PERIOPERATIVE NURSING a.

Notify the health care provider and surgical

- a term used to describe the nursing care provided during the total surgical unit immediately if you get a cold, have a
experience of the patient: preoperative, intraoperative, and postoperative. fever, or have any illness before the date of
surgery.
Preoperative Phase—from the time the decision is made for surgical b. Arrive at the specified time.
intervention to the transfer of the patient to the operating room. c. Do not ingest food or fluid before surgery
according to facility protocol. Less strict
Intraoperative Phase—from the time the patient is received in the operating guidelines for fasting have been advocated,
room until admitted to the postanesthesia care unit (PACU). but are controversial. The American Society
of Anesthesiology guidelines for
Postoperative Phase—from the time of admission to the PACU to the follow- preoperative fasting are available:
up evaluation. www.asahq.org/practice/spo/npoguide.htm
.
Anesthesia Care Provider—a professional who can administer and monitor d. Do not wear makeup or nail polish.
anesthesia during a surgical procedure; may be a licensed physician board- e. Wear comfortable, loose clothing and low-
certified in anesthesia (anesthesiologist) or a certified registered nurse heeled shoes.
anesthetist (CRNA). f. Leave valuables or jewelry at home.
g. Brush your teeth in morning and rinse, but
Types of Surgery do not swallow any liquid.
h. Shower the night before or day of the
Elective—the scheduled time for surgery is at the convenience of the patient; surgery.
failure to have surgery is not catastrophic (e.g., a superficial cyst). i. Follow the health care provider's
instructions for taking medications.
Required—the condition requires surgery within a few weeks (e.g., eye j. Have a responsible adult accompany you
cataract). and drive you home—have someone stay
with you for 24 hours after the surgery.
Emergency—the situation requires immediate surgical attention without
delay (e.g., intestinal obstruction). NURSING ALERT

AMBULATORY SURGERY a common occurrence for certain types of
procedures. The office nurse is in a key position to assess patient status; plan
the perioperative experience; and monitor, instruct, and evaluate the
patient.
Advantages
Reduced cost to the facility, and insuring and governmental agencies
Reduced psychological stress to the patient
Less incidence of hospital-acquired infection
Less time lost from work by the patient; minimal disruption of the patient's
activities and family life
Disadvantages
Less time to assess the patient and perform preoperative teaching
Less time to establish rapport between the patient and health care personnel
Prolonged fasting before surgery may result in undue thirst, hunger,
irritability, headache, and possibly dehydration, hypovolemia, and
hypoglycemia. Make sure that patients understand preoperative fasting
instructions per facility protocol. Nothing by mouth (NPO) after midnight
may not be necessary for surgeries scheduled later in the morning or
afternoon.
Preoperative Preparation
1. Conduct a nursing assessment, focusing on cardiovascular and
respiratory status. Obtain baseline vital signs, including an oxygen
saturation level and current pain score.
2. Review the patient's chart for witnessed and informed consent,
laterality (right or left, if applicable), lab work, and history and
physical.
3. Verify correct patient, correct site, and correct procedure.
4. Make sure the patient has followed food and fluid restrictions, has
removed all jewelry and dentures, and is appropriately dressed for
surgery.
5. Administer pre-procedural medication, if applicable.

Less opportunity to assess for late postoperative complications. (This
responsibility is primarily with the patient, although telephone and home
care follow-up is possible.)
Patient Selection
Criteria for selection include:
1. Surgery of short duration (varies by procedure and facility)
2. Non-infected conditions
3. Type of operation in which postoperative complications are
predictably low
4. Age usually not a factor, although too risky in a premature
neonate
Ambulatory Surgery Settings is performed in a variety of settings. A high
percentage of outpatient surgery occurs in traditional hospital operating
rooms in hospital-integrated facilities. Other ambulatory surgery settings may
be hospital-affiliated or independently owned and operated. Some types of
outpatient surgeries can be performed safely in the health care provider's
office.
Nursing Management
Initial Assessment
1. Develop a nursing history for the outpatient; this may
be initiated in the health care provider's office. The
history should include the patient's physical and
psychological status. You will also inquire about
allergies, tobacco, alcohol, and drug use, disabilities or
limitations, current medications (including over-the-
counter and herbs), current health conditions (focus
should be on cardiovascular and respiratory problems,
diabetes, and renal impairments), and any past
surgeries and/or problems with anesthesia.
2. Ensure availability of a signed and witnessed informed
consent that includes correct surgical procedure and
site.
3. Explain any additional laboratory studies needed and
state why.
4. Begin the health education regimen. Instructions to the
patient:
1
Postoperative Care
1. Check vital signs, including oxygen saturation, temperature, and
pain score.
2. Administer oxygen, if necessary.
3. Change the patient's position and progress activity—head of bed
elevated, dangling, ambulating. Watch for dizziness or nausea.
4. Ascertain, using the following criteria, that the patient has
recovered adequately to be discharged:
a. Vital signs stable and returned to preoperative level
b. Stands without excessive dizziness; able to ambulate
short distances
c. Pain score within tolerable level (usually less than 3
required)
d. Able to drink fluids
e. Oriented to time, place, and person
f. No evidence of respiratory distress
g. Has the services of a responsible adult who can escort
the patient home and remain with patient
h. Understands postoperative instructions and takes an
instruction sheet home
PATIENT EDUCATION GUIDELINES
Outpatient Post-anesthesia and Post-surgery Instructions and Information
 Although you will be awake and alert in the recovery room, small
amounts of anesthetic will remain in your body for at least 24
hours and you may feel tired and sleepy for the remainder of the
day. Once you are home, take it easy and rest as much as possible.
It is advisable to have someone with you at home for the
remainder of the day.
 Eat lightly for the first 12 to 24 hours, then resume a well-
balanced, normal diet. Drink plenty of fluids. Alcoholic beverages
are to be avoided for 24 hours after your anesthesia or I.V.
sedation.
 Nausea or vomiting may occur in the first 24 hours. Lie down on
your side and breathe deeply. Prolonged nausea, vomiting, or pain
should be reported to your surgeon.
 Ask your surgeon or anesthesiologist when you can resume your
daily medications after surgery.
 Your surgeon will discuss your postsurgery instructions with you
and prescribe medication for you as indicated. You will also
 receive additional instructions specific to your surgical procedure
before leaving the facility.
 Your family will be waiting for you in the facility's waiting room
area near the outpatient surgery department. Your surgeon will
speak to them in this area before your discharge.
 Do not operate a motor vehicle or any mechanical or electrical
equipment for 24 hours after your anesthesia.
 Do not make any important decisions or sign legal documents for
24 hours after your anesthesia.
INFORMED CONSENT (OPERATIVE PERMIT) is the process of informing the
patient about the surgical procedure; that is, risks and possible complications
of surgery and anesthesia. Consent is obtained by the surgeon. This is a legal
requirement. Hospitals usually have a standard operative permit form
approved by the hospital's legal department.
Adolescent Patient and Informed Consent
1. An emancipated minor is usually recognized as one who is not
subject to parental control. Regulations vary by jurisdiction but
generally include:
a. Married minor.
b. Those in military service.
c. Minor who has a child.
2. Most states have statutes regarding treatment of minors.
3. Standards for informed consent are the same as for adults.
Procedures Requiring a Permit
1. Surgical procedures whether major or minor
2. Entrance into a body cavity, such as colonoscopy,
paracentesis, bronchoscopy, cystoscopy, or lumbar
puncture
3. Radiologic procedures, particularly if a contrast
material is required (such as myelogram, magnetic
resonance imaging with contrast, angiography)
4. All procedures requiring any type of anesthesia
SURGICAL RISK FACTORS AND PREVENTIVE STRATEGIES
Obesity
Danger
1. Increases the difficulty involved in the technical aspects of
performing surgery; risk for wound dehiscence is greater
2. Increases the likelihood of infection because of
compromised tissue perfusion
3. Increases the potential for postoperative pneumonia and
other pulmonary complications because obese patients
chronically hypoventilate
4. Increases demands on the heart, leading to cardiovascular
compromise
5. Increases the risk for airway complications
6. Alters the response to many drugs and anesthetics
7. Decreases the likelihood of early ambulation
Therapeutic Approach
1. Encourage weight reduction if time permits.
2. Anticipate postoperative obesity-related complications.
3. Be extremely vigilant for respiratory complications.
4. Carefully splint abdominal incisions when moving or
coughing.
5. Be aware that some drugs should be dosed according to
ideal body weight versus actual weight (owing to fat
content); otherwise, an overdose may occur (digoxin
[Lanoxin], lidocaine [Xylocaine], aminoglycosides, and
theophylline [Theo-Dur]).
6. Avoid intramuscular injections in morbidly obese individuals
(I.V. or subcutaneous routes preferred).
7. Never attempt to move an impaired patient without
assistance or without using proper body mechanics.
8. Obtain a dietary consultation early in the patient's
postoperative course.
Poor Nutrition
Danger
1. Greatly impairs wound healing (especially protein and
calorie deficits and a negative nitrogen balance)
2. Increases the risk of infection
Therapeutic Approach
1. Any recent (within 4 to 6 weeks) weight loss of 10% of the
patient's normal body weight or decreased serum albumin
should alert the health care staff to poor nutritional status
and the need to investigate as to the cause of the weight
loss.
2. Attempt to improve nutritional status before and after
surgery. Unless contraindicated, provide a diet high in
proteins, calories, and vitamins (especially vitamins C and A);
this may require enteral and parenteral feeding.
3. Review a serum pre-albumin level to determine recent
nutritional status.
4. Recommend repair of dental caries and proper mouth
hygiene to prevent infection.
2
Fluid and Electrolyte Imbalance
Danger
1. Can have adverse effects in terms of general anesthesia and
the anticipated volume losses associated with surgery,
causing shock and cardiac dysrhythmias
Therapeutic Approach
1. Assess the patient's fluid and electrolyte status.
2. Rehydrate the patient parenterally and orally as prescribed.
3. Monitor for evidence of electrolyte imbalance, especially
Na+, K+, Mg++, Ca++.
4. Be aware of expected drainage amounts and composition;
report excess and abnormalities.
5. Monitor the patient's intake and output; be sure to include
all body fluid losses.
02 NURSING ALERT
Patients undergoing major abdominal operations (such as colectomies and
aortic repairs) often experience a massive fluid shift into tissues around the
operative site in the form of edema (as much as 1 L or more may be lost
from circulation). Watch for the fluid shift to reverse (from tissue to
circulation) around the third postoperative day. Patients with heart disease
may develop failure due to the excess fluid “load.”
Aging
Danger
1. Potential for injury is greater in older people
2. Be aware that the cumulative effect of medications is
greater in the older patient
3. Medications in the usual dosages, such as morphine, may
cause confusion, disorientation, and respiratory depression
Therapeutic Approach
1. Consider using lesser doses for desired effect.
2. Anticipate problems from chronic disorders such as anemia,
obesity, diabetes, hypoproteinemia.
3. Adjust nutritional intake to conform to higher protein and
vitamin needs.
4. When possible, cater to set patterns in older patients, such
as sleeping and eating.
Presence of Cardiovascular Disease
Danger
1. May compound the stress of anesthesia and the operative
procedure
2. May result in impaired oxygenation, cardiac rhythm, cardiac
output, and circulation
3. May also produce cardiac decompensation, sudden
arrhythmia, thromboembolism, acute myocardial infarction
(MI), or cardiac arrest
Therapeutic Approach
1. Frequently assess heart rate and blood pressure (BP) and
hemodynamic status and cardiac rhythm if indicated.
2. Avoid fluid overload (oral, parenteral, blood products)
because of possible MI, angina, heart failure, and pulmonary
edema.
3. Prevent prolonged immobilization, which results in venous
stasis. Monitor for potential deep vein thrombosis (DVT) or
pulmonary embolus.
4. Encourage position changes but avoid sudden exertion.
5. Use anti-embolism stockings and/or sequential compression
device intra-operatively and postoperatively.
6. Note evidence of hypoxia and initiate therapy.
Presence of Diabetes Mellitus
Danger
1. Hypoglycemia may result from food and fluid restrictions
and anesthesia.
2. Hyperglycemia and ketoacidosis may be potentiated by
increased catecholamines and glucocorticoids due to
surgical stress.
3. Chronic hyperglycemia results in poor wound healing and
susceptibility to infection.
Therapeutic Approach
1. Recognize the signs and symptoms of ketoacidosis and
hypoglycemia, which can threaten an otherwise uneventful
surgical experience. Dehydration also threatens renal
function.
2. Monitor blood glucose and be prepared to administer
insulin, as directed, or treat hypoglycemia.
3. Confirm what medications the patient has taken and what
has been held. Facility protocol and provider preference
varies, but the goal is to prevent hypoglycemia. If the patient
is NPO, oral agents are usually withheld and insulin may be
ordered at 75% of the usual dose.
 4. Reassure the diabetic patient that when the disease is
controlled, the surgical risk is no greater than it is for the
non-diabetic patient.
DRUG ALERT
Rare reports of lactic acidosis have raised concerns about the use of
metformin (Glucophage) in the perioperative period. Metformin is usually
held 48 hours before surgery and restarted when full food and fluid intake
has restarted and normal renal function has been confirmed.
Presence of Alcoholism
Danger
1. The additional problem of malnutrition may be present in
the presurgical patient with alcoholism. The patient may also
have an increased tolerance to anesthetics.
Therapeutic Approach
1. Note that the risk of surgery is greater for the patient who
has chronic alcoholism.
2. Anticipate the acute withdrawal syndrome within 72 hours
of the last alcoholic drink.
Presence of Pulmonary and Upper Respiratory Disease
Danger
1. Chronic pulmonary illness may contribute to
hypoventilation, leading to pneumonia and atelectasis.
Surgery may be contraindicated in the patient who has an
upper respiratory infection because of the possible advance
of infection to pneumonia and sepsis.
Therapeutic Approach
1. Patients with chronic pulmonary problems, such as
emphysema or bronchiectasis, should be evaluated and
treated prior to surgery to optimize pulmonary function with
bronchodilators, corticosteroids, and conscientious mouth
care, along with a reduction in weight and smoking and
methods to control secretions.
2. Opioids should be used cautiously to prevent
hypoventilation. Patient-controlled analgesia is preferred.
3. Oxygen should be administered to prevent hypoxemia (low
liter flow in chronic obstructive pulmonary disease).
Concurrent or Prior Pharmacotherapy
Danger
1. Hazards exist when certain medications are given
concomitantly with others (eg, interaction of some drugs
with anesthetics can lead to hypotension and circulatory
collapse). This also includes the use of many herbal
substances. Although herbs are natural products, they can
interact with other medications used in surgery.
Therapeutic Approach
1. An awareness of drug therapy is essential.
2. Notify the health care provider and anesthesiologist if the
patient is taking any of the following drugs:
a. Certain antibiotics
b. Antidepressants, particularly monoamine oxidase
inhibitors, and St. John's wort, an herbal product
c. Phenothiazines
d. Diuretics, particularly thiazides
e. Steroids
f. Anticoagulants, such as warfarin or heparin; or
medications or herbals that may affect
coagulation, such as aspirin, feverfew, ginkgo
biloba, nonsteroidal anti-inflammatory drugs,
ticlopidine (Ticlid), and clopidogrel (Plavix)
PREOPERATIVE CARE
PATIENT EDUCATION is a vital component of the surgical experience. May be
offered through conversation, discussion, the use of audiovisual aids,
demonstrations, and return demonstrations. It is designed to help the patient
understand the surgical experience to minimize anxiety and promote full
recovery from surgery and anesthesia. The educational program may be
initiated before hospitalization by the physician, nurse practitioner or office
nurse, or other designated personnel. This is particularly important for
patients who are admitted the day of surgery or who are to undergo
outpatient surgical procedures. The perioperative nurse can assess the
patient's knowledge base and use this information in developing a plan for an
uneventful perioperative course.
General Instructions
Preoperatively, the patient will be instructed in the following postoperative
activities. This will allow a chance for practice and familiarity.
Incentive Spirometry
3
Preoperatively, the patient uses a spirometer to measure deep breaths
(inspired air) while exerting maximum effort. The preoperative measurement
becomes the goal to be achieved as soon as possible after the operation.
1. Postoperatively, the patient is encouraged to use the incentive
spirometer about 10 to 12 times per hour.
2. Deep inhalations expand alveoli, which prevents atelectasis and
other pulmonary complications.
3. There is less pain with inspiratory concentration than with
expiratory concentration such as with coughing.
Coughing
Coughing promotes the removal of chest secretions. Instruct the patient to:
1. Interlace fingers and place hands over the proposed incision site;
this will act as a splint during coughing and not harm the incision.
2. Lean forward slightly while sitting in bed.
3. Breathe, using the diaphragm.
4. Inhale fully with the mouth slightly open.
5. Let out three or four sharp “hacks.”
6. With his mouth open, take in a deep breath and quickly give one
or two strong coughs.
7. Secretions should be readily cleared from the chest to prevent
respiratory complications (pneumonia, obstruction).
NURSING ALERT
Incentive spirometry, deep breathing, and coughing as well as certain
position changes may be contraindicated after some surgeries (eg,
craniotomy and eye or ear surgery).
Turning
Changing positions from back to side-lying (and vice versa) stimulates
circulation, encourages deeper breathing, and relieves pressure areas.
1. Help the patient to move onto his side if assistance is needed.
2. Place the uppermost leg in a more flexed position than that of the
lower leg, and place a pillow comfortably between the legs.
3. Make sure that the patient is turned from one side to the back
and onto the other side every 2 hours.
Foot and Leg Exercises
Moving the legs improves circulation and muscle tone.
1. Have the patient lie supine; instruct patient to bend a knee and
raise the foot—hold it a few seconds, and lower it to the bed.
2. Repeat above about five times with one leg and then with the
other. Repeat the set five times every 3 to 5 hours.
3. Then have the patient lie on one side and exercise the legs by
pretending to pedal a bicycle.
4. Suggest the following foot exercise: Trace a complete circle with
the great toe.
Evaluation of Teaching Program
A. Observe the patient for correct demonstration of expected
postoperative behaviors, such as foot and leg exercises and
special breathing techniques.
B. Ask pertinent questions to determine the patient's level of
understanding.
C. Reinforce information when necessary
PREPARATION OF THE OPERATIVE AREA
Skin
 Human skin normally harbors transient and resident bacterial
flora, some of which are pathogenic.
 Skin cannot be sterilized without destroying skin cells.
 Friction enhances the action of detergent antiseptics; however,
friction should not be applied over a superficial malignancy
(causes seeding of malignant cells) or areas of carotid plaque
(causes plaque dislodgment and emboli).
 It is ideal for the patient to bathe or shower using a bacteriostatic
soap (eg, Hibiclens) on the day of surgery. The surgical schedule
may require that a shower be taken the night before.
 The Centers for Disease Control and Prevention recommend that
hair not be removed near the operative site unless it will interfere
with surgery. Skin is easily injured during shaving and often results
in a higher rate of postoperative wound infection.
 If required, hair removal should be done by clipping, not shaving,
and should be performed within 2 hours of surgery. Scissors may
be used to remove hair greater than 3 mm in length.
 For head surgery, obtain specific instructions from the surgeon
concerning the extent of shaving.
Gastrointestinal Tract
 Preparation of the bowel is imperative for intestinal surgery
because escaping bacteria can invade adjacent tissues and cause
sepsis.
o Cathartics and enemas remove gross collections of
stool (eg, GoLYTELY).
o Oral antimicrobial agents (eg, neomycin, erythromycin)
suppress the colon's potent microflora.
o Enemas “until clear” are generally not necessary. If
ordered, they are given the night before surgery.
Notify the health care provider if the enemas never
return clear.
  Solid food is withheld from the patient for 6 hours before surgery.
Patients having morning surgery are kept NPO overnight. Clear
fluids (water) may be given up to 4 hours before surgery
depending on facility protocols.
Genitourinary Tract
 A medicated douche may be prescribed preoperatively if the
patient is to have a gynecologic or urologic operation.
PREOPERATIVE MEDICATION
With the increase of ambulatory surgery and same-day admissions, pre-
anesthetic medications, skin preps, and douches are seldom ordered.
Prophylactic antibiotics, however, are often ordered to prevent surgical site
infections. Research, however, points to an increase in Clostridium difficile
diarrheal infections due to antibiotic use. If used, antibiotics should be
administered just before surgery—preferably 1 hour before an incision is
made—to be effective when bacterial contamination is expected.
Administering “On Call” Medications
 Have the medication ready and administer it as soon as the call is
received from the operating room.
 Proceed with the remaining preparation activities.
 Indicate on the chart or preoperative checklist the time when the
medication was administered and by whom.
NURSING ALERT
Preanesthetic medication, if ordered, should be given precisely at the time
it is prescribed. If given too early, the maximum potency will have passed
before it is needed; if given too late, the action will not have begun before
anesthesia is started.
ADMITTING THE PATIENT TO SURGERY
Final Checklist
The preoperative checklist is the last procedure before taking the
patient to the operating room. Most facilities have a standard
form for this check.
Identification and Verification
This includes verbal identification by the perioperative nurse while
checking the identification band on the patient's wrist and written
documentation (such as the chart) of the patient's identity, the
procedure to be performed (laterality if indicated), the specific
surgical site marked by the surgeon with indelible ink, the
surgeon, and the type of anesthesia.
Review of Patient Record
Check for inclusion of the fact sheet; allergies; history and
physical; completed preoperative checklist; laboratory values,
including most recent results, pregnancy test, if applicable;
electrocardiogram (ECG) and chest X-rays, if necessary;
preoperative medications; and other preoperative orders by
either the surgeon or anesthesia care provider.
Consent Form
All nurses involved with patient care in the preoperative setting
should be aware of the individual state laws regarding informed
consent and the specific facility policy. Obtaining informed
consent is the responsibility of the surgeon performing the
specific procedure. Consent forms should state the procedure,
various risks, and alternatives to surgery, if any. It is a nursing
responsibility to make sure the consent form has been obtained
with the patient or guardian's signature and that it is in the chart.
Patient Preparedness
1. NPO status
2. Proper attire (gown)
3. Skin preparation, if ordered
4. I.V. started with correct gauge needle
5. Dentures or plates removed
6. Jewelry, contact lenses, and glasses removed and secured in a
locked area or given to a family member
7. Allow the patient to void
Transporting the Patient to the Operating Room
1. Adhere to the principle of maintaining the comfort and safety of
the patient.
2. Accompany operating room attendants to the patient's bedside
for introduction and proper identification.
3. Assist in transferring the patient from bed to stretcher (unless the
bed goes to the operating room floor).
4. Complete the chart and preoperative checklist; include laboratory
reports and X-rays as required by facility policy or the health care
provider's directive.
5. Make sure that the patient arrives in the operating room at the
proper time.
The Patient's Family
1. Direct the patient's family to the proper waiting room where
magazines, television, and a coffee station may be available.
2. Tell the family that the surgeon will probably contact them there
after surgery to inform them about the operation.
3. Inform the family that a long interval of waiting does not mean
the patient is in the operating room the whole time; anesthesia
preparation and induction take time, and after surgery the patient
is taken to the PACU.
4
4. Tell the family what to expect postoperatively when they see the
patient—tubes; monitoring equipment; and blood transfusion,
suctioning, and oxygen equipment.
INTRAOPERATIVE CARE
ANESTHESIA AND RELATED COMPLICATIONS
The goals of anesthesia are to provide analgesia, sedation, and muscle
relaxation appropriate for the type of operative procedure as well as to
control the autonomic nervous system.
Common Anesthetic Techniques
1. Moderate Sedation
 A specific level of sedation that allows patients to tolerate
unpleasant procedures by reducing the level of anxiety and
discomfort; previously known as conscious sedation.
 The patient achieves a depressed level of consciousness (LOC) and
altered perception of pain while retaining the ability to
appropriately respond to verbal and tactile stimuli.
 Cardiopulmonary function and protective airway reflexes are
maintained by the patient.
 Knowledge of expected outcomes is essential. These outcomes
include, but are not limited to:
o Maintenance of consciousness.
o Maintenance of protective reflexes.
o Alteration of pain perception.
o Enhanced cooperation.
 Adequate preoperative preparation of the patient will facilitate
achieving the desired effects.
 Nurses caring for patients receiving moderate sedation should be
specially trained in the agents used for moderate sedation, such
as midazolam (Versed) and fentanyl (Duragesic), and should be
skilled in advanced life support. Indeed, many facilities have strict
regulations and training requirements for staff handling such
patients.
 Nurses working in this setting should also be aware of the
regulations from the Board of Nursing in the state they are
practicing concerning the care of patients receiving conscious
sedation as well as of the American Nurses Association Statement
on the Role of the RN in the Management of Patients Receiving
Conscious Sedation for Short-Term, Therapeutic, Diagnostic, or
Surgical Procedures (available through www.nursingworld. org).
 If patients are not candidates for conscious sedation and require
more complex sedation, they should be managed by anesthesia
care providers.
1. Monitored Anesthesia Care
 Light to deep sedation that is monitored by an anesthesia care
provider.
 The patient is asleep but arousable.
 The patient is not intubated.
 The patient may receive local anesthesia and oxygen, is
monitored, and receives sedation and analgesia. Midazolam,
fentanyl, alfentanil, and propofol (Diprivan) are frequently used in
monitored anesthesia care procedures.
2. General Anesthesia
 A reversible state consisting of complete loss of consciousness.
Protective reflexes are lost.
 With the loss of protective reflexes, the patient's airway needs to
be maintained. This can be done by endotracheal intubation or
insertion of a laryngeal mask airway (LMA).
General anesthesia consists of three phases; induction, maintenance, and
emergence.
Induction can be accomplished either by parenteral or inhalation
route.
 Common agents for I.V. induction are propofol and
phenobarbital.
 In addition to the induction agent, a potent analgesic is
also often added (eg, fentanyl). The analgesic
potentiates the induction agent as well as provides
analgesia.
 Patients can also reach an unconscious state by
inhaling a potent, short-acting volatile gas. Sevoflurane
(Ultane) is one such example.
 Once the patient is asleep, and if the surgical
procedure so requires, a muscle relaxant is given and
the ET tube is inserted. Common muscle relaxants
include vecuronium, rocuronium, and succinylcholine
(Anectine).
Maintenance is accomplished through a continuous delivery of an
inhalation agent, such as sevoflurane, isoflurane (Forane), or
desflurane (Suprane); or, an I.V. infusion of an agent such as
propofol to maintain an unconscious state. Intermittent doses of
an analgesic are given as needed as well as intermittent doses of a
muscle relaxant for longer surgeries.

Emergence occurs at the end of the surgery when the continuous
delivery of either the gas or the I.V. infusion is stopped and the
patient slowly returns to a conscious state.
 If muscle relaxants are still in effect, they can be
reversed with neostigmine (Prostigmin) to allow for
adequate muscle strength and return of spontaneous
ventilations.
 A nerve stimulator can be used to assess if adequate
muscle control has returned before extubation of the
trachea.
 During emergence, the patient is very sensitive to any
stimuli and it is important to keep noise levels to a
minimum and refrain from manipulating the patient
during this stage.
3. Regional Anesthesia
Examples of regional anesthesia include spinal, epidural, and peripheral
blocks (eg, inter-scalen blocks, ankle-blocks.)
 Anesthesia is achieved by injecting a local anesthetic, such as
lidocaine (Xylocaine) or marcaine (Bupivacaine), in close
proximity to appropriate nerves.
 Nursing responsibilities include being familiar with the drug
used and maximum dose that can be given, knowing signs
and symptoms of toxicity, and maintaining a comfortable
environment for the conscious patient.
4.a. Spinal anesthesia is the injection of a local anesthetic into the
lumbar intrathecal space. The anesthetic blocks conduction in spinal
nerve roots and dorsal ganglia, thereby causing paralysis and analgesia
below the level of injection.
4.b. Epidural anesthesia involves injecting local anesthetic into the
epidural space. Results are similar to spinal analgesia but with a slower
onset.
Often a catheter is inserted for continuous infusion of the anesthetic to
the epidural space.
The catheter may be left in place to provide postoperative analgesia as
well.
4.c. Peripheral nerve block is achieved by injecting a local anesthetic
into a bundle of nerves (eg, axillary plexus) or into a single nerve to
achieve anesthesia to a specific part of the body (eg, hand or single
finger).
Intraoperative Complications:
1. Hypoventilation and hypoxemia—due to inadequate
ventilatory support
2. Oral trauma (broken teeth, oropharyngeal, or laryngeal
trauma)—due to difficult ET intubation
3. Hypotension—due to preoperative hypovolemia or
untoward reactions to anesthetic agents
4. Cardiac dysrhythmia—due to preexisting cardiovascular
compromise, electrolyte imbalance, or untoward reactions
to anesthetic agents
5. Hypothermia—due to exposure to a cool ambient operating
room environment and loss of normal thermoregulation
capability from anesthetic agents
6. Peripheral nerve damage—due to improper positioning of
the patient (eg, full weight on an arm) or use of restraints
7. Malignant hyperthermia
a. This is a rare reaction to anesthetic inhalants
(notably sevoflurane, enflurane [Ethrane],
isoflurane, and desflurane) and the muscle
relaxant, succinylcholine.
b. Caused by abnormal and excessive intracellular
accumulations of calcium with resulting
hypermetabolism, increased muscle contraction,
and elevated body temperature.
c. Treatment consists of discontinuing the inhalant
anesthetic, administering I.V. dantrolene
(Dantrium), and applying cooling techniques (eg,
cooling blanket, iced saline lavages).
Fluid and Electrolytes, Acid-Base Balance
 Fluid and electrolyte balance is a dynamic process that is crucial
for life and homeostasis.
 Fluid occupies almost 60% of the weight of an adult.
 Body fluid is located in two fluid compartments: the intracellular
space and the extracellular space.
 Electrolytes in body fluids are active chemicals or cations that
carry positive charges and anions that carry negative charges.
 The major cations in the body fluid are sodium, potassium,
calcium, magnesium, and hydrogen ions.
 The major anions are chloride, bicarbonate, sulfate, and
proteinate ions.
Homeostasis
5
Homeostasis is the dynamic process in which the body maintains
balance by constantly adjusting to internal and external stimuli.
Negative and Positive Feedback
Feedback is the relaying of information about a given condition to
the appropriate organ or system.
Negative feedback. Negative feedback occurs when the body
reverses an original stimulus for the body to regain physiologic
balance.
Positive feedback. Positive feedback enhances or intensifies the
original stimulus.
Examples. Blood pressure control and maintenance of normal
body temperature are examples of negative feedback while blood
clotting after an injury and a woman in labor are examples of
positive feedback.
Systems Involved in Feedback
The major systems involved in feedback are the nervous and endocrine
systems.
Nervous system. The nervous system regulates homeostasis by sensing
system deviations and sending nerve impulses to appropriate organs.
Endocrine system. The endocrine system uses the release and action of
hormones to maintain homeostasis.
Body Fluids
Fluids make up a large portion of the body, which is approximately 50%-60%
of the total body weight.
Location of Fluids
Main compartments. Body fluids are divided between two main
compartments: the intracellular fluid and the extracellular fluid
compartments.
Intracellular fluid. Intracellular fluid functions as a stabilizing agent for the
parts of the cell, helps maintain cell shape, and assists with transport of
nutrients across the cell membrane, in and out of the cell.
Extracellular fluid. Extracellular fluid mostly appears as interstitial tissue fluid
and intravascular fluid.
Fluid Regulation Mechanisms
The thirst center. The thirst center in the hypothalamus stimulates or inhibits
the desire for a person to drink.
Antidiuretic hormone. ADH regulates the amount of water the kidney
tubules absorb and is released in response to low blood volume or in
response to an increase in concentration of sodium and other solutes in the
intravascular fluids.
The RAA system. The RAA system controls fluid volume, in which when the
blood volume decreases, blood flow to the renal juxtaglomerular apparatus is
reduced, thereby activating the RAA system.
Atrial natriuretic peptide. The heart also plays a role in correcting overload
imbalances, by releasing ANP from the right atrium.
Normal Intake and Output
Daily intake. An adult human at rest takes appropriately 2,500 ml
of fluid daily.
Levels of intake. Approximate levels of intake include fluids 1, 200
ml, foods 1, 000 ml, and metabolic products 30 ml.
Daily output. Daily output should approximately equal in intake.
Normal output. Normal output occurs as urine, breathing,
perspiration, feces, and in minimal amounts of vaginal secretions.
Overhydration and Edema
Overhydration. Overhydration is an excess of water in the body.
Edema. Edema is the excess accumulation of fluid in interstitial
tissue spaces, also called third-space fluid.
Cause of edema. Edema is caused by a disruption of the filtration
and osmotic forces of the body’s circulating fluids.
Treatment of edema. Diuretics are commonly given for systemic
edema.
Dehydration
Dehydration. Dehydration is a deficiency of body water or
excessive loss of water.
External causes. External causes of dehydration include prolonged
sun exposure and excessive exercise, as well as diarrhea, vomiting,
and burns.
Treatment of dehydration. Supplemental fluids and electrolytes
are often administered.
Electrolytes
An electrolyte is a substance that will disassociate into ions when dissolved in
water.
Origins. Electrolytes are found in the form of inorganic salts, acids,
and bases.
Active chemicals. Electrolyte concentrations are measured
according to their chemical activity and expressed as
milliequivalents.
Ions. Each chemical element has an electrical charge, either
positive or negative.
Intracellular electrolytes. Important intracellular electrolytes are
potassium, magnesium, sulfate, and phosphate, and the most
 dominant cation iss potassium while the most dominant anion is
phosphate.
Extracellular electrolytes. Important extracellular electrolytes
include sodium, chlorine, calcium, and bicarbonate, and the most
essential cation is sodium while chlorine is the most important
anion.
Fluid and Electrolyte Transport
Total electrolyte concentration affects the body’s fluid balance.
The body cells. Nutrients and oxygen should enter body cells
while waste products should exit the body.
The cell membrane. The cell membrane separates the
intracellular environment from the extracellular environment.
Permeability. The ability of a membrane to allow molecules to
pass through is known as permeability.
Permeability of Membranes
Freely permeable membranes. These membranes
allow almost any food or waste substance to pass
through.
Selectively permeable. The cell membrane is
selectively permeable, meaning that each cell’s
membrane allows only certain specific substances to
pass through.
Passive Transport
Passive transport. Passive transport mechanisms include
diffusion, osmosis, and filtration.
Diffusion. Diffusion, or the process of “being widely spread”, is the
random movement of molecules from an area of higher
concentration to an area of lower concentration.
Osmosis. Osmosis is the diffusion of a pure solvent, such as water,
across a semipermeable membrane in response to a
concentration gradient in situations where the molecules of a
higher concentration are non diffusible.
Filtration. Filtration is the transport of water and dissolved
materials concentration already exists in the cell.
Active Transport
Mechanisms. Active transport mechanisms require specific
enzymes and an energy expenditure in the form of adenosine
triphosphate (ATP).
Processes. Active transport processes can move solutes “uphill”,
against the normal rules of concentration and pressure.
Fluid and Electrolyte Balance
Fluid and electrolyte balance is vital for proper functioning of all
body systems.
Osmolarity. This is the property of particles in a solution to
dissociate into ions.
Electroneutrality. This is the balance of positive and negative
charges.
Acid-Base Balance
Acid-base balance is another important aspect of homeostasis.
Acid, Bases, and Salts
Acid. An acid is one type of compound that contains the hydrogen
ion.
Base. A base or alkali is a compound that contains the hydroxyl
ion.
Salt. A salt is a combination of a base and an acid and is created
when the positive ions of a base replace the positive hydrogen
ions of an acid.
Important salts. The body contains several important salts like
sodium chloride, potassium chloride, calcium chloride, calcium
carbonate, calcium phosphate, and sodium phosphate.
Potential of Hydrogen
pH. The symbol of pH refers to the potential or power of
hydrogen ion concentration within the solution.
Low pH. If the pH number is lower than 7, the solution is an acid.
High pH. If the pH is greater than 7, a solution is basic or alkaline.
Neutral pH. If the pH is 7, then the solution is neutral.
Changes. A change in the pH of a solution by one pH unit means a
tenfold change in hydrogen concentration.
Buffers
Buffers. A buffer is a chemical system set up to resist changes,
particularly in hydrogen ion levels.
Bicarbonate buffer system. Sodium bicarbonate and carbonic acid
are the body’s major chemical buffers.
Carbon dioxide. The major compound controlled by the lungs is
CO2, and the respiratory system can very rapidly compensate for
too much acid and too little acid by increasing or decreasing the
respiratory rate, thereby altering the level of CO2.
6
Bicarbonate. Bicarbonate ions are basic components in the body,
and the kidneys are key in regulating the amount of bicarbonate
in the body.
Measurement of arterial blood gas. The pH level and amounts of
specific gases in the blood indicate if there is more acid or base
and their associated values.
Respiratory acidosis. Respiratory acidosis occurs when breathing
is inadequate and PaCO2 builds up.
Respiratory alkalosis. Respiratory alkalosis occurs as a result of
hyperventilation or excess aspirin intake.
Metabolic acidosis. In metabolic acidosis, metabolism is impaired,
causing a decrease in bicarbonates and a buildup of lactic acid.
Metabolic alkalosis. Metabolic alkalosis occurs when bicarbonate
ion concentration increases, causing an elevation in blood pH.
Classification
There are different fluid volume disturbances that may affect an individual.
Fluid volume deficit or hypovolemia occurs when loss of ECF
volume exceeds the intake of fluid.
Fluid volume excess or hypervolemia refers to an isotonic volume
expansion of the ECF caused by the abnormal retention of water
and sodium in approximately the same proportions in which they
normally exist in the ECF.
Disturbances in electrolyte balances are common in clinical practice and must
be corrected.
Hyponatremia refers to a serum sodium level that is less than 135
mEq/L
Hypernatremia is a serum sodium level higher than 145 mEq/L.
Hypokalemia usually indicates a deficit in total potassium stores.
Hyperkalemia refers to a potassium level greater than 5.0 mEq/L.
Hypocalcemia are serum levels below 8.6 mg/dl.
Hypercalcemia is calcium level greater than 10.2 mg/dl.
Hypomagnesemia refers to a below-normal serum magnesium
concentration.
Hypermagnesemia are serum levels over 2.3 mg/dl.
Hypophosphatemia is indicated by a value below 2.5 mg/dl.
Hyperphosphatemia is a serum phosphorus level that exceeds 4.5
mg/dl in adults.
Pathophysiology
Nurses need an understanding of the pathophysiology of fluid and
electrolyte balance to anticipate, identify, and respond to possible
imbalances.
Concentrations. Electrolyte concentrations vary from those in the
ICF to those in the ECF.
Sodium. Sodium ions outnumber any other cations in the ECF;
therefore it is essential in the fluid regulation of the body.
Potassium. The ECF has a low concentration of potassium and can
tolerate only small changes in its concentrations.
Maintenance. The body expends a great deal of energy in
maintaining the sodium and potassium concentrations through
cell membrane pumps that exchange sodium and potassium ions.
Osmosis. When two different solutions are separated by a
membrane that is impermeable to the dissolved substances, fluid
shifts from the region of low solute concentration to the high
solute concentration until the solutions are of equal
concentrations.
Diffusion. Diffusion is the natural tendency of a substance to
move in an area of higher concentration to an area of lower
concentration.
Causes
Causes of fluid and electrolyte imbalances are discussed below in
general.
Fluid retention. Retention of sodium is associated with fluid
retention.
Loss of sodium. Excessive loss of sodium is associated with
decreased volume of body fluid.
Trauma. Trauma causes release of intracellular potassium which is
extremely dangerous.
Loss of body fluids. FVD results from loss of body fluids and
occurs more rapidly when coupled with decreased fluid intake.
Fluid overload. Fluid volume excess may be related to a simple
fluid overload or diminished function of the homeostatic
mechanisms responsible for regulating fluid balance.
Low or high electrolyte intake. Diets low or excessive in
electrolytes could also cause electrolyte imbalances.
Medications. There are certain medications that could lead to
electrolyte imbalances when taken against the physician’s orders.
Clinical Manifestations
Signs and symptoms that occur in fluid and electrolyte imbalances
are discussed below.
 Fluid volume deficit. Clinical signs and symptoms include acute
weight loss, decreased skin turgor, oliguria, concentrated urine,
orthostatic hypotension, a weak, rapid heart rate, flattened neck
veins, increased temperature, thirst, decreased or delayed
capillary refill, cool, clammy skin, muscle weakness, and cramps.
Fluid volume excess. Clinical manifestations for FVE include
edema, distended neck veins, and crackles.
Hyponatremia. Signs and symptoms include anorexia, nausea and
vomiting, headache, lethargy, dizziness, confusion, muscle cramps
and weakness, muscular twitching, seizures, dry skin, and edema.
Hypernatremia. The signs and symptoms are thirst, elevated body
temperature, hallucinations, lethargy, restlessness, pulmonary
edema, twitching, increased BP and pulse.
Hypokalemia. Clinical manifestations are fatigue, anorexia,
muscle weakness, polyuria, decreased bowel motility, paresthesia,
ileus, abdominal distention, and hypoactive reflexes
Hyperkalemia. Signs and symptoms include muscle weakness,
tachycardia, paresthesia, dysrhythmias, intestinal colic, cramps,
abdominal distention, and anxiety.
Hypocalcemia. The signs and symptoms are numbness, tingling of
fingers, toes, and circumoral region, positive Trousseau’s sign and
Chvostek’s sign, seizures, hyperactive deep tendon reflexes,
irritability, and bronchospasm.
Hypercalcemia. The signs and symptoms include muscle
weakness, constipation, anorexia, nausea and vomiting,
dehydration, hypoactive deep tendon reflexes lethargy, calcium
stones, flank pain, pathologic fractures, and deep bone pain.
Hypomagnesemia. Clinical manifestations include neuromuscular
irritability, positive Trousseau’s and Chvostek’s sign, insomnia,
mood changes, anorexia, vomiting, and increased deep tendon
reflexes.
Hypermagnesemia. Signs and symptoms are flushing,
hypotension, muscle weakness, drowsiness, hypoactive reflexes,
depressed respirations, and diaphoresis.
Hypophosphatemia. Signs and symptoms include paresthesias,
muscle weakness, bone pain and tenderness, chest pain,
confusion, seizures, tissue hypoxia, and nystagmus.
Hyperphosphatemia. Clinical manifestations are tetany,
tachycardia, anorexia, nausea and vomiting, muscle weakness,
and hyperactive reflexes.
Complications
Fluid and electrolyte imbalances could result in complications if
not treated promptly.
Dehydration. Fluid volume deficit could result in dehydration of
the body tissues.
Cardiac overload. Fluid volume excess could result in cardiac
overload if left untreated.
SIADH. Water is retained abnormally in SIADH.
Cardiac arrest. Too much potassium administered could lead to
cardiac arrest.
Assessment and Diagnostic Findings
The following are laboratory studies useful in diagnosing fluid and
electrolyte imbalances:
BUN. BUN may be decreased in FVE due to plasma dilution.
Hematocrit. Hematocrit levels in FVD are greater than normal
because there is a decreased plasma volume.
Physical examination. Physical exam is necessary to observe the
signs and symptoms of the imbalances.
Serum electrolyte levels. Measurement of electrolyte levels
should be performed to check for presence of an imbalance.
ECG. ECG changes can also contribute to the diagnosis of fluid and
electrolyte imbalance.
ABG analysis. ABG analysis may reveal acid-base imbalances.
Medical Management
Isotonic electrolyte solutions. These solutions are used to treat
the hypotensive patient with FVD because they expand plasma
volume.
Accurate I&O. Accurate and frequent assessments of I&O should
be performed when therapy should be slowed or increased to
prevent volume deficit or overload.
Dialysis. Hemodialysis or peritoneal dialysis is performed to
remove nitrogenous wastes and control potassium and acid-base
balance, and to remove sodium and fluid.
Nutritional therapy. Treatment of fluid and electrolyte
imbalances should involve restrictions or enforcement of the
concerned electrolyte.
Pharmacologic therapy
AVP receptor agonists. These are new pharmacologic agents that
treat hyponatremia by stimulating free water excretion.
Diuretics. To decrease fluid volume in FVE, diuretics are
administered.
IV calcium gluconate. If serum potassium levels are dangerously
elevated, it may be necessary to administer IV calcium gluconate.
7
Calcitonin. Calcitonin can be used to lower the serum calcium
level and is particularly useful for patients with heart disease or
heart failure who cannot tolerate large sodium loads.
Nursing Management
Nurses may use effective teaching and communication skills to
help prevent and treat various fluid and electrolyte disturbances.
Nursing Assessment
Close monitoring should be done for patients with fluid and
electrolyte imbalances.
I&O. the nurse should monitor for fluid I&O at least every 8 hours,
or even hourly.
Daily weight. Assess the patient’s weight daily to measure any
gains or losses.
Vital signs. Vital signs should be closely monitored.
Physical exam. Physical exam is needed to reinforce other data
about a fluid or electrolyte imbalance.
Diagnosis
The following diagnoses are found in patients with fluid and
electrolyte imbalances.
 Excess fluid volume related to excess fluid intake and sodium
intake.
 Deficient fluid volume related to active fluid loss or failure of
regulatory mechanisms.
 Imbalanced nutrition: less than body requirements related to
inability to ingest food or absorb nutrients.
 Imbalanced nutrition: more than body requirements related to
excessive intake.
 Diarrhea related to adverse effects of medications or
malabsorption.
Nursing Care Planning & Goals
Planning and goals for fluid and electrolyte imbalances include:
1. Maintenance of fluid volume at a functional level.
2. Display of normal laboratory values.
3. Demonstration appropriate changes in lifestyle and behaviors
including eating patterns and food quantity/quality.
4. Reestablishment and maintenance of normal pattern and GI
functioning.
Nursing Interventions
There are specific nursing interventions for fluid and electrolyte
imbalances that can aid in alleviating the patient’s condition.
 Monitor turgor. Skin and tongue turgor are indicators of the fluid
status of the patient.
 Urine concentration. Obtain urine sample of the patient to check
for urine concentration.
 Oral and parenteral fluids. Administer oral or parenteral fluids as
indicated to correct the deficit.
 Oral rehydration solutions. These solutions provide fluid, glucose,
and electrolytes in concentrations that are easily absorbed.
 Central nervous system changes. The nurse must be alert for
central nervous system changes such as lethargy, seizures,
confusion, and muscle twitching.
 Diet. The nurse must encourage intake of electrolytes that are
deficient or restrict intake if the electrolyte levels are excessive.
POST-OPERATIVE CARE
POSTANESTHESIA CARE UNIT
To ensure continuity of care from the intraoperative phase to the immediate
postoperative phase, the circulating nurse or anesthesia care provider gives a
thorough report to the PACU nurse. This should include the following:
1. Type of surgery performed and any intraoperative
complications
2. Type of anesthesia (eg, general, local, sedation)
3. Drains and type of dressings
4. Presence of ET tube or type of oxygen to be
administered (eg, nasal cannula, T-piece)
5. Types of lines and locations (eg, peripheral I.V., central
line, arterial line)
6. Catheters or tubes, such as a urinary catheter or T-tube
7. Administration of blood, colloids, and fluids and
electrolytes
8. Drug allergies, and pertinent medical history
9. Preexisting medical conditions
10. Intraoperative course, including any complications or
instability in the patient's vital signs
STANDARDS OF CARE GUIDELINES
PACU Care
Postanesthesia care unit (PACU) care is geared towards recognizing the signs
of distress and anticipating and preventing postoperative difficulties.
Carefully monitor the patient coming out of general anesthesia until:
a. Vital signs are stable and are within normal range.
 b. The patient has no signs of respiratory distress and can maintain
his own airway.
c. Reflexes have returned to normal.
d. Pain is under control and at a tolerable level for the patient.
e. The patient is responsive and oriented to time and place.
Initial Nursing Assessment
Before receiving the patient, note the proper functioning of monitoring and
suctioning devices, oxygen therapy equipment, and all other equipment. The
following initial assessment is made by the nurse in the PACU:
1. Verify the patient's identity, the operative procedure, and the
surgeon who performed the procedure.
2. Obtain vital signs, including pulse oximetry and temperature.
3. Evaluate airway status, noting any stridor or snoring respirations.
4. Evaluate respiratory status, including rate and effort, and
auscultate breath sounds.
5. Assess circulatory status, noting skin color, peripheral pulses, and
ECG monitor.
6. Observe LOC and orientation to time and place.
7. Evaluate condition of surgical dressings and drains and check I.V.
lines and infusing fluids and/or I.V. medications.
8. Determine patient's pain level using a 1 to 10 scale.
9. Review the health care provider's orders.
Initial Nursing Diagnoses
1. Ineffective Airway Clearance related to effects of anesthesia
2. Impaired Gas Exchange related to ventilation-perfusion imbalance
3. Ineffective Tissue Perfusion (Cardiopulmonary) related to
hypotension postoperatively
4. Risk for Imbalanced Body Temperature related to medications,
sedation, and cool environment
5. Risk for Deficient Fluid Volume related to blood loss, food and
fluid deprivation, vomiting, and indwelling tubes
6. Acute Pain related to surgical incision and tissue trauma
7. Impaired Skin Integrity related to invasive procedure,
immobilization, and altered metabolic and circulatory state
8. Risk for Injury related to sensory dysfunction and physical
environment
9. Disturbed Sensory Perception related to effects of medications
and anesthesia
Initial Nursing Interventions:
Maintaining a Patent Airway
 Closely monitor the patient arriving with an oral or nasal airway in
place until fully awake.
 Monitor for return of cough and gag reflex. When the patient is
awake and able to protect his own airway, the oral or nasal airway
can be discontinued.
Maintaining Adequate Respiratory Function
 Encourage the patient to take deep breaths to aerate the lungs
fully and prevent atelectasis; use an incentive spirometer to aid in
this function.
 Assess lung fields frequently through auscultation.
 Periodically evaluate the patient's LOC—response to name or
command. Note: Alterations in cerebral function may suggest
impaired oxygen delivery.
 Administer humidified oxygen to reduce irritation of airways and
facilitate secretion removal.
Promoting Tissue Perfusion
 Monitor vital signs (BP, pulse, respiratory rate, and oxygen
saturation) according to protocol, normally every 15 minutes
while in the PACU. Monitor ECG tracing for arrhythmias.
o Report variations in BP, heart rate, respiratory rate,
and cardiac arrhythmias.
o Evaluate pulse pressure to determine status of
perfusion. (A narrowing pulse pressure indicates
impending shock.)
 Monitor intake and output closely.
 Recognize the variety of factors that may alter circulating blood
volume, such as blood loss during surgery and fluid shifts after
surgery.
o Recognize early symptoms of shock or hemorrhage.
 Cool extremities, decreased urine output (less than 30 mL/hour),
slow capillary refill (greater than 3 seconds), decreased BP,
narrowing pulse pressure, and increased heart rate are usually
indicative of decreased cardiac output.
o Intervene to improve tissue perfusion.
o Initiate oxygen therapy or increase fraction of inspired
oxygen of existing oxygen delivery system.
o Increase parenteral fluid infusion as prescribed.
o Place the patient in the shock position with his feet
elevated (unless contraindicated).
Stabilizing Thermoregulatory Status
 Monitor temperature every 15 minutes and be alert for
development of both hypothermia and hyperthermia.
8
 Report a temperature more than 101.5° F (38.6° C) or less than
95° F (35° C).
 Monitor for postanesthesia shivering that, although common in
hypothermic patients, may also occur in normothermic patients,
especially those who received inhalants during anesthesia. It
represents a heat-gain mechanism, which drastically increases
oxygen demand.
 Provide warm blankets for patients feeling cold.
 Provide active warming with forced warm air for hypothermic
patients.
Maintaining Adequate Fluid Volume
 Administer I.V. solutions as ordered.
 Monitor intake and output.
 Monitor electrolytes and recognize evidence of imbalance, such as
nausea, vomiting, and weakness.
 Evaluate mental status and skin color and turgor.
 Recognize signs of fluid imbalance.
o Hypovolemia—decreased BP, decreased urine output,
decreased central venous pressure (CVP), increased
pulse.
o Hypervolemia—increased BP; changes in lung sounds,
such as crackles in the bases; changes in heart sounds
(eg, S3 gallop); increased CVP.
 Evaluate I.V. sites to detect early infiltration. Restart lines
immediately to maintain fluid volume.
Promoting Comfort
 Assess pain by observing behavioral and physiologic
manifestations (change in vital signs may be a result of pain); have
the patient rate pain on a scale of 1 to 10.
 Administer analgesics and document efficacy.
 Position the patient to maximize comfort.
Minimizing Complications of Skin Impairment
 Perform hand washing before and after contact with the patient.
 Inspect dressings routinely and reinforce them if necessary.
 Record the amount and type of wound drainage (see “Wound
Management,” page 125).
 Turn the patient frequently and maintain good body alignment.
Maintaining Safety
 Keep the side rails up until the patient is fully awake.
 Protect the extremity into which I.V. fluids are running so that the
needle will not become accidentally dislodged.
 Avoid nerve damage and muscle strain by properly supporting and
padding pressure areas.
 Be aware that patients who have received regional anesthesia
may not be able to complain of an injury, such as the pricking of
an open safety pin or a clamp that is exerting pressure.
 Check the dressing for constriction.
 Determine the return of motor control following regional
anesthesia—indicated by how the patient responds to a request
to move a body part.
Minimizing Sensory Deficits
 Know that the ability to hear returns more quickly than other
senses as the patient emerges from anesthesia.
 Avoid saying anything in the patient's presence that may be
disturbing; the patient may appear to be sleeping but still
consciously hears what is being said.
 Explain procedures and activities at the patient's level of
understanding.
 Minimize the patient's exposure to emergency treatment of
nearby patients by drawing the curtains and lowering your voice
and noise levels.
 Treat the patient as a person who needs as much attention as the
equipment and monitoring devices.
 Respect the patient's feeling of sensory deprivation and
overstimulation; make adjustments to minimize this fluctuation of
stimuli.
 Demonstrate concern for and an understanding of the patient and
anticipate his needs and feelings.
 Tell the patient repeatedly that the surgery is over and that she is
in the PACU.
Evaluation: Expected Outcomes
1. Absence of respiratory distress
2. Lung sounds clear to auscultation
3. Vital signs stable and within preoperative ranges
4. Body temperature more than 95° F (35° C) and less than 101.5° F
(38.6° C)
5. Adequate pain control
6. Wound/dressing intact without excessive drainage
7. Side rails up; positioned carefully
8. Quiet, reassuring environment maintained
9. Movement of extremities after regional anesthesia
Transferring the Patient from the PACU 4. Encourage the early use of nonopioid analgesia because
Each facility may have an individual checklist or scoring guide used to many opiates increase the risk of constipation.
determine a patient's readiness for transfer. 5. Assess bowel sounds frequently.

Transfer Responsibilities Nursing Interventions

1. Relay appropriate information to the unit nurse regarding the 1. Ask the patient about any usual remedy for constipation and
patient's condition; point out significant needs, vital signs (trends try it, if appropriate.
and most recent set), fluid therapy, incision and dressing 2. Insert a gloved, lubricated finger and break up the fecal
requirements, intake needs, urine output, and color and amount impaction manually, if necessary.
of any drainage. 3. Administer an oil retention enema (180 to 200 mL), if
2. Physically assist in the transfer of the patient. prescribed, to help soften the fecal mass and facilitate
3. Orient the patient to the room, attending nurse, call light, and evacuation.
therapeutic devices. 4. Administer a return-flow enema (if prescribed) or a rectal
tube to decrease painful flatulence.
POSTOPERATIVE DISCOMFORTS 5. Administer GI stimulants, laxatives, suppositories, and stool
Most patients experience some discomforts postoperatively. softeners, as prescribed.
These are usually related to the general anesthetic and the
surgical procedure. The most common discomforts are nausea, POSTOPERATIVE PAIN
vomiting, restlessness, sleeplessness, thirst, constipation,
flatulence, and pain. General Principles
 Pain is one of the earliest symptoms that the patient expresses on
Postoperative Nausea and Vomiting return to consciousness.
Causes  Maximal postoperative pain occurs directly after surgery and
1. Occurs in many postoperative patients usually diminishes significantly by 48 hours.
2. Most commonly related to inhalation anesthetics (nitrous
oxide) and opioid use Clinical Manifestations
3. Can result from an accumulation of fluid or food in the Autonomic
stomach before peristalsis returns a. Elevation of BP
4. May occur as a result of abdominal distention, which follows b. Increase in heart and pulse rate
manipulation of abdominal organs c. Rapid and irregular respiration
d. Increase in perspiration
Preventive Measures Skeletal muscle
1. Insert a nasogastric (NG) tube intraoperatively for a. Increase in muscle tension or activity
operations on the GI tract to prevent abdominal distention, Psychological
which triggers vomiting. a. Increase in irritability
2. Evaluate patient preoperatively for risk factors for PONV, b. Increase in apprehension
such as being female, a nonsmoker, and a history of motion c. Increase in anxiety
sickness. d. Attention focused on pain
e. Complaints of pain
Nursing Interventions
1. Encourage the patient to breathe deeply to facilitate The patient's reaction depends on:
elimination of anesthetic. 1. Previous experience
2. Support the wound during retching and vomiting; turn the 2. Anxiety or tension
patient's head to the side to prevent aspiration. 3. State of health
3. Discard vomitus and refresh the patient—provide 4. Ability to be distracted
mouthwash and clean linens. 5. Meaning that pain has for the patient
4. Provide small sips of a carbonated beverage such as ginger
ale, if tolerated or permitted. Preventive Measures
5. Report excessive or prolonged vomiting so the cause may be 1. Reduce anxiety due to anticipation of pain.
investigated. 2. Teach patient about pain management.
6. Maintain an accurate intake and output record and replace 3. Review analgesics with patient and reassure that pain relief will be
fluids as ordered. available quickly.
7. Detect the presence of abdominal distention or hiccups, 4. Establish a trusting relationship and spend time with patient.
suggesting gastric retention.
8. Administer antiemetics such as ondansetron (Zofran) or Nursing Interventions:
promethazine (Phenergan) as directed; be aware that some Use Basic Comfort Measures
of these drugs may potentiate the hypotensive effects of a. Provide therapeutic environment—proper temperature and
opioids. humidity, ventilation, visitors.
b. Massage patient's back and pressure points with soothing strokes
Thirst —move patient gently and with prewarning.
Causes c. Offer diversional activities, soft music, or favorite television
1. Inhibition of secretions by medication with atropine program.
2. Fluid lost by way of perspiration, blood loss, and dehydration d. Provide for fluid needs by giving a cool drink; offer a bedpan.
due to NPO status e. Investigate possible causes of pain, such as bandage or adhesive
that is too tight, full bladder, a cast that is too snug, or elevated
Preventive Measures temperature indicating inflammation or infection.
1. Unfortunately, postoperative thirst is a common and f. Instruct patient to splint the wound when moving.
troublesome symptom that is usually unavoidable due to g. Keep bedding clean, dry, and free from wrinkles and debris.
anesthesia. The immediate implementation of nursing Recognize the Power of Suggestion
interventions is most helpful. a. Provide reassurance that the discomfort is temporary and that the
medication will aid in pain reduction.
Nursing Interventions b. Clarify patient's fears regarding the perceived significance of pain.
1. Administer fluids parenterally or orally, if tolerated and c. Assist patient in maintaining a positive, hopeful attitude.
permitted. Assist in Relaxation Techniques
2. Offer ice chips. a. Imagery, meditation, controlled breathing, self-hypnosis or
3. Apply a moistened gauze square over lips occasionally to suggestion (autogenic training), and progressive relaxation.
humidify inspired air. Apply Cutaneous Counter-stimulation
4. Allow the patient to rinse mouth with mouthwash. b. Vibration—a vigorous form of massage that is applied to a - site. It
lessens the patient's perception of pain. (Avoid applying this to
Constipation and Gas Cramps the calf because it may dislodge a thrombus.)
Causes c. Heat or cold—apply to the operative or non-operative site as
1. Trauma and manipulation of the bowel during surgery as prescribed. This works best for well-localized pain. Cold has more
well as opioid use. advantages than heat and fewer unwanted adverse effects (eg,
2. More serious causes: peritonitis or abscess. burns). Heat works well with muscle spasm.
Give Analgesics as Prescribed in a Timely Manner
Preventive Measures a. Instruct the patient to request an analgesic before the pain
1. Encourage early ambulation to aid in promoting peristalsis. becomes severe.
2. Provide adequate fluid intake to promote soft stools and b. If pain occurs consistently and predictably throughout a 24-hour
hydration. period, analgesics should be given around the clock—avoiding the
3. Advocate proper diet to promote peristalsis.

9
 usual “demand cycle” of dosing that sets up eventual dependency
and provides less adequate pain relief.
c. Administer prescribed medication to the patient before
anticipated activities and painful procedures (eg, dressing
changes).
d. Monitor for possible adverse effects of analgesic therapy (eg,
respiratory depression, hypotension, nausea, skin rash).
Administer naloxone (Narcan) to relieve significant opioid-induced
respiratory depression.
e. Assess and document the efficacy of analgesic therapy.
Pharmacologic Management:
Oral and Parenteral Analgesia
a. Surgical patients are commonly prescribed a parenteral analgesic
for 2 to 4 days or until the incisional pain abates. At that time, an
oral analgesic, opioid, or non-opioid will be prescribed.
b. Although the health care provider is responsible for prescribing
the appropriate medication, it is the nurse's responsibility to make
sure the drug is given safely and assessed for efficacy.
NURSING ALERT
The patient who remains sedated due to analgesia is at risk for
complications such as aspiration, respiratory depression, atelectasis,
hypotension, falls, and poor postoperative course.
DRUG ALERT
Opioid “potentiators,” such as hydroxyzine (Vistaril), may further sedate
the patient.
Epidural Analgesia
Requires injections of opioids into the epidural space by way of a catheter
inserted by an anesthesiologist under aseptic conditions
Benefit: provides for longer periods of analgesia.
POSTOPERATIVE COMPLICATIONS are a risk inherent in surgical procedures.
They may interfere with the expected outcome of the surgery and may
extend the patient's hospitalization and convalescence. The nurse plays a
critical role in attempting to prevent complications and in recognizing their
signs and symptoms immediately.
STANDARDS OF CARE GUIDELINES
Preventing and Recognizing Postoperative Complications
Care of the patient after surgery should include the following, until risk of
complications has passed:
1. Monitor vital signs (BP, pulse, respirations,
temperature, and LOC) frequently until stable, and
then periodically thereafter depending on the
condition of the patient.
2. Observe the wound site for drainage, odor, swelling,
and redness, which could indicate infection.
3. Observe the wound for intactness and stage of healing.
4. Assess the patient's pain level and monitor for unusual
increase in pain (which may indicate infection or other
problem) as well as oversedation related to opioid
administration.
5. Monitor fluid status through vital signs, presence of
edema, and intake and output measurements.
6. Assess for presence of bowel sounds before resuming
oral feedings, and monitor for abdominal distention,
nausea, and vomiting, which could indicate paralytic
ileus.
7. Provide measures to enhance circulation of the lower
extremities, such as pneumatic compression, elastic
wraps, range-of-motion exercises, and early
ambulation; and assess for tenderness, swelling, and
red streaking, which may indicate DVT.
8. Assess pulmonary status including respiratory effort
and rate; breath sounds; skin, mucous membrane, and
nailbed color; and transcutaneous oxygen saturation.
9. Make sure that the patient is voiding regularly after
surgery or after catheter removal.
10. Notify the surgeon if there is a significant deviation
from the norm in any one of these parameters, or if a
pattern of deviation is developing.
Shock
Shock is a response of the body to decreased tissue perfusion
culminating, eventually, in cellular hypoxia and death. (See page
1208 for classification and emergency management of shock.)
Preventive Measures
a. Have blood available if there is any indication that it may be
needed.
b. Accurately measure any blood loss and monitor all fluid intake and
output.
c. Anticipate the progression of symptoms on earliest manifestation.
d. Monitor vital signs per facility protocol until they are stable.
10
e. Assess vital sign deviations; evaluate BP in relation to other
physiologic parameters of shock and the patient's premorbid
values. Orthostatic pulse and BP are important indicators of
hypovolemic shock.
f. Prevent infection (eg, indwelling catheter care, wound care,
pulmonary care) because this will minimize the risk of septic
shock.
Hemorrhage
Hemorrhage is the escape of blood from a ruptured blood vessel.
Hemorrhage from an arterial vessel may be bright red in color and
come in spurts, whereas blood from a vein is dark red and comes
in a steady flow. Hemorrhage may be external or internal
(concealed).
Clinical Manifestations
a. Apprehension; restlessness; thirst; cold, moist, pale skin; and
circumoral pallor
b. Pulse increases, respirations become rapid and deep (“air
hunger”), temperature drops
c. With progression of hemorrhage:
d. Decrease in cardiac output and narrowed pulse pressure
e. Rapidly decreasing BP, as well as hematocrit and hemoglobin (if
hypovolemic shock is due to hemorrhage)
Nursing Interventions and Management
a. Treat the patient as described for shock (see Chapter 35).
b. Inspect the wound as a possible site of bleeding. Apply pressure
dressing over an external bleeding site.
c. Increase the I.V. fluid infusion rate and administer blood as
directed and as soon as possible.
d. Administer 100% oxygen.
NURSING ALERT
Numerous, rapid blood transfusions may induce coagulopathy and
prolonged bleeding time. The patient should be monitored closely for signs
of increased bleeding tendencies after transfusions.
Deep Vein Thrombosis
DVT occurs in pelvic veins or in the deep veins of the lower
extremities in postoperative patients. The incidence of DVT varies
between 10% and 40% depending on the complexity of the
surgery or the severity of the underlying illness. DVT is most
common after hip surgery, followed by retropubic prostatectomy,
and general thoracic or abdominal surgery. Venous thrombi
located above the knee are considered the major source of
pulmonary emboli.
Causes
1. Injury to the intimal layer of the vein wall
2. Venous stasis
3. Hypercoagulopathy, polycythemia
4. High risks include obesity, prolonged immobility, cancer, smoking,
estrogen use, advancing age, varicose veins, dehydration,
splenectomy, and orthopedic procedures
Clinical Manifestations
a. Most patients with DVT are asymptomatic
b. Pain or cramp in the calf or thigh, progressing to painful swelling
of the entire leg
c. Slight fever, chills, perspiration
d. Marked tenderness over the anteromedial surface of the thigh
e. Intravascular clotting without marked inflammation may develop,
leading to phlebothrombosis
f. Circulation distal to the DVT may be compromised if sufficient
swelling is present
Nursing Interventions and Management
1. Hydrate patient adequately postoperatively to prevent
hemoconcentration.
2. Encourage leg exercises and ambulate patient as soon as
permitted by surgeon.
3. Avoid restricting devices, such as tight straps, that can constrict
and impair circulation.
4. Avoid rubbing or massaging calves and thighs.
5. Instruct the patient to avoid standing or sitting in one place for
prolonged periods and crossing legs when seated.
6. Refrain from inserting I.V. catheters into legs or feet of adults.
7. Assess distal peripheral pulses, capillary refill, and sensation of
lower extremities.
8. Check for positive Homans' sign—calf pain on dorsiflexion of the
foot; this sign is present in nearly 30% of DVT patients.
9. Prevent the use of bed rolls or knee gatches in patients at risk
because there is danger of constricting the vessels under the
knee.
10. Initiate anticoagulant therapy either I.V., subcutaneously, or orally
as prescribed.
11. Prevent swelling and stagnation of venous blood by applying
appropriately fitting elastic stockings or wrapping the legs from
the toes to the groin with elastic bandage.
 12. Apply external pneumatic compression intraoperatively to
patients at highest risk of DVT. Pneumatic compression can
reduce the risk of DVT by 30% to 50%
Pneumatic compression. Pressures of 35 to 20 mm Hg are
sequentially applied from ankle to thigh, producing an increase in
blood flow velocity and improved venous clearing.
Pulmonary Complications
Causes and Clinical Manifestations:
Atelectasis
 Incomplete expansion of the lung or portion of it occurring within
48 hours of surgery.
 Attributed to absence of periodic deep breaths.
 A mucus plug closes a bronchiole, causing the alveoli distal to the
plug to collapse.
 Symptoms are typically absent—may comprise mild to severe
tachypnea, tachycardia, cough, fever, hypotension, and decreased
breath sounds and chest expansion of the affected side.
Aspiration
a. Caused by the inhalation of food, gastric contents, water, or blood
into the tracheobronchial system.
 Anesthetic agents and opioids depress the central nervous system
causing inhibition of gag or cough reflexes.
 NG tube insertion renders upper and lower esophageal sphincters
partially incompetent.
 Gross aspiration has 50% mortality.
 Symptoms depend on the severity of aspiration (it may be silent);
usually evidence of atelectasis occurs within 2 minutes of
aspiration; other symptoms: tachypnea, dyspnea, cough,
bronchospasm, wheezing, rhonchi, crackles, hypoxia, and frothy
sputum.
Pneumonia
 This is an inflammatory response in which cellular material
replaces alveolar gas.
 In the postoperative patient, most commonly caused by gram-
negative bacilli due to impaired oropharyngeal defense
mechanisms.
 Predisposing factors include atelectasis, upper respiratory
infection, copious secretions, aspiration, dehydration, prolonged
intubation or tracheostomy, history of smoking, impaired normal
host defenses (cough reflex, mucociliary system, alveolar
macrophage activity).
 Symptoms include dyspnea, tachypnea, pleuritic chest pain, fever,
chills, hemoptysis, cough (rusty or purulent sputum), and
decreased breath sounds over the involved area.
Preventive Measures
1. Report evidence of upper respiratory infection to the surgeon.
2. Suction nasopharyngeal or bronchial secretions if the patient can't
clear his own airway.
3. Use proper patient positioning to prevent regurgitation and
aspiration.
4. Recognize the predisposing causes of pulmonary complications:
a. Infections—mouth, nose, sinuses, throat
b. Aspiration of vomitus
c. History of heavy smoking, chronic pulmonary disease
d. Obesity
5. Avoid over-sedation.
Nursing Interventions and Management
1. Monitor the patient's progress carefully on a daily basis to detect
early signs and symptoms of respiratory difficulties.
a. Slight temperature, pulse, and respiration elevations.
b. Apprehension and restlessness or a decreased LOC.
c. Complaints of chest pain, signs of dyspnea or cough.
2. Promote full aeration of the lungs.
a. Turn the patient frequently.
b. Encourage the patient to take 10 deep breaths hourly,
holding each breath to a count of five and exhaling.
c. Use a spirometer or other device that encourages the
patient to ventilate more effectively.
d. Assist the patient in coughing in an effort to bring up
mucus secretions. Have patient splint chest or
abdominal wound to minimize discomfort associated
with deep breathing and coughing.
e. Encourage and assist the patient to ambulate as early
as the health care provider will allow.
3. Initiate specific measures for particular pulmonary problems.
a. Provide cool mist or heated nebulizer for the patient
exhibiting signs of bronchitis or thick secretions.
b. Encourage the patient to take fluids to help “liquefy”
secretions and facilitate expectoration (in pneumonia).
c. Elevate the head of the bed and ensure proper
administration of prescribed oxygen.
d. Prevent abdominal distention—NG tube insertion may
be necessary.
e. Administer prescribed antibiotics for pulmonary
infections.
11
Pulmonary Embolism
Causes
 Pulmonary embolism (PE) is caused by the obstruction of one or
more pulmonary arterioles by an embolus originating somewhere
in the venous system or in the right side of the heart.
 Postoperatively, the majority of emboli develop in the pelvic or
iliofemoral veins before becoming dislodged and traveling to the
lungs.
Clinical Manifestations
 Sharp, stabbing pains in the chest
 Anxiousness and cyanosis
 Pupillary dilation, profuse perspiration
 Rapid and irregular pulse becoming imperceptible—leads rapidly
to death
 Dyspnea, tachypnea, hypoxemia
 Pleural friction rub (occasionally)
Nursing Interventions and Management
1. Administer oxygen with the patient in an upright sitting position (if
possible).
2. Reassure and calm the patient.
3. Monitor vital signs, ECG, and arterial blood gases.
4. Treat for shock or heart failure as directed.
5. Give analgesics or sedatives as directed to control pain or
apprehension.
6. Prepare for anticoagulation or thrombolytic therapy or surgical
intervention. Management depends on the severity of the PE.
Urinary Retention
Causes
 Occurs postoperatively, especially after operations of the rectum,
anus, vagina, or lower abdomen
 Often seen in patients having epidural or spinal anesthesia
 Caused by spasm of the bladder sphincter
 More common in male patients due to inherent increases in
urethral resistance to urine flow
 Can lead to urinary tract infection and possibly renal failure
Clinical Manifestations
 Inability to void
 Voiding small amounts at frequent intervals
 Palpable bladder
 Lower abdominal discomfort
Nursing Interventions and Management
1. Help patient to sit or stand (if permissible) because many patients
are unable to void while lying in bed.
2. Provide patient with privacy.
3. Run tap water—frequently, the sound or sight of running water
relaxes spasm of bladder sphincter.
4. Use warmth to relax sphincters (eg, a sitz bath or warm
compresses).
5. Notify health care provider if the patient does not urinate
regularly after surgery.
6. Administer bethanechol (Urecholine) I.M. if prescribed.
7. Catheterize only when all other measures are unsuccessful.
NURSING ALERT
Recognize that when a patient voids small amounts (30 to 60 mL every 15
to 30 minutes), this may be a sign of an overdistended bladder with
“overflow” of urine.
Intestinal Obstruction
Intestinal obstructions result in a partial or complete impairment
to the forward flow of intestinal contents. Most obstructions
occur in the small bowel, especially at its narrowest point—the
ileum. (See page 687 for a full discussion of intestinal obstruction.)
Nursing Intervention and Management
1. Monitor for adequate bowel sound return after surgery. Assess
bowel sounds and the degree of abdominal distention (may need
to measure abdominal girth); document these findings every shift.
2. Monitor and document characteristics of emesis and NG drainage.
3. Relieve abdominal distention by passing a nasoenteric suction
tube as ordered.
4. Replace fluid and electrolytes.
5. Monitor fluid, electrolyte (especially potassium and sodium), and
acid-base status.
6. Administer opioids judiciously because these medications may
further suppress peristalsis.
7. Prepare the patient for surgical intervention if the obstruction
continues unresolved.
8. Closely monitor the patient for signs of shock.
9. Provide frequent reassurance to the patient; use nontraditional
methods to promote comfort (touch, relaxation, imagery).
Wound Infection
Wound infections are the second most common health care
related infection. The infection may be limited to the surgical site
(60% to 80%) or may affect the patient systemically.
Causes
 1. Drying tissues by long exposure, operations on contaminated
structures, gross obesity, old age, chronic hypoxemia, and
malnutrition are directly related to an increased infection rate.
2. The patient's own flora is most commonly implicated in wound
infections (Staphylococcus aureus).
3. Other common culprits in wound infection include Escherichia
coli, Klebsiella, Enterobacter, and Proteus.
4. Wound infections typically present 5 to 7 days postoperatively.
5. Factors affecting the extent of infection include:
a. Type, virulence, and quantity of contaminating
microorganisms.
b. Presence of foreign bodies or devitalized tissue.
c. Location and nature of the wound.
d. Amount of dead space or presence of hematoma.
e. Immune response of the patient.
f. Presence of adequate blood supply to wound.
g. Presurgical condition of the patient (eg, age,
alcoholism, diabetes, malnutrition).
Clinical Manifestations
1. Redness, excessive swelling, tenderness, warmth
2. Red streaks in the skin near the wound
3. Pus or other discharge from the wound
4. Tender, enlarged lymph nodes in the axillary region or groin
closest to the wound
5. Foul smell from the wound
6. Generalized body chills or fever
7. Elevated temperature and pulse
8. Increasing pain from the incision site
GERONTOLOGIC ALERT
Elderly people do not readily produce an inflammatory response
to infection, so they may not present with fever, redness, and
swelling. Increasing pain, fatigue, anorexia, and mental status
changes are signs of infection in elderly patients.
NURSING ALERT
Mild, transient fevers appear postoperatively due to tissue
necrosis, hematoma, or cauterization. Higher sustained fevers
arise with the following four most common postoperative
complications: atelectasis (within the first 48 hours); wound
infections (in 5 to 7 days); urinary infections (in 5 to 8 days); and
thrombophlebitis (in 7 to 14 days).
Nursing Interventions and Management
Preoperative
1. Encourage the patient to achieve an optimal nutritional level.
Enteral or parenteral alimentation may be ordered preoperatively
to reduce hypoproteinemia with weight loss.
2. Reduce preoperative hospitalization to a minimum to avoid
acquiring nosocomial infections.
Operative
1. Follow strict sterile technique throughout the operative
procedure.
2. When a wound has exudate, fibrin, desiccated fat, or nonviable
skin, it is not approximated by primary closure but through
secondary (delayed) closure.
Postoperative
1. Keep dressings intact, reinforcing if necessary, until prescribed
otherwise.
2. Use strict sterile technique when dressings are changed.
3. Monitor and document the amount, type, and location of
drainage. Ensure that all drains are working properly. (See Table
7-1 for expected drainage amounts from common types of drains
and tubes.)
4. Postoperative care of an infected wound
a. The surgeon removes one or more stitches, separates
the wound edges, and looks for infection using a
hemostat as a probe.
b. A culture is taken and sent to the laboratory for
bacterial analysis.
c. Wound irrigation may be done; have an aseptic syringe
and saline available.
d. A drain may be inserted or the wound may be packed
with sterile gauze.
e. Antibiotics are prescribed.
f. Wet-to-dry dressings may be applied (see page 125).
g. If deep infection is suspected, the patient may be taken
back to the operating room.
Wound Dehiscence and Evisceration
Causes
1. Commonly occurs between the fifth and eighth day
postoperatively when the incision has weakest tensile strength;
greatest strength is found between the first and third
postoperative day.
2. Chiefly associated with abdominal surgery.
3. This catastrophe is commonly related to:
12
a. Inadequate sutures or excessively tight closures (the
latter compromises blood supply).
b. Hematomas; seromas.
c. Infections.
d. Excessive coughing, hiccups, retching, distention.
e. Poor nutrition; immunosuppression.
f. Uremia; diabetes mellitus.
g. Steroid use.
Preventive Measures
 Apply an abdominal binder for heavy or elderly patients or those
with weak or pendulous abdominal walls.
 Encourage the patient to splint the incision while coughing.
 Monitor for and relieve abdominal distention.
 Encourage proper nutrition with emphasis on adequate amounts
of protein and vitamin C.
Clinical Manifestations
 Dehiscence is indicated by a sudden discharge of serosanguineous
fluid from the wound.
 Patient complains that something suddenly “gave way” in the
wound.
 In an intestinal wound, the edges of the wound may part and the
intestines may gradually push out. Observe for drainage of
peritoneal fluid on dressing (clear or serosanguineous fluid).
Nursing Interventions and Management
1. Stay with patient and have someone notify the surgeon
immediately.
2. If the intestines are exposed, cover with sterile, moist saline
dressings.
3. Monitor vital signs and watch for shock.
4. Keep patient on absolute bed rest.
5. Instruct patient to bend the knees, with head of the bed elevated
in semi-Fowler's position to relieve abdominal tension.
6. Assure patient that the wound will be properly cared for; attempt
to keep patient calm and relaxed.
7. Prepare patient for surgery and repair of the wound.
Psychological Disturbances:
Depression
Cause—perceived loss of health or stamina, pain, altered body
image, various drugs, and anxiety about an uncertain future.
Clinical manifestations—withdrawal, restlessness, insomnia, nonadherence
to therapeutic regimen, tearfulness, and expressions of hopelessness.
Nursing interventions and management.
a. Clarify misconceptions about surgery and its future implications.
b. Listen to, reassure, and support the patient.
c. If appropriate, introduce the patient to representatives of ostomy,
mastectomy, or amputee support groups.
d. Involve the patient's family and support people in care; psychiatric
consultation is obtained for severe depression.
Delirium
Cause—prolonged anesthesia, cardiopulmonary bypass, drug reactions,
sepsis, alcoholism (delirium tremens), electrolyte imbalances, and other
metabolic disorders.
Clinical manifestations—disorientation, hallucinations, perceptual
distortions, paranoid delusions, reversed day-night pattern, agitation,
insomnia; delirium tremens often appears within 72 hours of last alcoholic
drink and may include autonomic overactivity—tachycardia, dilated pupils,
diaphoresis, and fever.
Nursing interventions and management.
1. Assist with the assessment and treatment of the underlying cause
(restore fluid and electrolyte balance, discontinue the offending
drug).
2. Reorient the patient to environment and time.
3. Keep surroundings calm.
4. Explain in detail every procedure done to the patient.
5. Sedate the patient, as ordered, to reduce agitation, prevent
exhaustion, and promote sleep. Assess for oversedation.
6. Allow extended periods of uninterrupted sleep.
7. Reassure family members with clear explanations of the patient's
aberrant behavior.
8. Have contact with the patient as much as possible; apply
restraints to the patient only as a last resort if safety is in question
and if ordered by the health care provider.
WOUND CARE
WOUNDS AND WOUND HEALING
A wound is a disruption in the continuity and regulatory processes of tissue
cells; wound healing is the restoration of that continuity. Wound healing,
however, may not restore normal cellular function.
Wound Classification
Mechanism of Injury
1. Incised wounds—made by a clean cut of a sharp instrument, such
as a surgical incision with a scalpel.
2. Contused wounds—made by blunt force that typically does not
break the skin but causes considerable tissue damage with
bruising and swelling.
 3. Lacerated wounds—made by an object that tears tissues
producing jagged, irregular edges; examples include glass, jagged
wire, and blunt knife.
4. Puncture wounds—made by a pointed instrument, such as an ice
pick, bullet, or nail.
Degree of Contamination
1. Clean—an aseptically made wound, as in surgery, that does not
enter the alimentary, respiratory, or genitourinary tracts.
2. Clean-contaminated—an aseptically made wound that enters the
respiratory, alimentary, or genitourinary tracts. These wounds
have slightly higher probability of wound infection than do clean
wounds.
3. Contaminated—wounds exposed to excessive amounts of
bacteria. These wounds may be open (avulsive) and accidentally
made, or may be the result of surgical operations in which there
are major breaks in sterile techniques or gross spillage from the
gastrointestinal tract.
4. Infected—a wound that retains devitalized tissue or involves
preoperatively existing infection or perforated viscera. Such
wounds are often left open to drain.
Physiology of Wound Healing
The phases of wound healing—inflammation, reconstruction
(proliferation), and maturation (remodeling)—involve continuous
and overlapping processes.
Inflammatory Phase (lasts 1 to 5 days)
1. Vascular and cellular responses are immediately
initiated when tissue is cut or injured.
2. Transient vasoconstriction occurs immediately at the
site of injury, lasting 5 to 10 minutes, along with the
deposition of a fibrinoplatelet clot to help control
bleeding.
3. Subsequent dilation of small venules occurs;
antibodies, plasma proteins, plasma fluids, leukocytes,
and red blood cells leave the microcirculation to
permeate the general area of injury, causing edema,
redness, warmth, and pain.
4. Localized vasodilation is the result of direct action by
histamine, serotonin, and prostaglandins.
5. Polymorphic leukocytes (neutrophils) and monocytes
enter the wound to engage in destruction and
ingestion of wound debris. Monocytes predominate
during this phase.
6. Basal cells at the wound edges undergo mitosis;
resultant daughter cells enlarge, flatten, and creep
across the wound surface to eventually approximate
the wound edges.
Proliferative Phase (lasts 2 to 20 days)
1. Fibroblasts (connective tissue cells) multiply and
migrate along fibrin strands that are thought to serve
as a matrix.
2. Endothelial budding occurs on nearby blood vessels,
forming new capillaries that penetrate and nourish the
injured tissue.
3. The combination of budding capillaries and
proliferating fibroblasts is called granulation tissue.
4. Active collagen synthesis by fibroblasts begins by the
fifth to seventh day, and the wound gains tensile
strength.
5. By 3 weeks, skin obtains 30% of its pre-injury tensile
strength, intestinal tissue about 65%, and fascia 20%.
Remodeling Phase (21 days to months or years)
1. Scar tissue is composed primarily of collagen and
ground substance (muco-polysaccharide,
glycoproteins, electrolytes, and water).
2. From the start of collagen synthesis, collagen fibers
undergo a process of lysis and regeneration. The
collagen fibers become more organized, aligning more
closely to each other and increasing in tensile strength.
3. The overall bulk and form of the scar continue to
change once maturation has started.
4. Typically, collagen production drops off; however, if
collagen production greatly exceeds collagen lysis,
keloid (greatly hypertrophied, deforming scar tissue)
will form.
5. Normal maturation of the wound is clinically observed
as an initial red, raised, hard immature scar that molds
into a flat, soft, and pale mature scar.
6. The scar tissue will never achieve greater than 80% of
its pre-injury tensile strength.
Types of Wound Healing
First Intention Healing (Primary Closure)
13
 Wounds are made sterile by minor debridement and
irrigation, with a minimum of tissue damage and tissue
reaction; wound edges are properly approximated with
sutures.
 Granulation tissue is not visible, and scar formation is
typically minimal (keloid may still form in susceptible
people).
Secondary Intention Healing (Granulation)
 Wounds are left open to heal spontaneously or are surgically
closed at a later date; they need not be infected.
 Examples in which wounds may heal by secondary intention
include burns, traumatic injuries, ulcers, and suppurative
infected wounds.
 In wounds that are later sutured, the two opposing
granulation surfaces are brought together.
 Secondary intention healing produces a deeper, wider scar.
 The cavity of the wound fills with a red, soft, sensitive tissue
(granulation tissue), which bleeds easily. A scar (cicatrix)
eventually forms.
 In infected wounds, drainage may be accomplished by use of
special dressings and drains. Healing is thus improved.
Delayed Primary Closure, also known as Healing by Tertiary Intention.
 A combination of healing by primary and secondary
intention, and is usually instigated by the wound care
specialist to reduce the risk of infection.
 In delayed primary closure, the wound is first cleaned and
observed for a few days to ensure no infection is apparent
before it is surgically closed.
 Examples of wounds that are closed in this way include
traumatic injuries such as dog bites or lacerations involving
foreign bodies.
Classification of wound healing. (A) First intention: A clean incision is made
with primary closure; there is minimal scarring. (B) Second intention: The
wound is left open so that granulation can occur; a large scar results. (C)
Delayed closure: The wound is initially left open and later closed when there
is no further evidence of infection.
WOUND MANAGEMENT
Many factors promote wound healing, such as adequate nutrition,
cleanliness, rest, and position, along with the patient's underlying
psychological and physiologic state. Of added importance is the application
of appropriate dressings and drains
Dressings
Purpose of Dressings
1. To protect the wound from mechanical injury
2. To splint or immobilize the wound
3. To absorb drainage
4. To prevent contamination from bodily discharges (feces, urine)
5. To promote hemostasis, as in pressure dressings
6. To debride the wound by combining capillary action and the
entwining of necrotic tissue within its mesh
7. To inhibit or kill microorganisms by using dressings with antiseptic
or antimicrobial properties
8. To provide a physiologic environment conducive to healing
9. To provide mental and physical comfort for the patient
Advantages of Not Using Dressings
1. When the initial dressing on a clean, dry, and intact incision is
removed, it is often not replaced. This may occur within 24 hours
after surgery.
2. Permits better visualization of the wound.
3. Eliminates conditions necessary for growth of organisms (warmth,
moisture, and darkness).
4. Minimizes adhesive tape reaction.
5. Aids bathing.
Types of Dressings
Dry dressings
 Used primarily for wounds closing by primary intention.
 Offers good wound protection, absorption of drainage, and
aesthetics for the patient and provides pressure (if needed)
for hemostasis.
 Disadvantage—they adhere to the wound surface when
drainage dries. (Removal can cause pain and disruption of
granulation tissue.)
Wet-to-dry dressings
 These are particularly useful for untidy or infected wounds
that must be debrided and closed by secondary intention.
 Gauze saturated with sterile saline (preferred) or an
antimicrobial solution is packed into the wound, eliminating
dead space.
 The wet dressings are then covered by dry dressings (gauze
sponges or absorbent pads).
 As drying occurs, wound debris and necrotic tissue are
absorbed into the gauze dressing by capillary action.
  The dressing is changed when it becomes dry (or just 3. Eat small, regular meals and make them as nourishing as possible
before). If there is excessive necrotic debris on the dressing, to promote wound healing.
more frequent dressing changes are required. Sleeping
Wet-to-wet dressings 1. If sleeping is difficult because of wound discomfort, try taking your
 Used on clean open wounds or on granulating surfaces. pain medication at bedtime.
Sterile saline or an antimicrobial agent may be used to 2. Attempt to get sufficient sleep to aid in your recovery.
saturate the dressings. Wound Healing
 Provides a more physiologic environment (warmth, 1. Your wound will go through several stages of healing. After initial
moisture), which can enhance the local healing processes as pain at the site, the wound may feel tingling, itchy, numb, or tight
well as ensure greater patient comfort. Thick exudate is (a slight pulling sensation) as healing occurs.
more easily removed. 2. Do not pull off any scabs because they protect the delicate new
 Disadvantage—surrounding tissues can become macerated, tissues underneath. They will fall off without any help when ready.
there is an increased risk for infection, and bed linens Change the dressing according to the surgeon's instructions.
become damp. 3. Consult your health care provider if the amount of pain in your
Drains wound increases or if you notice increased redness, swelling, or
Purpose of Drains discharge from wound.
1. Drains are placed in wounds only when abnormal fluid collections Bowels
are present or expected. 1. Irregular bowel habits can result from changes in activity and diet
2. Drains are placed near the incision site: or the use of some drugs.
a. Usually in compartments (eg, joints and pleural space) 2. Avoid straining because it can intensify discomfort in some
that are intolerant to fluid accumulation. wounds; instead, use a rocking motion while trying to pass stool.
b. In areas with a large blood supply (eg, the neck and 3. Drink plenty of fluids and increase the fiber in your diet through
kidney). fruits, vegetables, and grains, as tolerated.
c. In infected draining wounds. 4. It may be helpful to take a mild laxative. Consult your health care
d. In areas that have sustained large superficial tissue provider if you have any questions.
dissection (eg, the breast). Bathing, Showering
3. Collection of body fluids in wounds can be harmful in the 1. You may get your wound wet 3 days after your operation if the
following ways: initial dressing has already been changed (unless otherwise
a. Provides culture media for bacterial growth. advised).
b. Causes increased pressure at surgical site, interfering 2. Showering is preferable because it allows for thorough rinsing of
with blood flow to area. the wound.
c. Causes pressure on adjacent areas. 3. If you are feeling too weak, place a plastic or metal chair in the
d. Causes local tissue irritation and necrosis (due to fluids shower so you can be seated during showering.
such as bile, pus, pancreatic juice, and urine). 4. Be sure to dry your wound thoroughly with a clean towel and
dress it as instructed before discharge.
Wound Drainage Clothing
1. Drains are commonly made of latex, polyvinylchloride, or silicone 1. Avoid tight belts and underwear and other clothes with seams
and placed within either wounds or body cavities. that may rub against the wound.
2. Drains placed within wounds are typically attached to portable 2. Wear loose clothing for comfort and to reduce mechanical trauma
(or, rarely, wall) suction with a collection container. to wound.
a. Examples include the Hemovac, Jackson-Pratt, and Driving
Surgivac drainage systems. 1. Ask your health care provider when you may resume driving. Safe
3. Drains may also be used postoperatively to form hollow driving may be affected by your pain medication. In addition, any
connections from internal organs to the outside to drain a body violent jarring from an accident may disrupt your wound.
fluid, such as the T-tube (bile drainage), nephrostomy, Bending and Lifting
gastrostomy, jejunostomy, and cecostomy tubes. 1. How much bending, stretching, and lifting you are allowed
4. Drains create a portal for entry and exit of infectious depends on the location and nature of your surgery.
microorganisms; therefore, the risk of infection exists. 2. Typically, for most major surgeries, you should avoid lifting
5. Drains within wounds are removed when the amount of drainage anything heavier than 5 lb for 4 to 8 weeks.
decreases over a period of days or, rarely, weeks. 3. It is ideal to obtain home assistance for the first 2 to 3 weeks after
6. Body fluid drains are often left in for longer periods of time. discharge.
a. Careful handling of these drains and collection bags is
essential.
b. Accidental early removal may result in caustic drainage Care of Clients With Problems in Inflammatory and
leaking within the tissues.
Immunologic Response
c. The risk is reduced within 7 to 10 days when a wall of
fibrous tissue has been formed. Top leading causes of morbidity according to the DOH:
7. The amount of drainage varies with the procedure. Most common
surgical procedures (eg, appendectomy, cholecystectomy,  Pneumonia
abdominal hysterectomy) have minimal wound drainage by the  Diarrhea
third or fourth postoperative day. Drains are not commonly used  Bronchitis/bronchiolitis
after these operations.  Influenza
 Hypertension
NURSING ALERT  TB respiratory
 Diseases of the heart
The greatest amount of drainage is expected during the first 24 hours;  Malaria
closely monitor dressing and drains.  Chicken Pox
 Measles
PATIENT EDUCATION
Rest and Activity
1. It is common to feel tired and frustrated about not being able to Top 10 leading causes of mortality:
do all the things you want; this is normal.
2. Plan regular naps and quiet activities, gradually increasing your  Heart diseases
exercise over the following weeks.  Vascular System disease
3. When you begin to exercise more, start by taking a short walk two  Cancer
or three times per day. Consult your health care provider if more  Accidents
specific exercises are required.  Pneumonia
4. Climbing stairs in your home may be surprisingly tiring at first. If  Tuberculosis
you have difficulty with this activity, try going upstairs backward  Hypertension
(“scooching”) on your “bottom” until your strength has returned.  Chronic Lower Respiratory diseases
5. Consult your health care provider to determine the appropriate  Diabetes
time to return to work.  Perinatal conditions
Eating
1. Follow dietary instructions provided at the facility before your COMMUNICABLE DISEASE
discharge.
2. Your appetite may be limited or you may feel bloated after meals;  An illness due to an specific infectious agent or its toxic products that
this problem should lessen as you become more active. (Some is transmitted directly or indirectly to a susceptible host through an
prescribed medications can cause this.) If symptoms persist, intermediate plant or animal host, vector or the inanimate environment
consult your health care provider. INFECTIOUS DISEASE

14
 Disease of man or animal resulting from infection that requires direct a) Toxicity - Ability to produce toxins that damages
inoculation through break in the skin or mucous membrane tissues
b) Invasiveness - Ability to move and damage tissues
4. Immunogenicity - Ability to induce specific immunity
All communicable diseases are Infectious and most but not all infectious are
communicable
Characteristics of the Host
Factors of Care in Communicable Disease
1. Age
1. Cause of disease and methods of transmission 2. Sex
2. What secretions harbor the organism 3. Race
3. How long the patient may transmit the disease 4. Religion
4. Whether or not the patient may remain a carrier 5. Nutrition
5. How to protect one’s self and other from contracting the disease 6. Civil status
7. Occupation
8. Family size
The basic function of the nurse is to provide nursing care to patients with 9. Genetics
communicable disease 10. Intermittent infection
11. Human behavior
12. Resistance
Nursing Care for a Communicable Disease patient:

 Self-protection Normal Defense Mechanisms

 Preventing spread of infectious agents through asepsis and disinfection
 Nonspecific immune defenses
 Physical care of the patient
 Specific immune defenses
 Emotional support
 Spiritual aspect of care
Work in harmony to defend the host from pathogens.
INFECTION Nonspecific Defense Mechanisms
 is an invasion and multiplication of microorganisms in the body tissue  Protect the host from all microorganisms
of man or animal that results in cellular injury.  Not dependent on prior exposure to the antigen
 the implantation and successful replication of the organisms in the  Skin and Normal Flora
tissue of the host  Tearing Reflexes
Elements of Infection  Elimination
 Acidic Environment
1. Causative organism
 Mucous Membranes
2. Reservoir
 Sneeze, Cough Reflexes
3. Mode of Exit
 Inflammatory Response
4. Route of Transmission
Nonspecific Immune Defenses
5. Mode of Entry to host
6. Susceptible Host  Skin
 Intact skin is the body’s first line of defense against infection.
 Sebum is produced by the skin and contains fatty acids that kill
Host-Agent-Environment Interaction
some bacteria.
 Host - Organism that is capable of being infected by a specific agent  Normal Flora
 Agent - An element, a substance or force either animate or inanimate  Normal flora residing on the skin compete with pathogenic flora
under proper environmental condition that may serve as stimulus to initiate for food and inhibit their multiplication.
a disease process  Inappropriate antibiotic use may disrupt the balance of normal
 Environment - Sum total of all external condition and all influences flora.
that affect the life of an organism (agent and host)  Mucous Membranes
 Mucus entraps infectious agents and contains substances that
inhibit bacterial growth.
3 BASIC PROVISIONS IN DISEASE CAUSATION  Cilia trap and propel mucus and microorganisms away from the
lungs.
1. Disease results from an imbalance between the disease agent and host  Sneeze and Cough Reflexes
2. The nature and extent of the imbalance depends upon the nature and  Physically expel mucus and microorganisms from the respiratory
characteristics of the agent and the host tract and oral cavity with force
3. The characteristics of the agent and the host and their interaction are  Tearing Reflex
directly related to and largely dependent on the nature of the physical,  Protects the eyes by continually flushing away microorganisms
biologic and socio-economic environment  Elimination Patterns and Acidic Environment
 Resident flora of the large intestines
 Mechanical process of defecation
Characteristics of the Agent  Flushing action of urination
 Acidic environment of urine and vagina
 Morphology – size, structure
 Inflammatory Response
 Chemical structure – antigenic structure
 Tissue injury caused by bacteria, trauma, chemicals, heat, or any
Properties related to its initiation as agent
other phenomenon
 Viability  Release of substances that produce secondary changes in the
 Growth requirements tissue
 Range of hosts
 Vulnerability to treatment
Specific Immune Defense
(Immune Responses)
Properties related to its initiation as agent
 Immunity
 Viability - Ability to survive in adverse conditions  is a specific defense mechanism that creates an immune
 Growth requirements - bacteria, virus response to a specific invading antigen
 Range of hosts  condition of a being secured or protected against any particular
 Vulnerability to treatment - Antibacterial or antiviral may shorten or disease
lengthen natural history of the disease  Immunization
 introduction of specific protective antibodies in a
susceptible person or animal, or the production of cellular
Properties related to the host immunity in such person or animal
 IMMUNE SYSTEM
1. Infectivity - Property of being able to lodge and multiply or the  Protection against infective or allergic diseases by a system of
minimum number of causative agent needed to establish an infection antibodies, immunoglobulins and related resistance factors.
2. Pathogenicity - Ability to induce disease after entering the body,  ANTIBODY
depending on rapidity of multiplication process and extent of tissue damage
3. Virulence - Severity of resulting disease that depends on:

15
 a specific immune substance produced by the lymphocytes of  B lymphocytes recognize the antigen as an enemy.
the blood of tissue juices of man or animal in response to the introduction  Immunoglobulins are plasma protein cells that produce five different
into the body of an antigen classes of antibodies (IgG, IgA, IgM, IgE, and IgD).
 ANTIGEN  Immunoglobulins circulate throughout the bloodstream for the
 Triggering agent of the immune system purpose of destroying antigens.
 Foreign substance introduced into the body causing the body to
produce antibodies
TYPES OF ANTIGENS: IMMUNOGLOBULINS ( IG’S)

 INACTIVATED (KILLED ORGANISM)  IgG

 Not long lasting  Most prevalent antibody 80%
 Multiple doses needed  Produced later in the immune response
 Booster dose needed  Only Ig that can cross placenta
 ATTENUATED (LIVE WEAKENED ORGANISM)  IgA
 Single dose needed  Found in colostrum, tears, saliva and sweat
 Long lasting immunity  IgM
 Principal antibody of blood
 Quickly produced in response to an antigen
** all vaccines lose their potency after a certain time  Responds to artificial immunization

Immune Responses
 IgE
1) Active immunity  Responds to allergic reaction
2) Passive immunity  IgD
3) Acquired immunity  Unknown
4) Natural immunity  Antigen receptor
5) Artificial immunity  Found in the surface of B Cells
Cell-Mediated Immunity

 Active immunity  Fights pathogens that survive inside cells.

 results from the development within the body  Antigen stimulates the release of activated T cells.
of antibodies that neutralize the infective agent.  T-helper cells
 Passive immunity  T-suppressor cells
 is acquired by the introduction of preformed  T-cytotoxic cells
antibodies. Environment
 Acquired immunity
 results either from exposure to an antigen or from the  Physical environment – refers to the inanimate surroundings and its
passive injection of immunoglobulins. features
 Natural immunity  Biological environment – refers to the fauna and flora which serves as
 refers to the genetically determined response of food source for the infectious agent, source of the infectious agent
protection within a specific species.  Socio-economic environment – refers to the nature of occupation,
 Innate urban/rural characteristics
 within the HOST
 Immune System
 Artificial immunity CHAIN OF INFECTION
 produced following a vaccine.
 outside the HOST - process by which an infectious agent is transmitted from
environment to host, invades the host and causes diseases

 Natural = active or passive 1. Infectious Agent

 Artificial = active or passive 2. Reservoir of Source
3. Portal of Exit from reservoir of source
4. Mode of Transmission
T³ypes of Acquired Immunity 5. Portal of Entry to Host
6. Susceptible Host

Infectious Agents
Types of Acquired Immunity
 organisms capable of causing disease
 Active Acquired Immunity  Bacteria
 results if antibodies are actually produce within the person’s  Viruses
body  Rickettsia
 Protozoa
 Fungi
 Natural Active Immunity  Parasites
 Acquired in response to the entry of a live pathogen into the  Spirochete
body  Chlamydia
 through exposure from diseases 1. Bacteria - A simple, one celled microbe with double cell
 had the disease & recovered membrane that protect them from harm.
 Artificial Active Immunity
 Acquired in response to vaccines - They reproduce rapidly and considered as the
 Introduction of antigen
Ex. Vaccines ; toxoids - Most common cause of fatal infectious diseases.

(No exposure; preventive measure) gives long immunity–months to years  Attack both living and non-living organism
 Usually has shorter incubation period
 Passive Acquired Immunity  Short or no immunity acquired
 Person receive antibodies that were produced by another  Bacterial infection can be treated easily due to the advent of
sponsor by animals antibiotics
 Protection is usuall Classified according to:
 Natural Passive Immunity
 Acquired by a fetus when it receives maternal antibodies in  Shape - cocci, bacilli, spirillae
utero  Need for O2 - aerobic, anaerobic
 By an infant when it receives maternal antibodies in colostrums  Response to staining - gram (+), gram (–) or acid fast
 Acquired through placental transfer  Motility - motile, non motile
 Artificial Passive Immunity  Tendency to capsulate - encapsulated, capsulated
 Acquired when a person receives antibodies contain antisera,  Capacity to form spore - spore forming, non spore forming
antitoxins or gamma globulin 2. Virus
Ex. TAT ( tetanus antitoxin) gives short immunity
- The smallest known microbe.

- They can’t replicate independently in the host’s cells

The Humoral Immune Response

16
 and stimulate it to participate in the formation of  Frank cases or the very ill – with typical signs and symptoms
 Case – a person whose body has been invaded by the infectious agent
additional viruses. with the resulting signs and symptoms
 Sub-clinical, silent inapparent, missed or ambulatory - those cases
a. Attack only living organisms with vague signs and symptoms
 Carriers – a person who harbors the infectious agent without
b. Usually has longer incubation period
demonstrating signs and symptoms of the disease
c. Person acquire longer or lifetime immunity  Carriers - an individual who harbors the organism and is capable
of transmitting it to a susceptible host without showing manifestations
d. Self-limiting of the disease
1. Incubatory carrier
3. Rickettsia  one who is incubating the illness

- Small, gram – bacteria-like microbe that can induce

2. Convalescent carrier
life threatening infections.  recovery stage of illness but continue to shed the pathogenic
 organism
- Like viruses, they require a host’s cell for replication.
3. Intermittent carrier
These are usually transmitted through bite of arthropod carrier like flea,  occasionally sheds the pathogenic organism
ticks, lice as well as through waste products. 4. Chronic or sustained carrier
 always has infectious organism in his system
a. Unable to grow on artificial media Mode of Escape from Reservoir

b. All rickettsial diseases are transmitted by arthropods (ticks, flea, mites, lice) - place of exit providing a way for a microorganism to leave
the reservoir
c. Require living cell for growth and multiplication
 Respiratory tract
4. Protozoa  GI tract
 GU tract
- Much larger than bacteria.  Open lesion, Skin
 Mechanical escape - bites from insects
- The simplest single-celled organism of animal kingdom.  Blood
Mode of Transmission
- Parasitic protozoa absorb nutrients from the body of the host.
 Method of transfer by which the organism moves or is carried
Composed of two stages;
from one place to another
a) Throphozoite is the motile, feeding, and dividing

stage of life cycle  passes from the portal of exit from the reservoir to the
susceptible host
b) Cyst - the dormant, survival stage  easiest link to break the chain of infection
Route of Transmission
5. Fungi
 Contact Transmission
 Found almost everywhere on earth.  Airborne Transmission
 They live in soil, water or animals and plants.  Vehicle Route
 They also live inside or outside human body  Vectorborne Transmission
 Some are harmful, some are beneficial Contact Transmission Contact - any person or animal who had been in close
association with an infected person, animal or freshly soiled materials

6. Parasites  Direct contact – refers to the direct physical transfer between

and infected or colonized person and a susceptible host
 Live on or within other organisms  Direct skin to skin contact - by hand shaking
 Live on the expenses of others  Direct mucous membrane to mucous membrane
 They don’t kill the host but take the nutrients they need. - kissing or sexual intercourse

 Indirect contact – refers to the personal contact of susceptible

7. Spirochete
- Are bacteria with flexible, slender, undulating
spiral rods that possess cell wall. (treponema, leptospira, borilla)
- Move in an spiral, helical, or inch-worm manner
8. Chlamydia
- smaller than rickettsiae but larger than viruses
- usually are transmitted through sexual contact
The ability of a microorganism to infect a client is related to:
host with contaminated usually an inanimate object
 contamination of food water by fecal material
 transfusion of contaminated blood or blood products from ill
persons or by Parenteral infections
 Soiled dressings and instruments
 Droplet contact – infectious agents coming in contact with
conjunctiva, nose or mouth of susceptible host, droplets travel only up to 3
feet and therefore contact is not airborne
 Coughing and sneezing
Airborne transmission
- occurs when fine microbial particles or dust particles containing
microbes remain suspended in the air for a prolong period

1. Pathogenicity – ability to cause the disease - spread by air current and inhaled

2. Virulence – severity of the disease  Droplet nuclei – are small residues that result from evaporated fluid
droplets coughed or sneezed by an infected person
3. Invasiveness – ability to enter and move through the tissue  Can survive in air for long periods of time
 Dust – contains infectious agent
4. Infective dose – number of organisms needed to initiate infection
Vehicle Borne/ Route
5. Elaboration of toxin
- articles or substances that harbor the organism until it is ingested
6. Organism Specificity – host preference or inoculated into the host

7. Susceptibility of the Host - infectious agents are transmitted through inanimate objects, such
as food, water, drugs, blood, fomites
Source or Reservoir
Example:
 A place within which microorganisms can thrive, reproduce and to
survive while awaiting a host  Food - salmonellosis
 May allow the organism to multiply, making it more dangerous.  Water - shigellosis, legionellosis
 The human body is the most common reservoir.  Drugs - bacteremia resulting from infusion of a contaminated
 Food, plants (fungi and molds), animals (rodents and pets), feces. infusion product
Human Reservoir  Blood - hepatitis B, or non-A non-B hepatitis
Vector-borne Transmission

17
 occurs when an intermediate carriers transfer the microbes to another Community Reaction to disease condition
living organism
 via contaminated or infected arthropods such as;  Sporadic Disease
1. Flies diseases that occur intermittently or occasionally and irregularly with no
2. Mosquitoes specific pattern in a particular/ specific area
3. Rodents,
4. Fleas Ex. Tetanus, gangrene
5. Ticks
 Endemic
Mode of Entry into Human Body

- An opening allowing the microorganism to enter the host

 Habitual presence of a disease in a certain locality
- use the same avenues when they exit from the reservoir  Present in a population or community at times usually involve
few people during specific time
1) Respiratory tract Ex. Schistosomiasis is rampant in Samar and Leyte
2) GI tract
3) GU tract Cholera, Typhoid
4) Mucous membrane or skin
5) Placenta  Epidemic
Susceptible Host  diseases that occurs greater than the expected number in a
specific area over a specific time
 A person who cannot resist a microorganism invading the body, Ex. Increase number of diarrhea in an evacuation area
multiplying and resulting in infection.
 A person with a reduced immune response has increased Dengue
susceptibility.
 The immune response is the body’s natural defense against infection. Meningococcemia
 Susceptibility is the degree of resistance of an individual has to
 Pandemic
pathogens
 Occurrence of a disease that affects the several countries or
continents
Four Stages of Infection
Ex. HIV/AIDS & SARS
1. Incubation - the time between exposure to a pathogenic organism and
Principles in the prevention and control of communicable disease
the onset of symptoms of a disease
 Colonization  Understand the natural history of the disease
 Cellular Response  Scrutinize the interrelation of the ecologic triad to determine the
 Pathophysiology weakest link in the disease causation and once discovered concentrate on
 Pathognomonic Sign and symptoms this
2. Prodromal - initial stage or the earliest phase of the developing disease  Know or recognize the different foci of infections and sources of
manifested by early signs and symptoms infection
Example: Body Malaise, Low grade fever Illness Measures directed toward the disease agent
3. Convalescence- period of recovery after an illness 1. When the disease agent is the reservoir of infection
Spectrum of an infection  Elimination of the animal reservoir
 Removal of infected parts of the individual
 Exposure
 If eradication is impossible
 Incubation Period
 Treatment of the reservoir
 Prodromal Stage
 Limitation of movement of the human reservoir
 Period of Communicability
 Isolation
 Time during which agents can be transmitted from an infected
 Quarantine
person to another
 Surveillance
 Full stage of Disease – client manifests specific type of infection
 Segregation
 Convalescence/ Recovery stage – acute symptom of infection
 Control of known carriers
disappears, length of recovery depends on the severity of infection and
2. When the disease agent is in transit from the reservoir of infection to
client’s general state of health
the susceptible host
 Death
 Sanitary measures in handling vehicles of transmission
Factors Influencing Production of an Infectious Disease
3. Control of diarrheal disease
 Age 4. Malaria control disease
 Heredity 5. Schistosomiasis control program
 Stress 6. Legislation on health sanitation code
 Surgery 7. Expanded program for immunization (EPI)
 Nutrition Isolation - separation of patient of patient with communicable disease from
 Health Status others so as to prevent or reduce transmission of infectious agent directly or
Factors Influencing Production of an Infectious Disease indirectly

 Age - other terms are: protective aseptic technique or barrier technique

 The elderly and children under two years of age are at greatest
Purpose - confine the infectious agent to a circumscribed area and to prevent
risk
its escape from that area
 Heredity
 Conditions or diseases resulting in the absence of or inability to Seven categories recommended in isolation
form immune defenses
 Stress 1) Strict isolation
 Increase in metabolic rate which results in using up stored 2) Contact isolation
energy 3) Respiratory isolation
 Elevation of blood cortisol, decreasing anti-inflammatory 4) TB isolation
responses 5) Enteric isolation
 Continued stress produces exhaustion, further depleting ability 6) Drainage/secretion precaution
to ward off infection. 7) Universal precaution when handling blood and body fluids
 Surgery
 Eliminates primary barrier of infection.
 Predisposes clients to surgical site infections. Types of Isolation
 Localized infection at wound site can progress to a systemic
infection.  Strict Isolation
 Additional risks include catheters and tubes. Purpose: Designed Prevent Transmission of highly
 Nutrition contagious or virulent infections spread by airborne droplet and
 Insufficient protein consumption reduces antibody production contact transmission
and inhibits the body’s ability to ward off infection.
Wash hands every after contact with the patient or potentially contaminated
 Health Status
articles & before taking care of another patient
 Clients w/ disease of their immune system are at greater risk.
 Chronic diseases can predispose the client to infection. Articles contaminated with infectious materials should be appropriately
discarded or bagged & labeled before being sent for decontamination &
processing
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STRICT ISOLATION  Handwashing
Disease requiring Isolation:
Specification: Private Room – necessary
 Hepatitis viral (type A)
Hand Washing  Gastroenteritis caused by highly infectious organism
 Cholera
Gown  Diarrhea, acute with infectious etiology.
Masks
 Drainage/secretion precautions
Gloves
to prevent infections that are transmitted by direct or indirect contact with
Articles – Discard or bag and label and send for purulent materials or drainage from an infected body site
decontamination and reprocessing.

Negative pressure to surrounding area is desirable

Technique includes
Diseases requiring Isolation:
 Gown if soiling is likely
Diphtheria (pharyngeal)  Gloves for touching infective material

Smallpox
Disease requiring Isolation
Varicella
 Abscess
 Contact Isolation - Designed for highly transmissible infections that are  Burn infection
not spread by airborne droplet nuclei but are transmitted primarily by close  Conjunctivitis
or direct contact  Decubitus- ulcer skin or wound infection.
Patients with large draining wound  Universal Precaution
 All patient’s blood and body fluids be considered potentially
Technique includes infected with blood borne pathogen
 Defined by center for disease control (CDC) 1996
 Private room  Primary strategy for reducing the risk of & controlling
 Mask for those personnel providing close direct care Nosocomial infections
 Gown if soiling is likely  Used for care of all hospitalized patients, regardless of diagnosis
 Gloves for touching infective material and are presumed infectious
Diseases requiring Isolation:  Protect healthcare workers from contamination and infection
( i.e. HIV, HBV)
 Acute Resp. infection in infant and young children
Disease requiring Isolation:
 Herpes simplex
 Impetigo  AIDS
 Multiple resistant bacterial infection.  Hepatitis - viral (Type B)
 Malaria,
 Syphilis - primary and secondary.
Infection Control Signage Universal Precaution

 Respiratory Isolation Hand Washing

prevent transmission of infectious disease over short distances through the
air (droplet transmission)  Routine: Plain (non microbial) soap
 Outbreak Control: Antimicrobial/Antiseptic Agent
Technique includes  Wash After:
1.touching blood and other body fluids
 Private room or cohorting patient with same organism
 Mask for those providing close direct care 2. touch contaminated items
Disease requiring Isolation:
3. removal of gloves
 Measles
 Meningitis 4. between patient contact, task, procedure
 Pneumonia
 Hemophilus Influenza in children Universal Precaution Materials
 Mumps.
Gloves
 TB Isolation or AFB isolation
for TB patient with positive smear or chest X- ray which strongly suggest  Must be worn when touching blood, body fluids, secretions, excretions
active tuberculosis and contaminated items, mucous membranes and non- intact skin
 Change gloves between tasks or procedures
Technique includes
 Remove gloves after use and before going to another patient
 Private room with negative airflow Masks, Eye Protection, Face Shields, Gowns
 Use of appropriate respiratory protection
 Wear in procedures that can generate splashes or sprays of blood,
Specification:
body fluids, secretions or excretions or cause soiling of clothing
Private Room – necessary Environmental Control

Hand Washing  Routine care, cleaning and disinfection of environmental surfaces

Patient Care Equipment
Gown – Wear if soiling is likely
 Prevent contaminating yourself or transfer microbes to others
Masks – wear if client is coughing and does not consistently cover mouth  Properly clean, disinfect or sterilize
 Dispose single – use items
Gloves – not necessarily Linens

Articles – Rarely involved in transmission of  Handled, transported and processed to prevent contamination and
transfer of microorganisms
TB. Should still be thoroughly cleansed and Occupational Health and Blood –borne Pathogens
disinfected.
 Never recap used needles
 Enteric Isolation  Puncture – resistant containers
designed to prevent infections that are transmitted by direct or indirect
contact with feces
Reverse Isolation
Technique includes
 Protective or neutropenic isolation
 Private room if with poor hygiene and likely to contaminate  Used for patients with:
environment  severe burns
 Gown if soiling is likely  eukemia
 Gloves for touching infective material
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 Transplant
 immuno deficient persons
 receiving radiation treatment
 leukopenic patients
 Those that enter the room must wear masks and sterile gowns to
prevent from introducing microorganisms to the room
Waste management

- is the collection, transport, processing, recycling or disposal of waste

materials.

Involves:

1. Sharps

2. Solid infectious – cotton swab, dressing

3. Anatomic Infectious – placenta / organ

4. Solid non-infectious – used IV / bottle IV

5. General waste – scrap paper / food material

Philippine set-up

 Black plastic bags

- are for non-biodegradable and noninfectious

wastes such as cans, bottles, styropore, straw, plastic, boxes,

wrappers, newspapers.

 Green plastic bags

are biodegradable wastes

fruits and vegetables' peelings, leftover food flowers, leaves, and twigs.

 Yellow plastic bags

for infectious waste

disposable materials used for collection of blood and body fluids like diapers,
sanitary pads;

materials (like tissue paper) with blood secretions and other exudates;
dressings, bandages, used cotton balls, gauze; IV tubings, used syringes;
Foleys catheter/ tubings; gloves and drains.

Means of controlling the spread of CD

1. Elimination of the source of infection

2. Interruption of transmission
3. Protection of susceptible host.

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