Pathophysiology ▪ Neoplastic disease

• Study of the underlying changes in the body physiology that result • Abnormal or uncontrolled cellular growth
from disease or injury • Example: Cancer
• Provides understanding of the mechanism of the disease and to • Pathogenesis
explain how and why alterations lead to signs and symptoms o Development of a disease
• Allows health care workers to plan better o Sequence of events that leads from cause of disease to
• Pathology structural and functional abnormalities, how the disease
o Study of structural and functional changes caused by a manifests itself and finally to the resolution or recovery of
disease the disease
• Physiology • Etiology
o Study of the functions of the body o Causes of a disease
• Disease o Some diseases are multicausal
o A state in which a bodily function is no longer occurring o Types:
normally ▪ Intrinsic
o Types of disease • Coming from within
▪ Hereditary disease • Ex: genetic, metabolic, endocrine disorders
• Diseases that are transmitted before birth ▪ Extrinsic
• Involves genetic material which makes • Originating from external factors
them susceptible to disease • Ex: infectious diseases, physical trauma,
• Ex: medications
• Gene BRCA12 = breast cancer ▪ Idiopathic
▪ Genetic diseases • Cause is unknown
• Abnormalities in genetic makeup • 99% of psychiatric disorders are idiopathic
• Mutation of genes • Risk Factors
• Ex: Trisomy 21 = 21 Down syndrome (when o Predisposing factors (Precipitating factors = immediate
autosome 21 mutates thrice) trigger to a disease)
▪ Developmental disease o Increases the probability of becoming ill
• Issue arises from embryonic/fetal o Types:
development ▪ Non Modifiable
• Ex. Fetal alcohol syndrome • Age (Very young and Very old)
▪ Congenital disease • Sex
• Present at birth • Genetic makeup
▪ Inflammatory disease ▪ Modifiable
• Diseases that trigger an inflammatory • Stress
response • Elevates corticosteroids in the body
▪ Metabolic disease which weakens the immune system
• Affects metabolism • Lifestyle
• Ex: diabetes • Occupations
▪ Degenerative disease • Ex: teachers may get laryngeal
• Causes a body part to deteriorate cancer
 • Pre-existing illness (Co-morbidities) o Etiology = "related to"
• Environmental exposure o Signs/Symptoms = "as evidenced by"
• Manifestation • Example:
o How a disease presents itself (Clinical manifestation or o Hyperthermia related to bacterial infection as evidenced by
presentation) T=38.9C and WBC of 15,000 m3
o Signs o Ineffective airway breathing related to impaired gas
▪ Objective physical observations as noted by the exchange as evidenced by RR of 26 cpm secondary to [insert
examiner medical term]
o Symptoms • Principles of prioritization
▪ Subjective perception of anomaly or discomfort o Use of ABC = Airway, Breathing, Circulation
• Treatment (Therapy) o Maslow's hierarchy of needs
o Interventions carried out in order to attempt a cure Planning
o Types: • Formulate your goals of care
▪ Supportive therapy • Time
• Are conservative therapy that includes o Short term
optimal nutrition, fluids, possible antibiotics ▪ Within shift hours
to prevent secondary infections o Long term
▪ Palliative therapy ▪ Within several days
• Symptomatic therapy which only provides • Must be SMART
relief from signs and symptoms but not cure o Specific
▪ Preventive therapy ▪ Patient Specific
• Care that is given to prevent a disease o Measurable
• Prognosis o Attainable
o The predicted or expected outcome of the disease o Realistic
o Types o Time-bound
▪ Good prognosis ▪ Within specific time frame
• Full recovery Interventions
▪ Guarded prognosis • Used to solve nursing problem
• Full recovery may or may not occur • Dependent, independent, collaborative
▪ Poor prognosis • EBP
• Not expected to recover o Align each intervention with a rationale and in-text citation
Assessment Evaluation
1. Data gathering (raw data) • Evaluation is compared against goals of care
2. Cluster the data • Assessment after interventions
3. Analyze the data • Serves as basis of the next course of action
Diagnosis • Three things after evaluations
• Statement of the nursing problem o COntinue
• Diagnostic statements are from NANDA ▪ Goals unmet
• Follows a specific format o MOdify
o Problem = Diagnostic statement ▪ Goals partially met
 o Terminate ▪
Patient requires prompt attention but it can be
▪ Goals fully met delayed within 24 - 30 hours
▪ Ex: Laparotomy cholecystectomy
Creating pathophysiology o Required
• Provide legends ▪ Patients needs surgery but may be delayed up to
• Indicate patient-specific risk factors few weeks and months
• Connect risk factors to main medical/surgical diagnosis o Elective
• Trace the disease progression to the signs/symptoms/abnormal ▪ Patient should have surgery but failure to do so is
laboratory findings manifested by the patient not catastrophic
• Indicate appropriate nursing diagnosis o Optional
• Connect to a good or bad prognosis ▪ decision rests within the patient
• Produce something not taken from the internet • Nomenclature of surgery
o
Surgery Suffix Meaning Example
• The art and science of treating diseases, injuries and deformities by
operation and instrumentation -ectomy Excision or Appendectomy
• Not the first option; the first option is conservative care removal of
• Classification according to purpose: -lysis Destruction of Electrolysis
o Diagnostic
-orrhaphy Repair or suture Herniorrhaphy
▪ Determination of the presence and extent of a of
pathologic condition
▪ Ex: Biopsy -oscopy Looking into Endoscopy
o Curative -otomy Cutting into or Tracheotomy
▪ Eliminate or repair of pathologic condition incision
▪ Ex: appendectomy
-plasty Repair or Mammoplasty
o Palliative
reconstruction
▪ Alleviation of symptoms without cure
▪ Ex: Mastectomy -ostomy Creating of Colostomy
o Cosmetic improvement opening
o Exploratory Historical perspective
▪ Surgical examination to determine the nature or • Operating room nursing
extent of a disease o Used to describe the care of patients in the immediate
▪ Ex: Exploratory Laparotomy preoperative, intraoperative and post operative phases
• Classification according to urgency • Perioperative nursing
o Emergent o Implies the delivery of comprehensive patient care within
▪ The patient requires immediate attention as the the preoperative, intraoperative and post operative periods
disorder may be life/limb threatening of the patient's experience during a operative and other
▪ Ex: Gunshot wound invasive procedures by using the framework of the nursing
o Urgent process
• Minimally invasive surgery
 o Less time in hospital increased
o May need only a band-aid BP and HR
o Less complications
Garlic (Allum Reported to Can
• Robot-assisted precision surgery
o Makes incision accurate and precise sativum) lower BP and increase
Phases of perioperative nursing cholesterol bleeding
levels
• Preoperative phase
o Begins when the decision to proceed with surgical Ginkgo Biloba Used to Can
intervention is made and ends with the transfer of the improve increase
patients onto the operating room (OR) bed memory bleeding
• Intraoperative phase Ginseng Used to Can
o Begins with the transfer of the patients onto the operating
increase increase HR
room (OR bed) til the patient is admitted to the PACU concentration and risk of
• Post operative phase bleeding
o This begins when the person is admitted to the PACU and
ends with the follow up evaluation in the clinical setting or Kava-Kava (Piper Used to Can
home methysticum) decrease increase
o No specific time frame anxiety the effect
of
Preoperative phase anesthesia
• Assessments St. John's wort Used to May
o Ask about allergies and comorbidities (iodine based solution (Hypericum decrease prolong the
used during surgery might cause allergic reaction) perforatum) anxiety, help effects of
▪ NKA = No Known Allergies with some types
o Obtain baseline vital signs depression of
o Perform physical assessments and sleep anesthesia
▪ Skin assessment problems
▪ Joint mobility
Valerian Used as a May
o Medication history
(Valeriana officinalis) sleep aid prolong the
▪ "medication reconciliation"
effects of
▪ (OTC, herbal, etc.)
some types
Herb or supplement Indications Possible of
for use surgical risk anesthesia
Ephedra (Ma-huang) Appetite May Vitamin E Thought to Can
suppressant interact slow the increase
with aging process bleeding
medications and may
to cause cause BP
problems
Agent Effects of interaction with
anesthetic
Corticosteroids Cardiovascular collapse can
(Dexamethasone) occur if discontinued
suddenly. Therefore a bolus
of corticosteroids may be
administered IV immediately
before and after surgery.
Diuretics During anesthesia, may cause
(Hydrochlorothiazide) excessive respiratory
depression resulting from an
associated electrolyte
imbalance
Phenothiazines May increase the
(Chlorpromazine hypotensive action of
Hydrochloride) anesthetics
Tranquilizers May cause anxiety, tension,
(Diazepam) and even seizures if
withdrawn suddenly
Insulins (Insulin) Interaction between
anesthetics and insulin must
be considered when a patient
with diabetes is undergoing
surgery. IV insulin may need
to be given to keep glucose
within the normal range.
Anticoagulants Can increase the risk of
(Warfarin) bleeding during the
intraoperative and post
operative phase; should be
discontinued in anticipation
of elective surgery. The
surgeon will determine how
long before the elective
surgery the patient should
stop taking an anticoagulant,
depending on the type of
planned procedure and the
medical condition of the
patient.
Anticonvulsant IV administration of
medications medication may be needed
(Carbamazepine) to keep patient seizure free
in the intraoperative and post
operative periods
Thyroid hormone IV administration may be
(Levothyroxine needed during the post
sodium) operative period to maintain
thyroid levels
Opioid levels Long term use for opioids for
(Morphine sulfate) chronic pain (>6 months) in
the post operative period
may alter the patient's
response to analgesic agents.
• Psychosocial spiritual assessment
o Emotional state influences stress response and thus, the
surgical outcome
o Stress will release catecholamines, corticosteroids, (high
corticosteroid levels cause bad healing)
▪ Catecholamines include epinephrine and
norepinephrine
o Assessment
▪ Fear of death
• Nursing responsibility
• Notify physician
• Surgery may be delayed until
situation improves
▪ Fear of pain and discomfort
• Nursing responsibility
• Reassure the patient that drugs are
available for both anesthesia and
analgesia during surgery
 • After surgery, instruct patient to ask
for pain medication before it
becomes severe
• Pain cardinal rules
• Always believe patient's pain
• Quantify and specify the pain
• Instruct the patient to ask for pain
medication before severity
▪ Fear of mutilation/alteration of body image
• Nursing responsibility
• Determine perceived or potential
changes in roles or relationships
and their impact on body image
• Identify current roles or
relationships and view of self
• Refer them to councilors
▪ Fear of the unknown
• Nursing responsibility
• Identify specific areas and degree of
anxiety and fears related to the
surgery
• Identify expectations of surgery,
changes, in current health status,
effects on daily living and sexual
activity
• Informed consent
o Is the patient's autonomous decision about whether to
undergo surgical procedure
o Purposes
▪ Protect the patient from unsanctioned surgery
▪ Protect surgeon from claims of unauthorized
operation or battery (battery = operation without
consent; assault = threatening)
o Elements of informed consent
▪ Voluntary consent
• Consent must be freely given without
coercion
• Patient must be 18 years old, unless
emancipated minor (military or underaged
parent)
• Patient must not be incompetent
• Legal competence
• Individual who is not
autonomous and cannot
give or withhold consent
▪ Informed subject
• Consent must be in writing and should
contain
• Explanation of procedure and risks
• Descriptions of benefits and
alternatives
• An offer to answer questions about
procedure
• Instructions that the patient may
withdraw consent
• A statement informing the patient if
the protocols differ from customary
procedure
▪ Patient should be able to comprehend
• Non-English speaking patients
• Provide consent in a language that
is understandable to the patient
• Consult with a trained medical
interpreter
• Patients with visual or hearing impairment
• Use of alternative forms of
communication
• Braille, large font, sign
interpreter
• Nursing responsibility
• The nurse may ask the patient to
sign the form and witness the
signature
• Clarify information provided by the
physician
• If additional information is
requested, notify physician
• Ascertain that consent is signed
before any psychoactive medication
 • Note: The informed consent is placed in the
front page of the patient's medical record
and accompanies the patient to the OR
• Preoperative teaching
o Characteristics of an effective health teaching plan:
▪ Individualized (specific to the patient)
▪ Integrates varied strategies
▪ Begun as soon as possible
▪ Allow time for the patient to assimilate information
▪ Goes beyond description of the sensations the
patient will experience
▪ Contains enough details
o Exercises
▪ Diaphragmatic breathing
• Refers to a flattening of the dome of the
diaphragm during inspiration with resultant
enlargement of the upper abdomen as air
rushes in. During expiration, the abdominal
muscles contract
• Practice in the same position you would
assume in bed after surgery: a semi-fowler's
position propped in bed with the back and
shoulders on pillows
• Feel the movement with your hands resting
lightly on the front of the lower ribs and
fingertips against the chest
• Breath out gently and fully as the ribs sink
down and inward midline
• Then take a deep breath through your nose
and mouth, letting the abdomen rise as the
lungs fill with air
• Hold this breath for a count of five
• Exhale and let out all the air through your
nose and mouth
• Repeat this exercise five times with a short
rest after each group of five
• Do this twice a day
▪ Coughing
• Lean forward slightly from a sitting position
in bed, interlace your fingers together, and
place your hands across the incision site to
act as a splint for support when coughing
• Breathe with the diaphragm as described
under diaphragmatic breathing"
• With your mouth slightly open, breathe in
fully
• Hack out sharply for three short breaths
• Then, keeping your mouth open, take in a
quick breath and immediately give a strong
cough once or twice. This helps clear
secretions from your chest. It may cause
some discomfort but will not harm your
incision
▪ Leg exercise
• Lie in a semi-fowler position and perform
the following simple exercises to improve
circulation
• Bend your knee and raise your foot
- Hold it a few seconds, then extend
the leg lower and lower it to the
bed
• Do this five times with one leg then
repeat with the other leg
• Then trace circles with the feet by
bending them down, in toward each
other, up and then out
• Repeat these movement five times
▪ Turning to the side
• Turn on your side with the upper leg flexed
most and supported on a pillow
• Grasp the side rail as an aid to maneuver to
the side
• Practice diaphragmatic breathing and
coughing while on your side
▪ Cognitive coping strategies
• Imagery
• The patient concentrates on a
pleasant experience of restful scene
• Distraction
 • The patient thinks of an enjoyable • Antimicrobial soap day before
story or recites a favorite poem or surgery
song • Hair is generally not removed unless it is
• Optimistic expected to interfere with operation
• The patient recites optimistic • Shave (shaving might injure skin),
thoughts wax, clip (before transfer to OR)
• Positive self talk ▪ The day of the surgery
• Music • Let the patient wear a hospital gown, untied
• Music therapy and open at the back
• The patient listens to soothing • If patient has long hair, braid it, remove hair
music pins (to avoid contracting electricity) cover
• Special considerations with disposable surgical caps
o Summary of the 2016 national patient safety goals • Remove dentures, jewelry, including
▪ Identify patients correctly wedding rings and body piercing
▪ Improve staff communication • Let the patient void immediately before
▪ Use medicine safely going to the OR
▪ Use alarms safely • If already in the OR, offer things to
▪ Prevent infection void in
▪ Identify patient safety risks • Side rails up after preanesthetic
▪ Prevent mistakes in surgery medications and environmental noise
o NPO should be kept to a minimum to promote
▪ Non per Orem relaxation. The patient may also react to
▪ Purpose sounds
• To prevent aspirations • Bring patient to OR holding area about 30 to
• When something non gaseous 60 minutes before anesthetics are given
enters the respiratory tract • Provide additional blankets in holding area
• Causes because the ideal temperature of the OR is
• Anesthesia 21C - 24C
• Positioning o Bowel preps
▪ Preoperative fasting recommendation ▪ Indication: abdominal and pelvic surgeries
▪ Anesthesiologist will be the one to give the order ▪ Fecal matter might contaminate peritoneum (this
for fasting may lead to peritonitis then septic shock, then
o Patient safety death)
o Skin preps ▪ Enemas can be delegated to nursing aid
▪ Purposes: to decrease bacteria without injuring the ▪ Laxatives and antibiotic strictly for nurses
skin Intraoperative phase
▪ Principles: • OR components:
• Antiseptic skin cleansing protocols (if o Anesthesia machine
applicable) ▪ Delivers oxygen and inhalation anesthetics
• Could be feminine wash (gynepro) o OR lights
 ▪ Used to illuminate the organs of the patient • Assist the surgeon during the procedure by
o Mayo table anticipating the monitoring instruments and
▪ Specific instruments needed for the specific surgery supplies that will be required
o OR bed • Does counting of all needles, sponges, and
▪ Where the patient will be placed, electronic instruments with the circulating nurse
o Back table • Labels tissue specimen obtained during
▪ Where the instruments and gowns are places: surgery and sent to the lab by the
anything sterile circulating nurse
o Cart Sterile Not
▪ Extra supplies Sterile
o Pendulum
▪ Ports for electronics Patient ✔️
o NOTE: Scalpel is a blade + blade holder. Surgeon ✔️
▪ 15 - 20 = 3
Anesthesiologist ✔️
▪ 20+ = 4
• Surgical team Scrub nurse ✔️
o Patient, oxygen, anesthesiologist
Circulatory ✔️
o In other countries, nurses can give anesthesia
nurse
▪ CRTA or Certified nurse anesthesiologist
o Nurse's roles ▪ Whoever wears a gown is sterile
▪ Circulating nurse ▪ Sign in
• RN • Before anesthesia
▪ Time out
• Manages the OR
• Is not a part of the surgical team • Before skin incision (performed by circulatory nurse)
▪ Sign out
• Monitors strict observance of aseptic
technique • Before patient leaves operating room
• Documents specific activities throughout • Surgical environment
o Unrestricted zone
the operation
▪ Street clothes are allowed
• Facilitates time out
o Semi restricted zone
• Protects patient's safety and health by
monitoring activities of surgical team ▪ Scrub suit
• Ties OR gown ▪ Mask
▪ Scrub role ▪ Cap
• RN or LPN or Surgical technologist ▪ OR shoes
o Restricted zone
• Does surgical hand scrub
• Sets up sterile field and equipment ▪ Mask
▪ Scrub suit
• Prepares sutures (needle and thread),
▪ Cap
ligatures (only thread) and special
equipment ▪ OR shoes
▪ Shoe covers
 ▪ OR gown (for sterile members) ▪ OB = Gauge 20: Pink
▪ Other PPE o Sedation
o Principles of asepsis ▪ To prevent patient from going wild
▪ All materials in contact with the surgical wound or o Induction
used within the sterile field must be sterile. Sterile ▪ When the anesthetics is given
surfaces or articles may touch other sterile areas or o Losing consciousness
articles and remain sterile; contact with unsterile o Intubation (if necessary)
objects at any point renders a sterile area o Receiving combination anesthetics (because anesthetics
contaminated have a short half life)
▪ Gowns of a surgical team are considered sterile in • Methods of induction
front from the chest to the level of the waist the o Inhalation (gases)
level of sterility on the arms are from 2 inch above ▪ Uses volatile liquid agents and gases
the elbow to the stockinette cuff ▪ Anesthesia is produced when patients inhale the
▪ Whenever a sterile barrier is breached, the area vapor from these anesthetic agents
must be considered contaminated ▪ Given in combination with oxygen
▪ If you see strikes on a tape then that means that the ▪ Could be through the nose or the mouth
item is sterile ▪ GETA (General endotracheal anesthesia)
• Usually has a date but autoclave can only • Consists of introducing a soft rubber or
keep an item sterile for 30 days plastic ETT into the trachea by means of
▪ NOTE: "when in doubt, throw it out" laryngoscope
o Double gloving • Size is usually 6-8 Fr
▪ Routinely done in trauma and other types of ▪ Intranasal intubation
surgery where sharp bones/fragments are present • An alternative of anesthesia induction
▪ Other PPEs where in the ETT is inserted through the
• Rubber boots nose into the trachea
• Waterproof aprons ▪ LMA (Laryngeal Mask airway)
• Sleeve protectors • A flexible tube with an inflatable silicone
• Goggles (for amputation) ring and cuff that can be inserted into the
• Bubble mask (looks like an astronaut) larynx
Anesthesia o Intravenous (liquids)
• Analgesia, relaxation and reflex loss ▪ May be used to induce and/or anesthesia
• Any medication in the OR is given by the anesthesiologist ▪ May be combined with inhalation anesthetics or
• Consciousness, reflexes, muscle contractility, respiratory drive used alone
decrease ▪ Has a short duration of action and patient awakens
• Amnesia is a side effect of general anesthesia with little nausea or vomiting
• Anesthesia experience ▪ Useful for short procedure
o Starting IV line ▪ TIVA
▪ Most anesthetic agents or medication in OR is • Total intravenous anesthesia
through an IV line • Stages
▪ Generally = Gauge 18: Green o Stage one: Beginning Anesthesia
 ▪ Dizziness • Addictive • Can also
▪ Feeling of detachment substance be used
▪ Ringing, roaring, or buzzing in ears for acute
▪ Exaggerated perception of noise suicidal
▪ Rapid pulse rate tendency
▪ Irregular respirations Methohexital
• Can be prevented by pre-anesthetics (brevital)
o Stage two: Excitement • Commonly
▪ Bizarre behavior used in
• Struggling , shouting, talking, singing, ECT
laughing or crying (Electro
▪ Dilated pupils convulsive
o Stage three: Surgical Anesthesia therapy)
▪ Unconsciousness
▪ Small pupils but still react to light respirations are Muscular Vecuronium Aracurium
regular relaxant (tracrium)
▪ Pulse becomes normal Cistracurium
▪ Skin is pink or lightly flushed
(wimbex)
o Stage four: Medullary depression Pancorium
▪ Must be prevented (pavulom)
▪ Shallow respirations Rocuronium
▪ Weak and thready pulse
(zemuron)
▪ Fixed, dilated pupils Succinylcholine
▪ Cyanosis
(anectine)
▪ Death • Types of anesthesia
o General anesthesia
Inhalation Isoflurane Desoflorane
▪ Abbreviated as GA
anesthetics (Florane) (sufrane)
▪ Characteristics of people receiving GA
Enflurane
• Not arousable even to pain
(ethrane)
• Loss of spontaneous ventilation
Nitrous oxide (for
• Possible impairment of CV function
dental use)
• Some anesthetics make cv unstable
Sevoflurane
o Regional anesthesia (RA)
(ultane)
▪ Characteristics
Intravenous Propofol Etomidate ▪ Awake (may or may not be)
anesthetics (diprivan) (amidate) ▪ Aware of surrounding unless intentionally sedated
• Most Fospropofol ▪ Mechanism of action
common (lusedra) • An anesthetic agent is injected around
• Looks like Ketamine (ketalar) nerves so that the region supplied by those
milk nerves is anesthetized
▪ Types • Leakage of
• Epidural anesthesia SF
• Achieved by injecting a local • We can
anesthetic agent into the epidural prevent
space that surrounds the dura CSF leakage
mater of the spinal cord by
• Spinal anesthesia positioning
• An extensive conduction nerve our patient
block that is produced when a local flat for 6-8
anesthetic agent is introduced into hours after
he subarachnoid space at the anesthesia
lumbar level, usually between L4 was
and L5 administer
• Chronic side effect is back pain ed
• Ex: Bupivacaine, Bupivacaine Heavy o Moderate sedation
• CSEA
▪ A form of anesthesia that involves the IV administration of
• Combines spinal and epidural
sedatives or medications to reduce patient anxiety and
anesthesia
control pain during diagnostic or therapeutic procedures
Epidural Spinal ▪ Goal: to reduce level of consciousness to moderate level to
Epidural Location Subarachnoi enable procedures to be performed while ensuring comfort
space d space and cooperation
▪ Characteristics of patient receiving moderate sedation
Higher Dose Lower than
• Able to maintain patent airway
than epidural
• Retains protective airway reflexes (gag and cough)
Spinal
• Responds to verbal and physical interference
Anesthesi
▪ Monitored anesthesia care (MAC)
a since
• A form of moderate sedation give by an
the agent
anesthesiologist or CRNA who must be prepared
does not
and qualified to convert to general anesthesia if
make
necessary
direct
• Indications
contact
• Minor surgical procedure
with
• Critically ill patients who are unable to
spinal
tolerate
cord or
• Monitoring and pharmacological support
nerve o Local anesthesia
roots
▪ Is the injection (called infiltration) of a solution containing
Absent Spinal headache Present the anesthetic agent into the tissues at the planned incision
site
 ▪ Often used in combination with epinephrine • Epinephrine SQ
• Epinephrine constricts blood vessels, which • Hypothermia
prevents rapid absorption of the anesthetics agent o A core temperature that is lower than 36.6C
and thus prolongs its local action and prevents o Intraoperative causes
seizures ▪ Low temperature in OR (because of infection
▪ Sample: Lidocaine (also called anti-arrhythmic which can control)
cause seizures) ▪ Infusion of cold fluids (ex: cold NSS to prevent
▪ Contraindications bleeding)
• High pre-operative level of anxiety ▪ Inhalation of cold gases
• Major surgeries ▪ Open wounds/cavities
Intraoperative complications ▪ Decreased muscle activity
• Anesthesia awareness ▪ Advanced age (loss of fats)
o Unintended intraoperative awareness refers to a patient ▪ Medications
becoming cognizant of surgical interventions while under o Pathophysiology
general anesthesia and then recalling the incident ▪ Catecholamines released
o Occurs to 0.1 to 0.2% of general anesthesia patients ▪ Increased HR, RR, BP
o Manifestations ▪ Shivering
▪ Increase in BP (could be because the patient feels ▪ Glucose depletion, T<32.2C
pain) ▪ Shivering stops (all compensatory mechanisms will
▪ Rapid HR eventually fail)
▪ Presence of patient movements ▪ HR, RR begins to decrease
o Prevention ▪ Cardiac arrest
▪ Premedication with amnesia agents o Management
▪ Avoidance of muscle relaxants unless absolutely ▪ Temporarily increasing OR temp to 25C to 26.6C
necessary ▪ Warm IV and irrigating fluids
• Nausea and vomiting ▪ Warm air blankets
o Occurs as a side effect of anesthetic agents ▪ Minimize exposure
o Management • Malignant hyperthermia
▪ Anti-emetics (metoclopramide IV) o A rare inherited muscle disorder that is chemically induced
▪ Turn patient to the side by anesthetic agents
▪ Lower head of the bed o Occurs in 1 in 50, 000 to 100,000 adults
▪ Provide basin to collect vomitus o Mortality rate can be as high a 70% but can be lowered to
▪ Suction oral cavity 10% with early detection and prompt treatment
• Anaphylaxis o Risk factors
o Serious, life threatening reaction ▪ People with strong and bulky muscles
o Intraoperative causes (medications and latex) ▪ History of muscle cramps/weakness and
o Manifestations unexplained temperature elevation
▪ Periorbital swelling, rash, flushing, laryngeal edema ▪ History of unexplained death of a family member
and cyanosis that was accompanied by febrile response
▪ Management ▪ Inhalation anesthetic and muscle relaxant
 o Clinical manifestations o The patient is supported in position by padded shoulder
▪ Generalized muscle rigidity (Earliest sign) braces, bean bags, and foam paddings
▪ Tachycardia: (SVT) HR>150 bpm (early cardiac sign) o Used for surgery on lower abdomen and pelvis to obtain
▪ Hypercapnia (early respiratory sign) good exposure by displacing the intestines into the upper
▪ Hypotension abdomen
▪ Oliguria (UO<30 CC/hour) • Reverse Trendelenburg position
▪ Rapid increase in body temperature (1C to 2C every o Head and body are elevated
5 minutes( (Late sign) o Provides the space to operate on the upper abdomen by
o Management shifting the intestines into the pelvis
▪ Discontinue anesthesia o A paddled foot board and other supportive cushioning
▪ Dantolene sodium (Dantium) muscle relaxant preserve a safe environment for the patient
▪ Decreased body temperature • Lithotomy position
• Cooling blankets o Patient positioned on the back with the legs and thighs
• Lower OR temp flexed
• Cooled IVF o The position is maintained by placing the feet on stirrups
Intraoperative positioning o Used for nearly all perineal, rectal and vaginal surgical
• Principles of intraoperative positioning procedures
o The patient should be as comfortable as possible, whether • Kidney position
conscious or unconscious o Patient lies on unaffected side for kidney surgery
o The operative field must be adequately exposed o The table is spread apart to provide space between the
o An awkward anatomical position, under pressure on a body lower limbs and pelvis
part, or the use of stirrups or traction should not obstruct o The upper leg is extended ; the lower leg is flexed at the
the vascular supply knee and hip joints
o Respirations should not be impeded by pressure of arms on o A pillow is placed between the legs
the chest or by a gown that constricts the chest
o Nerves must be protected from undue pressure. Improper Post operative phase
positioning of the arms, hands, leg or feet can cause serious • Goals of care:
injury o Reestablishment of physiologic equilibrium
o Precautions for patient safety must be observed, o Alleviation of pain (because anesthesia has a short half life)
particularly with older adults o Preventing complications
• Dorsal recumbent (Supine) o Education on self-care
o Flat on back • Post anesthesia care unit (PACU) (also called recovery room)
o Both arms positioned at side of table: one with the hand o Located adjacent to the theaters
placed palm down and the other carefully positioned on an o Patients still under anesthesia or recovering from
arm board to facilitate infusion anesthesia are placed in this unit for easy access to
o Used for most abdominal surgeries, except for surgery of experienced, highly skilled nurses, anesthesia providers,
gallbladder or pelvis surgeons, advanced hemodynamic and pulmonary
• Trendelenburg position monitoring and support, special equipment and medications
o Head and body are lowered o Head of PACU is anesthesiologist
o Within 24 hours post-op, anything related to pain is referred
to anesthesiologist, beyond this time, refer to surgeon
o Nursing care in PACU
▪ Provide supplemental oxygen as ordered (2L/min is
the maximum amount a student nurse can
administer)
▪ Begin initial assessment
• Vital signs
• Level of consciousness
• Surgical role for drainage hemorrhage
▪ Connection of drainage tubes and monitoring lines
▪ IV fluids and medications
▪ Monitor every 15 minutes
▪ Administer post operative analgesics as ordered
(most of the time opioid [morphine] analgesics}
▪ Post operative drains
• Allows escape of fluids that could otherwise
serve as a culture medium for bacteria
• Penrose drain
• Uses gravity
• Has a pin to prevent it from going
inside
• Doctor will be the one to remove it
(this applies to all drainages)
• Clean from inner to outer or top to
bottom
• JP drain (looks like a grenade)
• Appendicitis rupture
• Use negative pressure (sucks the
contents into the drain) (this is
done by pinching the drain)
• Maximum storage is 100 ml
• Hemovac
• Works similar to JP drain
• Monitor color of drainage
• Immediately post-op
• Bloody
(serosanguineous)
• Within 3-5 days
• Light red to pinkish
• Respiratory complications
o Hydro pharyngeal obstruction
▪ Occurs when the patient lies on their back, the
lower jaw and tongue fall backward and the air
passages become obstructed
▪ Manifestation
• Choking
• Noisy and irregular respirations
• Desaturation
• Cyanosis
▪ Management
• Tilt the head back and forward on the angle
of the lower jaws as if to push the lower in
front of the upper teeth
o Hypotension
▪ Causes
• Blood loss; most common
• Hyperventilation
• Position changes
• Pooling of blood in extremities
• Side effects of medications and anesthetics
▪ Nursing responsibilities
• Fluid replacement, as ordered (Bolus of
PNSS)
• Blood transfusion, if blood loss > 500 mL as
ordered
• BP = cardiac output/systemic muscular
resistance
• Cardiac complications
o A systolic blood pressure of less than 90 mmHg is usually
considered immediately reportable. However the patients
preoperative or baseline blood pressure is used to make
informed postoperative comparisons. A previously stable
blood pressure that shows a downward trend of 5 mmHg at
each 15 minute reading should be reported.
o Hemorrhage
▪ An uncommon yet serious complication of surgery
that can result in hypovolemic shock and death
▪ Clinical manifestations
• Hypotension
 • Rapid, thready pulse • Hemorrhage is in a body cavity and
• Disorientation cannot be seen
• Restlessness ▪ Management
• Oliguria (caused by decreased blood flow to • If bleeding is evident
kidneys) • Apply sterile gauze pad and
• There is more than 500 mL blood loss pressure dressing
▪ Timeframe • Elevate site of bleeding to a heart
• Primary level if possible (this decreases the
• Hemorrhage occurs at the time of blood flow out the site)
the surgery • Place in modified Trendelenburg
• Intermediary (this increases return of blood to
• Hemorrhage occurs during the first the heart)
few hours after surgery when the • If bleeding I suspected but cannot
rise of blood pressure to its normal be visualized
level dislodges insecure clots from • Patient is taken back to OR
untied vessels for emergency exploration
• Secondary of surgical site
• Hemorrhage may occur sometime o Hypovolemic shock
after surgery if a suture slips ▪ Clinical manifestations
because a blood vessel was not • Pallor
securely tied, become infected or • Cool, moist skin
was eroded by a drainage tube • Rapid breathing
• Pooling of blood means blood clot • Cyanosis
▪ Types • Rapid, weak, thready pulse (cannot be
• Arteries easily felt)
• Spurting blood • Hypotension
• Pulsating flow • Narrowing pulse pressure
• Bright red color (because • Concentrated and low urine output
oxygenated) ▪ Nursing responsibilities
• Veins • Position in modified Trendelenburg - the
• Steady, slow flow patient is placed flat with the legs elevated,
• Dark red color (because usually with a pillow
unoxygenated) • Fluid replacement as ordered
• Capillaries • Administer supplemental oxygen, as
• Slow, even flow ordered
▪ Visibility • Administer vasopressors, ordered if
• Evident unresponsive to fluid replacement
• Hemorrhage is on the surface and • NOTE: in board exam, usually when they
can be seen ask for an initial nursing intervention and
• Concealed
 there is a positioning option then that is
usually the right answer
o Controlling pain
▪ Determine pain score using appropriate pain
assessment tool
▪ Give post-operative analgesics before pain gets
severe
• IV opioids are commonly used in PACU as
they provide immediate pain relief and are
short acting
• Tramadol is usually diluted in the PNSS (Ex:
tramadol 50 mg+ 3 dose, slow IVTT. Ecery 8
hours x 3 doses then PRN thereafter
▪ We can use pain as a distraction from pain
o Control post operative nausea and vomiting (PONV)
▪ At the slightest indication of nausea, the patient is
turned completely to one side to promote mouth
drainage and prevent aspiration of vomitus, which
can cause asphyxiation and death
▪ Management
• Reposition to side
• Administer anti-emetics as ordered
(metoclopramide or plasil)
• Engage DBE
• Aromatherapy (essential oils and scented
candles)
• Acupuncture on the wrist
o Discharging from PACU
▪ Aldrete score
• Used to determine te patient's general
condition and readiness for transfer from
the PACU
• Interpretation
• Score of 7 - 10 : discharge
• Score <7: remain in PACU until
condition improves
▪ Usual stay of patient in PACU is 2 hours
▪ Same day surgery (patient will be discharges on the
same day as the surgery
Upper respiratory tract
• Oral cavity
• Tonsils
• Nasal cavity
• Pharynx
• Larynx
• Trachea
Lower respiratory tract
• Lungs
• Bronchi
• Bronchioles
• Alveoli (thin walled for the gas exchange to happen)
Care of clients with respiratory disorders
• Diagnostic tests and therapeutic interventions
o Pulmonary function test (PFT)
▪ (Pulmonary or lung function structures)
▪ Performed to assess respiratory function and to
determine the extent of dysfunction, response to
therapy, and as screening tests in potential
hazardous industries
▪ Administered using a spirometer (which is
connected to the computer)
▪ Indications
• Chronic respiratory disorders
• Patients for thoracic and upper abdominal
surgery
• Obese (Lungs cant expand due to
subcutaneous fats
• Symptomatic patient with a history
suggesting high risk
▪ Steps
• Patient inserts mouthpiece
• Patient takes as deep breath as possible
• Exhales as hard, as fast and as long as
possible
• Computer calculates patient's percentage of
predicted values
• Percentage predicted value
• How well a patient breaths
• FVC (Forced Vital Capacity)
 • FEV1 (Forced Expiratory Volume in
1 second)
• Most important for COPD
• If short, there is air
trapping
• TLC (Total lung capacity
• Observed and divided by normal values
then multiplied by 100
▪ Patient preparation
• Instruct patient to avoid
• Smoking for 24 hours
• Drinking alcohol for at least 4 hours
• Vigorous exercise for at least 30
minutes before
• Wearing any tight clothing
• Eating a large meal for at least 2
hours
• Taking short acting bronchodilators
for 4 hours
• Taking long acting beta 2 agonist
inhalers for 12 hours
• Taking slow-release medicines that
affect respiratory function and
theophylline-based drugs for 24
hours
• Arterial Blood Gas
o Assess oxygenation and acid base balance
o Preparation
▪ No special preparations
o Specimen
▪ Arterial blood
▪ Bright, red color blood
o Location
▪ Radial artery
▪ Femoral artery
o Summary of the procedure
▪ Radial artery is the most common site for
withdrawal of specimen
▪ Perform Allen's test
• Occluding the wrist arteries
▪ Use heparinized syringe to draw blood specimen to
prevent clotting
▪ Place specimen in a container with ice to prevent
hemolysis
• If hemolysis occurs, oxygen and carbon
dioxide are released and cannot be
measured accurately
• Also potassium will be released
• Pulse oximetry
o Factors affecting pulse oximetry readings
▪ Anemia
▪ Abnormal hemoglobin
▪ Carbon monoxide poisoning
• NOTE: the two chemicals that bond to
hemoglobin are oxygen and carbon
monoxide but carbon monoxide just has a
higher affinity with hemoglobin
▪ Use of dyes (methylene blue)
▪ Dark skin
▪ Nail polish
▪ Bright lights
▪ Patient movement, including shivering
• Culture and Sensitivity
o Culture: identifies pathogen
▪ Bacteria, fungi
▪ Viruses can't be cultured because viruses rely on
living hosts
o Sensitivity: tests which drug is/are effective against the
identified pathogen
▪ Identified pathogen
• Sensitive
• Intermediate
• Resistant (abuse of antibiotics)
• MRSA = methicillin resistant aureus
• VRE = vancomycin resistant cocci
▪ Empirical treatment
• Before C&S results come out
• Cephalosporins (Cephalexin)
o All culture should obtained prior to the initiation of
antibiotic therapy
 o Preliminary results are usually available after 24 hours ▪ Inform patient that x-rays do not require fasting and
o Final results are available after 48 to 72 hours is not painful
o Specimen • CT-Scans
▪ Throat swabbing o Computed tomography
• Useful in detecting streptococcal infections o Provides cross-sectional view of the chest
▪ Nasopharyngeal swab o Nursing intervention
• Useful in detecting staphylococcus aureus, ▪ Patient required to remain supine for 30 minutes
influenza ▪ If contrast medium will be used
▪ Sputum collection • Assess for allergy to iodine
• Sputum studies • Monitor kidney function (dye s filtered by
• Thick type of mucous produced in the kidney)
the lungs • Maintain NPO for 4 hours before procedure
• Gram staining as ordered
• Rapid method of detecting o CIN
bacterial infection; ▪ Contrast induced nephropathy
indicates whether its gram ▪ Contrast raises creatinine levels
positive or negative ▪ Acetylcysteine (Flyimvial)
• Acid-fast bacilli o CT scan machine is protected by the cold temperature of
• To test for PTB the room
• Sputum GenXpert • MRI
• Confirmative test for PTB o Uses magnetic fields and radio frequency instead of
o Samples radiation
▪ Mucoid sample o Can produce a much more detailed diagnostic image than x-
▪ Purulent sample (S. aureus) rays and CT Scan
▪ Bloody sample (due to irritation of membranes) o Costs 20-35K
▪ Salivary sample o Contraindications
o Specimen collection ▪ Metallic implants
▪ Obtain early in the morning before intake of food ▪ Pacemakers
and fluids ▪ Morbid obesity
▪ Instruct patient to rice mouth with water prior to ▪ Confused/agitated patients
collection ▪ Claustrophobia
▪ Let patient expectorate sputum into sterile o Nursing interventions
container ▪ Remove all metal items
▪ Offer oral care after ▪ Instruct to remain still for approximately 30 to 90
• Chest X-rays minutes (benadryl could be used to sedate patients)
o Helps detect densities produced by fluid, tumors, foreign ▪ Administer anxiolytics as ordered, in case of
bodies and other pathologic conditions claustrophobia
o Contraindication: Pregnancy Upper respiratory tract
o Nursing intervention • Oral cavity
• Tonsils
 • Nasal cavity • Most important for COPD
• Pharynx • If short, there is air
• Larynx trapping
• Trachea • TLC (Total lung capacity
Lower respiratory tract • Observed and divided by normal values
• Lungs then multiplied by 100
• Bronchi ▪ Patient preparation
• Bronchioles • Instruct patient to avoid
• Alveoli (thin walled for the gas exchange to happen) • Smoking for 24 hours
• Drinking alcohol for at least 4 hours
Care of clients with respiratory disorders • Vigorous exercise for at least 30
• Diagnostic tests and therapeutic interventions minutes before
o Pulmonary function test (PFT) • Wearing any tight clothing
▪ (Pulmonary or lung function structures) • Eating a large meal for at least 2
▪ Performed to assess respiratory function and to hours
determine the extent of dysfunction, response to • Taking short acting bronchodilators
therapy, and as screening tests in potential for 4 hours
hazardous industries • Taking long acting beta 2 agonist
▪ Administered using a spirometer (which is inhalers for 12 hours
connected to the computer) • Taking slow-release medicines that
▪ Indications affect respiratory function and
• Chronic respiratory disorders theophylline-based drugs for 24
• Patients for thoracic and upper abdominal hours
surgery • Arterial Blood Gas
• Obese (Lungs cant expand due to o Assess oxygenation and acid base balance
subcutaneous fats o Preparation
• Symptomatic patient with a history ▪ No special preparations
suggesting high risk o Specimen
▪ Steps ▪ Arterial blood
• Patient inserts mouthpiece ▪ Bright, red color blood
• Patient takes as deep breath as possible o Location
• Exhales as hard, as fast and as long as ▪ Radial artery
possible ▪ Femoral artery
• Computer calculates patient's percentage of o Summary of the procedure
predicted values ▪ Radial artery is the most common site for
• Percentage predicted value withdrawal of specimen
• How well a patient breaths ▪ Perform Allen's test
• FVC (Forced Vital Capacity) • Occluding the wrist arteries
• FEV1 (Forced Expiratory Volume in ▪ Use heparinized syringe to draw blood specimen to
1 second) prevent clotting
 ▪ Place specimen in a container with ice to prevent o Specimen
hemolysis ▪ Throat swabbing
• If hemolysis occurs, oxygen and carbon • Useful in detecting streptococcal infections
dioxide are released and cannot be ▪ Nasopharyngeal swab
measured accurately • Useful in detecting staphylococcus aureus,
• Also potassium will be released influenza
• Pulse oximetry ▪ Sputum collection
o Factors affecting pulse oximetry readings • Sputum studies
▪ Anemia • Thick type of mucous produced in
▪ Abnormal hemoglobin the lungs
▪ Carbon monoxide poisoning • Gram staining
• NOTE: the two chemicals that bond to • Rapid method of detecting
hemoglobin are oxygen and carbon bacterial infection;
monoxide but carbon monoxide just has a indicates whether its gram
higher affinity with hemoglobin positive or negative
▪ Use of dyes (methylene blue) • Acid-fast bacilli
▪ Dark skin • To test for PTB
▪ Nail polish • Sputum GenXpert
▪ Bright lights • Confirmative test for PTB
▪ Patient movement, including shivering o Samples
• Culture and Sensitivity ▪ Mucoid sample
o Culture: identifies pathogen ▪ Purulent sample (S. aureus)
▪ Bacteria, fungi ▪ Bloody sample (due to irritation of membranes)
▪ Viruses can't be cultured because viruses rely on ▪ Salivary sample
living hosts o Specimen collection
o Sensitivity: tests which drug is/are effective against the ▪ Obtain early in the morning before intake of food
identified pathogen and fluids
▪ Identified pathogen ▪ Instruct patient to rice mouth with water prior to
• Sensitive collection
• Intermediate ▪ Let patient expectorate sputum into sterile
• Resistant (abuse of antibiotics) container
• MRSA = methicillin resistant aureus ▪ Offer oral care after
• VRE = vancomycin resistant cocci • Chest X-rays
▪ Empirical treatment o Helps detect densities produced by fluid, tumors, foreign
• Before C&S results come out bodies and other pathologic conditions
• Cephalosporins (Cephalexin) o Contraindication: Pregnancy
o All culture should obtained prior to the initiation of o Nursing intervention
antibiotic therapy ▪ Inform patient that x-rays do not require fasting and
o Preliminary results are usually available after 24 hours is not painful
o Final results are available after 48 to 72 hours • CT-Scans
 o Computed tomography • Trachea
o Provides cross-sectional view of the chest Lower respiratory tract
o Nursing intervention • Lungs
▪ Patient required to remain supine for 30 minutes • Bronchi
▪ If contrast medium will be used • Bronchioles
• Assess for allergy to iodine • Alveoli (thin walled for the gas exchange to happen)
• Monitor kidney function (dye s filtered by
the kidney) Care of clients with respiratory disorders
• Maintain NPO for 4 hours before procedure • Diagnostic tests and therapeutic interventions
as ordered o Pulmonary function test (PFT)
o CIN ▪ (Pulmonary or lung function structures)
▪ Contrast induced nephropathy ▪ Performed to assess respiratory function and to
▪ Contrast raises creatinine levels determine the extent of dysfunction, response to
▪ Acetylcysteine (Flyimvial) therapy, and as screening tests in potential
o CT scan machine is protected by the cold temperature of hazardous industries
the room ▪ Administered using a spirometer (which is
• MRI connected to the computer)
o Uses magnetic fields and radio frequency instead of ▪ Indications
radiation • Chronic respiratory disorders
o Can produce a much more detailed diagnostic image than x- • Patients for thoracic and upper abdominal
rays and CT Scan surgery
o Costs 20-35K • Obese (Lungs cant expand due to
o Contraindications subcutaneous fats
▪ Metallic implants • Symptomatic patient with a history
▪ Pacemakers suggesting high risk
▪ Morbid obesity ▪ Steps
▪ Confused/agitated patients • Patient inserts mouthpiece
▪ Claustrophobia • Patient takes as deep breath as possible
o Nursing interventions • Exhales as hard, as fast and as long as
▪ Remove all metal items possible
▪ Instruct to remain still for approximately 30 to 90 • Computer calculates patient's percentage of
minutes (benadryl could be used to sedate patients) predicted values
▪ Administer anxiolytics as ordered, in case of • Percentage predicted value
claustrophobia • How well a patient breaths
Upper respiratory tract • FVC (Forced Vital Capacity)
• Oral cavity • FEV1 (Forced Expiratory Volume in
• Tonsils 1 second)
• Nasal cavity • Most important for COPD
• Pharynx • If short, there is air
• Larynx trapping
 • TLC (Total lung capacity • If hemolysis occurs, oxygen and carbon
• Observed and divided by normal values dioxide are released and cannot be
then multiplied by 100 measured accurately
▪ Patient preparation • Also potassium will be released
• Instruct patient to avoid • Pulse oximetry
• Smoking for 24 hours o Factors affecting pulse oximetry readings
• Drinking alcohol for at least 4 hours ▪ Anemia
• Vigorous exercise for at least 30 ▪ Abnormal hemoglobin
minutes before ▪ Carbon monoxide poisoning
• Wearing any tight clothing • NOTE: the two chemicals that bond to
• Eating a large meal for at least 2 hemoglobin are oxygen and carbon
hours monoxide but carbon monoxide just has a
• Taking short acting bronchodilators higher affinity with hemoglobin
for 4 hours ▪ Use of dyes (methylene blue)
• Taking long acting beta 2 agonist ▪ Dark skin
inhalers for 12 hours ▪ Nail polish
• Taking slow-release medicines that ▪ Bright lights
affect respiratory function and ▪ Patient movement, including shivering
theophylline-based drugs for 24 • Culture and Sensitivity
hours o Culture: identifies pathogen
• Arterial Blood Gas ▪ Bacteria, fungi
o Assess oxygenation and acid base balance ▪ Viruses can't be cultured because viruses rely on
o Preparation living hosts
▪ No special preparations o Sensitivity: tests which drug is/are effective against the
o Specimen identified pathogen
▪ Arterial blood ▪ Identified pathogen
▪ Bright, red color blood • Sensitive
o Location • Intermediate
▪ Radial artery • Resistant (abuse of antibiotics)
▪ Femoral artery • MRSA = methicillin resistant aureus
o Summary of the procedure • VRE = vancomycin resistant cocci
▪ Radial artery is the most common site for ▪ Empirical treatment
withdrawal of specimen • Before C&S results come out
▪ Perform Allen's test • Cephalosporins (Cephalexin)
• Occluding the wrist arteries o All culture should obtained prior to the initiation of
▪ Use heparinized syringe to draw blood specimen to antibiotic therapy
prevent clotting o Preliminary results are usually available after 24 hours
▪ Place specimen in a container with ice to prevent o Final results are available after 48 to 72 hours
hemolysis o Specimen
▪ Throat swabbing
 • Useful in detecting streptococcal infections o Nursing intervention
▪ Nasopharyngeal swab ▪ Patient required to remain supine for 30 minutes
• Useful in detecting staphylococcus aureus, ▪ If contrast medium will be used
influenza • Assess for allergy to iodine
▪ Sputum collection • Monitor kidney function (dye s filtered by
• Sputum studies the kidney)
• Thick type of mucous produced in • Maintain NPO for 4 hours before procedure
the lungs as ordered
• Gram staining o CIN
• Rapid method of detecting ▪ Contrast induced nephropathy
bacterial infection; ▪ Contrast raises creatinine levels
indicates whether its gram ▪ Acetylcysteine (Flyimvial)
positive or negative o CT scan machine is protected by the cold temperature of
• Acid-fast bacilli the room
• To test for PTB • MRI
• Sputum GenXpert o Uses magnetic fields and radio frequency instead of
• Confirmative test for PTB radiation
o Samples o Can produce a much more detailed diagnostic image than x-
▪ Mucoid sample rays and CT Scan
▪ Purulent sample (S. aureus) o Costs 20-35K
▪ Bloody sample (due to irritation of membranes) o Contraindications
▪ Salivary sample ▪ Metallic implants
o Specimen collection ▪ Pacemakers
▪ Obtain early in the morning before intake of food ▪ Morbid obesity
and fluids ▪ Confused/agitated patients
▪ Instruct patient to rice mouth with water prior to ▪ Claustrophobia
collection o Nursing interventions
▪ Let patient expectorate sputum into sterile ▪ Remove all metal items
container ▪ Instruct to remain still for approximately 30 to 90
▪ Offer oral care after minutes (benadryl could be used to sedate patients)
• Chest X-rays ▪ Administer anxiolytics as ordered, in case of
o Helps detect densities produced by fluid, tumors, foreign claustrophobia
bodies and other pathologic conditions Hematopoiesis
o Contraindication: Pregnancy • Blood cell formation
o Nursing intervention • Begins in the red bone marrow
▪ Inform patient that x-rays do not require fasting and o Two types of bone marrow
is not painful ▪ Yellow bone marrow
• CT-Scans • At least half of red marrow has turned into
o Computed tomography yellow bone marrow by age of 7
o Provides cross-sectional view of the chest • Cholesterol based
 ▪ Red bone marrow Red Blood Cells (Erythrocytes) 4-6 Transport
• Is in selected few bones million/mm3 oxygen bound
• Mostly in flat bones such as the hip bones, hemoglobin
sternum, cranium. Also long bones but at molecules
the epiphysis
White Blood Cells 4,800 -
• Stem cells are found inside
(Leukocytes) 10,800/mm3
• Hemopoietic stem cells
Laboratory and diagnostic procedures • WBC
• Complete Blood Count Differentials
o A series of tests used to evaluate the composition and
• Neutrophils 40-70% Active
concentration of the cellular components of blood phagocytes.
o The test measures the following:
Phagocytosis is
▪ The total number of blood cells (leukocytes,
the process of
erythrocytes, and platelets) engulfing debris
▪ NOTE: anemia can only be diagnosed through CBC, and bacteria.
not blood pressure
▪ Differential WBC count • Eosinophils 1-4% Elevated in
• Specific patterns of WBC parasitic
▪ Hemoglobin infection and
• A protein in the RBC which carries oxygen allergic
▪ Hematocrit reactions
• Percentage blood volume, consisting of • Basophils 0-1% Releases
erythrocytes histamine at
• Ratio of solid (erythrocyte) to liquid site of
(plasma)component of blood inflammation.
• If blood plasma is low then patient is Side effect:
dehydrated vasodilation
• If hematocrit level is low, then it could and redness.
mean hemorrhage or anemia
• Lymphocytes 20-45% B lymphocytes
▪ RBC indices
produce
• Calculated values of the size and
antibodies; T
Hemoglobin concentration of RBCS
lymphocytes
• Help physician in diagnosing specific
fight tumors
anemias
and viruses.
Component Normal value Function
• Monocytes 4-8% Active
(Values could
vary from phagocytes that
hospital to evolve into
hospital) macrophages in
tissues,
 increased in • Never Let Monkeys Eat Banana: Neutrophils, Lymphocytes,
chronic Monocytes, Eosinophils, and Basophils. This represents the order by
infections which WBC rush into the side of infection/surgery
• Clotting studies
Platelets 150,000- Needed for o Purpose is to test the integrity of each pathways and test
400,000 normal blood bleeding disorders
clotting cascade o Coagulation cascade
by clinging to ▪ The body's process in creating blood clots
torn area ▪ Two pathways
Hemoglobin (Hgb) Male: 13.0- • Intrinsic Pathway
16.0 gdL • XII
Female: 12.0- • XI
16.0 gdL • IX
(Reason is • VIII
that women • Extrinsic pathways
have • Tissue factor
menstrual • VII
periods)
Hematocrit (Hct) Male: 37-49%
Female: 36-
36%
• RBC Indices
• Mean Male: 78- Measurement
Corpuscular 79um3 of the average
Volume Female: 78- size of RBCs
(MCV) 102 um3
• Mean 25-35 pg/cell Measurement ▪
Corpuscular of the average
Hemoglobin weight of the
(MCH) hemoglobin
inside a red
blood cell
• Mean 31-37 g Hg/dL Measurement
Corpuscular RBC of the average
Hemoglobin concentration
Concentration of hemoglobin
(MCHC) inside an RBC

▪ ▪ The time interval between the skin puncture and
o APTT (activated Partial Thromboplastin Time)
▪ Measures the time it takes for a clot to form via the
intrinsic pathway
▪ Evaluates heparin therapy (anticoagulant)
▪ Normal: 25-35 seconds
o PT (Prothrombin time)
▪ Measures the time it takes for a clot to form via the
extrinsic pathways
▪ Evaluates warfarin therapy (anticoagulant)
▪ Normal: 11-16 seconds
▪ International Normalized Ratio (INR)
• A standardized system of reporting PT
based on a reference calibration model and
calculated by comparing the patient's PT
with a control value
• If your patient has high INR then that means
your patient has a higher risk of bleeding or
they're taking warfarin
• Normal: 2-3
•
o Bleeding time
spontaneous, unassisted stoppage of bleeding
▪ Done to check platelet function
▪ Normal: 2-7 minutes
o Clotting time
▪ The time interval between entry of blood into the
glass capillary tube, or a syringe, and the formation
of fibrin threads
▪ Used to diagnose hemophilia
▪ Normal: 5-15 minutes
o D-dimer
▪ A protein fragment created when a blood clot
dissolves
▪ Blood clot shouldn't remain in the body forever
because this may get dislodged and lodge in
capillaries and interfere with circulation
▪ It reflects ongoing activation of the hemostatic
system
▪ Could be used to diagnose deep vein thrombosis,
pulmonary embolism, disseminated intravascular
coagulation
▪ Normal: <250 ng/mL
• Bone marrow Aspiration and Biopsy (inbvasive)
o Assesses how a person's blood cells are being formed as
well as the quantity and quality of each type of cell
produced
o It is also used to document infection or tumor within the
marrow
o Performed by a surgeon but we have to prepare the patient
▪ Before the procedure
• Ensure that informed consent was obtained
and signed
 • Allay patient's anxiety by explaining the • Blood disorders (ex: ITP [Idiopathic
procedure Thrombocytopenic Purpura)
• Local anesthetics will be given (can • Hypersplenism (may cause decrease of
only reach as deep as the muscles blood cells of the body)
and not the bone) ▪ Preferred approach: laparoscopic splenectomy
• Pressure sensation will be felt as • Associated with decreased morbidity
the needle is advanced into position ▪ Postoperative complications
• A sharp but brief pain will be felt as • Atelectasis
the marrow is aspirated - advise to • Pneumonia (the pain from the incision
take deep breaths or use relaxation might prevent the patient from breathing
techniques normally)
• Positioning the patient • Abdominal distention
• Posterior iliac crest (PIC) [MOST • Abscess formation (indicate infection)
IDEAL] • Therapeutic apheresis
• Lateral decubitus position o Apheresis - "separation"
(fetal, c or shrimp position, o Blood is taken from the patient and passed through a
knees flexed, pillow under centrifuge, where a specific component is separated from
head, eyes away the blood and removed
• Anterior iliac crest (AIC) o The remaining blood is then returned to the patient
• Supine position, hips and o Just like dialysis
knees flexed, eyes away
• Sternum supine position (not ideal
because of the underlying organs)
• Head and eyes away, light
towel over face "to keep
things sterile" (and cover
eyes)
▪ After the procedure
• Apply pressure to the site for several o
minutes (to facilitate clotting or stopping
bleeding) then cover with sterile occlusive
dressing
• Administer analgesics, as ordered
• Avoid aspiring-containing analgesics (may
prevent platelet aggregation)
Therapeutic approaches to hematologic disorders
• Splenectomy
o Surgical removal of the spleen (left abdominal upper
quadrant[under the ribs]) o Blood mixed with anticoagulant to prevent clotting
▪ Indication o Not all apheresis uses albumin for the return of the blood
o Types or Apheresis • Hematopoietic stem cell transportation (HSCT)
▪ o Involves the intravenous infusion of hematopoietic stem
Procedure Purpose Examples of cells in order to reestablish blood cell production in patients
clinical use whose bone marrow or immune system is damaged or
defective
Plateletpheresis Remove Extreme o Involves donor and recipient
platelets thrombocytosis, ▪ Autologous - patient himself is the donor and the
essential recipient
thrombocythemia ▪ Allogenic - the donor is another person (sibling or
(temporary unrelated)
measure), single- ▪ Syngeneic - donor is the identical twin
donor platelet
• Therapeutic phlebotomy
transfusion o Removal of a certain amount of blood under controlled
Leukapheresis Remove Extreme conditions
WBCs (can leukocytosis, (e.g., o Indications
be specific to AML, CML) very ▪ Polycythemia vera (true polycythemia)
neutrophils temporary • All blood components increased
or measure; harvest • Done little by little otherwise shock
lymphocytes) WBCs for ▪ Hemochromatosis
transfusion • Too much iron in blood
Erythropheresis Remove RBC dyscrasias • Your patient's skin is bronze
RBCs (e.g., sickle cell
disease); RBCs
replaces via
transfusion
Plasmapheresis Remove Hyperviscosity
plasma syndrome,
proteins treatment for
some renal and
neurologic
diseases (e.g.,
Goodpasture
syndrome, TTP,
Gullain-Barre,
myasthenia gravis
Stem cell Remove Transplantation
harvest circulating (donor harvest or
stem cells autologous)