or enemas if ordered
Hiccups or Singultus

• Cause: Irritation of the phrenic nerve

– Distended stomach, peritonitis,
abdominal distention, chest pleurisy,
tumors pressing on nerves, surgery
performed near diaphragm
– Indirect – toxemia, uremia
– Reflex – exposure to cold, drinking very
cold or very hot liquids, intestinal
obstruction
Nursing Interventions for
Hiccups or Singultus
• Remove the cause if possible – gastric
lavage for abdominal distention
• Hold breath while taking large swallow of
water
• Apply finger pressure on the eyeballs
through closed lids for several minutes
• Inhaling carbon dioxide through paper bag
• Medications as prescribed –
chlorpromazine, benzedrine, quinidine, or
barbiturates
Post-operative
Complications
• Pain
– Subjective symptom in which the patient
exhibits a feeling of distress
Causes of Pain
• Cutting, pulling and manipulating of
tissues and organs
• Stimulation of nerve endings by chemical
substances released during surgery
• Tissue ischemia caused by interference of
blood supply to tissues
• Trauma to nerve fibers
• Extensive dissection and prolonged
retraction of muscle and fascia
Nursing Assessment of Pain

• Elevation of blood pressure

• Increase in heart rate and pulse rate
• Rapid and irregular respiration
• Outpouring of epinephrine
• Increase in muscle tension or activity
• Increase irritability, apprehension
and anxiety
Nursing Interventions for
Pain
• Assess the nature, location, quality,
intensity and duration of pain
• Initiate measures to reduce the
likelihood of pain like turning,
verbalizing and giving analgesics
– Principle of care: do not wait until the
pain is so severe before giving pain
medication
Nursing Interventions for
Pain
• Employ comfort measures such as
providing therapeutic environment,
massage, diversional therapies
• Relieves localized pain by supporting
painful areas, elevating painful
extremities, hot or cold applications and
follow prescribed exercise program.
• Never use hot applications on a postop
wound