Lesson 3 Artificial Airway Chest Surgery

ARELLANO UNIVERSITY
College of Nursing
PACUCOA Level III Re-Accredited Status
2600 Legarda St., Sampaloc, Manila
www.arellano.edu.ph
STUDENT NAME: _______________________________________________________________________
Class Schedule / Section: ______________________________ Date: _________________________
SKILLS LAB WORKSHEET #2: Pre-Task Activity

LESSON 3: ARTIFICIAL AIRWAY & CHEST SURGERY
(60 points)
INSTRUCTION:
1. Word Hunting: Inside the box are 10 words related to the concept of AIRWAY MANAGEMENT
AND CHEST SURGERY. As you find the words, shade it and briefly define each in the space
provided below:
2. 3-points for every word found; 3 points for every correct definition = 60 points
3. Date of Submission: August 24, 2021
4. Submit your Worksheet#2 at : amelia.manaois@arellano.edu.ph
C I R C U L A T I N G N U R S E
H X Q O B P T A F F P A P K C P
E X E N N O H S G G O S O E R O
S C T S M K N D H J K A K N U K
T V U E J J F F H K J L J Y B J
S B I N U H D F T E H A H D N H
U N P T U G D G Y B G I G F U G
R M O A L F D H N V F R F G R F
G Z I S O R A L A I R W A Y S W
E X U D B S O O O T T A F A E E
R C Y F E D T V B B F Y A W O R
Y V T G C D F G H J N T Y Y Y T
O B R H T A R F G H Y J U K U Y
P N E W O U N D H E A L I N G U
O M W H M D F G H J N T Y Y Y I
L Z Q J Y F F G H J N T Y Y Y I
K X P N E U M O N E C T O M Y I
DEFINITION OF WORDS FOUND: (use additional sheet / page as necessary)
Prepared by Prof. Amelia Z. Manaois for AU - College of Nursing to be used as Instructional Material only for the NCM112 – SKILLS LAB
Lecture. Refrain from reproducing this material without the consent of the preparer and the AU-CON
SKILLS LABORATORY MODULE
BASIC NURSING SKILLS ON RESPIRATORY, CARDIO AND HEMATOLOGIC CARE MODALITY
WHILE TASK ACTIVITY – MODULE CONTENT:

LESSON 3: ARTIFICIAL AIRWAY AND CHEST SURGERY
I. ARTIFICIAL AIRWAY
Acute respiratory failure is caused by a wide range of etiologies. Progression to cardiopulmonary
arrest and ultimately death is likely in the absence of effective and timely airway management.
Therefore, one of the primary goals of airway management is to provide adequate ventilation
and oxygenation to avoid or halt the progression to cardiopulmonary arrest. Effective and timely
airway management is also an essential component of successful cardiopulmonary resuscitation.
a. ORAL AIRWAYS or OROPHARYNGEAL AIRWAY (OPA)

Oropharyngeal airways are rigid intraoral devices that conform to the tongue and displace it
away from the posterior pharyngeal wall, thereby restoring pharyngeal airway patency
It is an airway adjunct used to maintain or open the airway by stopping the tongue from
covering the epiglottis. In this position, the tongue may prevent an individual from breathing.
This sometimes happens when a person becomes unconscious because the muscles in the
jaw relax causing the tongue to obstruct the airway
Indication:
• Unconscious patients in a bag-valve-mask ventilation
• Spontaneously breathing patients with soft tissue obstruction of the upper airway
(such as the tongue) who are deeply obtunded and have no gag reflex
Contraindication:
• Absolute Contraindication: Conscious patient with an intact gag reflex.
• Relative Contraindication (inserting OPA may not be feasible due to)
o A foreign body obstructing the airway
o Oral trauma such as fracture and active bleeding
o Trismus
Complications of Oropharyngeal Airway
• Airway obstruction by an improperly sized or improperly inserted oropharyngeal
airway
• Gagging and the potential for vomiting and aspiration
Considerations for Oropharyngeal Airway

• An oropharyngeal airway used concurrently with a nasopharyngeal airway may
improve oxygenation and ventilation
PRE-SELECTED VIDEO FOR SKILLS DEMONSTRATION:

https://www.youtube.com/watch?v=vgqOrmBskaw : Oropharyngeal Airway Insertion
b. NASAL AIRWAYS or NASOPHARYNGEAL AIRWAY (NPA)
Also known as “nasal trumpet”, is a soft rubber or plastic tube inserted into the nostril and
advanced along the pharynx
Indications:
• Spontaneously breathing patients with soft tissue obstruction of the upper airway
• Sometimes for dilation and anesthesia of the nasal passage to prepare for
nasotracheal intubation
• Preferred for patients who are obtunded with intact gag reflexes than
oropharyngeal airways
• Nasopharyngeal airways can be used in some settings where oropharyngeal
airways cannot:
o Oral trauma or trismus
• Nasopharyngeal airways may also help facilitate bag-valve-mask ventilation
Contraindications:
• Absolute contraindication: Suspected basilar skull fracture
• Significant nasal trauma
Complications:
• Epistaxis
• Gagging and the potential for vomiting and aspiration in conscious patients
• Sinusitis
Considerations for Nasopharyngeal Airway

• Two airways, one in each nostril, may be used to improve oxygenation and
ventilation.
• An oropharyngeal airway may be used concurrently with nasopharyngeal airways.
• Nasopharyngeal airways can usually be used even with major facial injuries.
• Although topical vasoconstrictors and/or anesthetics are sometimes used, no
evidence indicates that they decrease complications or pain.
PRE-SELECTED VIDEO FOR SKILLS DEMONSTRATION:

https://www.youtube.com/watch?v=uALM3HqtTnI Nasopharyngeal Airway Insertion
c. TRACHEOSTOMY
TRACHEOSTOMY- is a surgical procedure done

to provide long-term airway support or as an
emergency procedure when an endotracheal
tube cannot be passed successfully. An
opening (stoma) is made in the trachea below
the cricoid cartilage, and a semirigid plastic
tube (tracheostomy tube) is passed through
the opening and into the trachea. A cuff,
similar to that in an endotracheal tube, is
inflated near the distal airway.
A tracheostomy is a 51- to 76-mm (2- to 3-

inch) curved metal or plastic tube inserted
into a stoma through the neck and into the
trachea to maintain a patent airway. It is
placed in patients who require long-term
airway management because of airway
obstruction, airway clearance needs, and long-
term intubation (Regan and Dallachiesa,
2009).
PURPOSES:
• To maintain airway patency by removing mucus and encrusted secretions.

• To maintain cleanliness and prevent infection at the tracheostomy site
• To facilitate healing and prevent skin excoriation around the tracheostomy
incision
• To promote comfort
• To prevent displacement.
PARTS OF TRACHEOSTOMY TUBE
A commonly used tracheostomy tube consists of three parts: outer cannula with flange (neck
plate), inner cannula, and an obturator. The outer cannula is the outer tube that holds the
tracheostomy open. A neck plate extends from the sides of the outer tube and has holes to
attach cloth ties or Velcro strap around the neck. The inner cannula fits inside the outer
cannula. It has a lock to keep it from being coughed out, and it is removed for cleaning. The
obturator is used to insert a tracheostomy tube. It fits inside the tube to provide a smooth
surface that guides the tracheostomy tube when it is being inserted.
EQUIPMENT
Bedside table
▪ Towel
▪ Tracheostomy suction supplies
▪ Sterile tracheostomy care kit, if available (be sure to collect supplies listed that are
not available in kit), or two sterile 4 × 4–inch gauze pads
• Sterile cotton-tipped applicators

• Sterile tracheostomy dressing (precut and sewn surgical dressing)
• Sterile basin
• Normal saline
• Small sterile brush (pipe cleaner) (or disposable inner cannula)
• Roll of twill tape, tracheostomy ties, or tracheostomy holder
• Scissors
▪ Pulse oximeter
▪ Clean gloves (two pair)
▪ Mask, goggles, or face shield
PRE-SELECTED VIDEO FOR SKILLS DEMONTRATION:

https://youtu.be/Z1x1x5vNO4E : Tracheostomy Care Equipment
https://youtu.be/ci9c8fsu38Q : Cleaning and Caring for Tracheostomy
NURSING CONSIDERATION:
Unexpected Outcomes Related Interventions

1 Excessively loose or tight tracheostomy • Adjust ties or apply new ties/tracheostomy
ties/tracheostomy holder. holder
• Increase frequency of
tracheostomy care.
• Apply topical antibacterial
solution, allow it to dry, and apply
bacterial barrier.
2 Inflammation of tracheostomy stoma.
• Apply hydrocolloid or transparent
dressing just under stoma to
protect skin from breakdown.
Consult with skin care specialist.
• Increase frequency of tracheostomy care and
keep dressing under faceplate at all times.
3 Patient has pressure area around tracheostomy
tube. • Consider using double dressing or applying
hydrocolloid or stoma adhesive dressing around
stoma.
• Call for assistance.

• Replace old tracheostomy tube
with new tube. Some experienced
nurses or respiratory therapists
may be able to quickly reinsert
tracheostomy tube.
• Keep spare tracheostomy tube of
same size and kind at bedside in
event of emergency replacement
(Weber-Jones, 2010).
4 Accidental decannulation.
• Same-size ET tube can be inserted
in stoma in an emergency.
• Insert suction catheter to confirm
that new tube is in trachea.
• Be prepared to manually ventilate
patients in whom respiratory
distress develops with Ambu bag
until tracheostomy is replaced.
• Notify health care provider.
• Remove inner cannula if applicable

for cleaning or suction cannula.
• Notify health care provider if
5 Respiratory distress from mucus plug in cannula.
tracheostomy tube requires
replacement (Weber-Jones, 2010).
SPECIAL CONSIDERATIONS
Teaching
• Different types of tracheostomy tubes have different faceplates. Some are
rigid; others are not. Instruct caregivers not to lift up rigid faceplates or they
will dislodge tube.
• Some commercial tracheostomy tube holders require removal of excess tie
material to fit properly.
• If you anticipate long-term placement of tracheostomy, plan to teach patient
and family tracheostomy care.
• Patients with new tracheostomy frequently have bloody secretions for 2 to 3
days after procedure and for 24 hours after each tracheostomy tube change
(Frace, 2010).
Pediatric
• Children generally have shorter necks, making the stoma more difficult to
clean.
• Pediatric tracheostomy tubes (smaller than size 4) do not contain an inner
cannula.
• Nurses perform routine tracheostomy tube changes weekly after a tract has
formed, generally 5 days (Hockenberry and Wilson, 2011).
Gerontologic
• Some older adults may have more fragile skin and are more prone to skin
breakdown from secretions or pressure (Meiner and Lueckenotte, 2011).
• Some older adults with impaired nutrition do not heal well.
II. CHEST SURGERY
SURGERY –
A branch of medicine which treats diseases, injuries and deformities by manual or operative
procedure
A procedure concerned with restoration, reconstruction, correction or improvement in the shape

and appearance of body structure that are defective or damaged by injury, diseases or growth
and development
1. CLASSIFICATION OF SURGERY
A. ACCORDING TO PURPOSE:
a. Diagnostic Surgery
A surgical procedure performed through excision of a body part or
tissue for purposes of analyzing its pathological component and
characteristics.
Examples: Lung Biopsy
Thoracoscopy
Exploratory Thoracotomy
b. Curative
A surgical procedure performed for treatment or therapeutic purposes
by repairing or removing the cause
Examples: Decortication
c. Transplant
Replacing malfunctioning structures
Examples: Lung Transplant
d. Reparative / Restorative
A surgical procedure performed for purposes of improving a client’s
functional ability.
Example: Lung Transplant
e. Reconstructive or cosmetic
A surgical procedure performed for purposes of altering or enhancing
personal appearance.
Example: Mammoplasty
Face-lift
Rhinoplasty
Liposuction
f. Palliative
A surgical procedure performed to relieve symptoms of a disease
process (pain), but does not cure
Example: Pneumonectomy
Lobectomy
B. ACCORDING TO CONDITION
a. Emergency
Disorder may be life-threatening, requires immediate attention
without delay
Example: Severe bleeding
Bladder or intestinal obstruction
Fractured skull
Gunshot or stab wounds
Appendectomy
b. Urgent
Patient requires prompt attention. It may be life-threatening if
treatment is delayed more than 24-48hrs.
Example: Acute Gallbladder Infection / obstruction
Kidney or Ureteral stones
Bone fracture
Eye injury
c. Elective
Planned surgery for correction of non-acute problem.
(Failure to have surgery is not catastrophic).
Example: Cataract removal
Hernia repair
Hemorrhoidectomy
d. Optional
Decision rests with patient.
(Personal preference).
Example: Cosmetic surgery
C. ACCORDING TO DEGREE OF RISK

a. Major Surgery
Procedure of greater risk, usually longer or extensive than minor
procedure
(General anesthesia is used)
b. Minor Surgery
Procedure without significant risk
(Often done with local anesthesia)
Example: Biopsy
D. ACCORDING TO THE EXTENT

a. Simple
Only the most overtly affected areas are removed/repaired
Example: Segmental Resection
Wedge Resection
b. Minimally Invasive Surgery (MIS)

Surgery performed in a body cavity or body area through one or more
endoscopes; can correct problems, remove organs, take tissue for
biopsy, re-route blood vessels and drainage systems; is a fast-growing
and ever-changing type of surgery
Example: Lung lobectomy
c. Radical
Extensive surgery beyond the area obviously involved directed at finding
a root cause
E. SUFFIXES & TERMS RELATED TO SURGERY

Ectomy
Removal of excision of a body organ
(Ex. Lobectomy)
Otomy
Procedures involving cutting into an organ or tissue
(ex. Thoracotomy)
Oscopy
making a small incision through which an instrument is inserted for
visualization
(Ex. Bronchoscopy)
Ostomy
Formation of a permanent or semi-permanent opening
(Colostomy)
Oplasty
Reconstruction, plastic or cosmetic surgery of a body part
(Rhinoplasty)
Rrhapy
Reparation of damaged or congenital abnormal structure
(Ex. Perineorrhaphy, Herniorrhaphy)
Amputation
involves cutting off a body part, usually a limb or digit
Replantation
reattaching a severed body part
Transplant
Replacement of an organ or body part by insertion of another from
different human (or animal) into the patient
In this particular lesson, the concept will focus on the PERIOPERATIVE NURSING CARE MANAGEMENT of
patient undergoing lung surgery:
F. LUNG SURGERIES:
a. PNEUMONECTOMY
Surgical excision of a lung
b. LOBECTOMY
Surgical excision of a lobe removed
c. SEGMENTAL / WEDGE RESECTION

Surgical excision of a segment
d. DECORTICATION
Removal of fibrous tissues over the lung
that is thick, inelastic, restricting lung
expansion
e. EXPLORATORY THORACOTOMY
A valuable diagnostic surgical procedure
to decry prolonged observation for
diagnosis
THE PERIOPERATIVE NURSING

Connotes the delivery of nursing care to patient in three operative phases:
1. PRE-OPERATIVE PHASE
Begins when the decision for surgical intervention is made and ends with the transfer of the
patient to the operating room table.
The preoperative nurse participates in the assessment of risk for the surgical patient and
collaborates with other members of the perioperative team to safely transition the patient to
the intraoperative phase of care (Malley et al., 2015)
Goal:
Preoperative nursing aims to place special emphasis on SAFETY, advocacy, and patient
education.
Anticipated Nursing Problems: Safety, lack of information, fear and anxiety
A. The Scope of Nursing Management:

a. Establishing a baseline evaluation of the patient before the day of surgery. When
taking a history, patient is assessed for problems that may increase the risk for
complications during and after surgery.
Physical Assessment:
- Vital Signs
- Nutritional Status
- Drug or Alcohol use
- Respiratory status
- Cardiovascular status
- Hepatic and Renal function
- Endocrine Function (DM – risk for hypo or hyperglycemia)
Previous anesthetic history
Presence of known allergies (Immunologic functions)
b. Psychosocial Assessment
• Fear and Anxiety
• Spiritual and Cultural Beliefs
c. Preadmission testing (Laboratories):

• Urinalysis
• Blood typing and screen
• CBC
• Chest X-ray, ECG
d. Informed Consent –
• Voluntary and informed written consent from the patient is necessary before
surgery can be performed.
• It protects the patient from unsanctioned surgery and protects the surgeon and
the healthcare team from claims of an unauthorized operation
• Clear and simple explanation should be provided by the surgeon on what the
surgery will entail, risks, complications, disfigurement, disability and removal of
body parts. Nurses reinforce this explanation.
• Any additional information that the patient needs, the nurse must inform the
physician
• Consent must be signed before administration of the premedication
e. Health Teaching
• preparatory education regarding recovery from anesthesia and postoperative
management:
o Deep breathing and coughing exercise
o Encouraging mobility and active body movement
o Explaining pain management
o Teaching Cognitive Coping Strategies
o Imagery & distraction
o Optimistic self-recitation
o Providing information
o Alleviating Fear and anxiety
f. Pre-operative Nursing Intervention:

• Initiation of intravenous infusion
• Restriction of nutritional intake (NPO)
• Removal of dentures, prosthetic devices, nail polish
• Preparing the bowel for surgery (enema)
• Preparing the skin (shaving, clipping, prepping)
• Empty the bladder
• Administering preanesthetic medication
• Atropine 0.3mg IM
• Demerol 50 mg IM
• Maintaining a pre-operative checklist / preoperative record
• Transporting the patient to the presurgical suite
• Attending to family needs
g. Evaluation of Care:
• Evaluate the care of the preoperative patient based on the identified patient
problems. The expected outcomes include that the patient:
o States understanding of the informed consent and preoperative
procedures
o Demonstrates postoperative exercises and techniques for prevention
of complications
o Verbalizes reduced anxiety
o Patient is safely endorsed to Intraoperative care
2. INTRAOPERATIVE PHASE
The intraoperative period begins when the patient enters the surgical suite and ends at the time
of transfer to the post anesthesia recovery area, same-day surgery unit, or intensive care unit.
Goal:
The priorities for Intraoperative Nursing care are SAFETY and patient advocacy by preventing,
reducing, avoiding, and managing the risk factors in the intraoperative environment.
Anticipated Nursing Problems:

In the OR the patient is at risk for infection, impaired skin TISSUE INTEGRITY, increased anxiety,
inadequate thermoregulation and altered body temperature, and injury related to positioning
and other intraoperative interventions.
A. The Surgical Team:

a. The Circulating Nurse
• Is a registered nurse
• Manages the operating room and protects the safety and health needs of the
patient by monitoring the activities of the members of the surgical team
• The scope of responsibilities include:
o verifying consent
o coordinating the team
o ensuring cleanliness
o ensuring proper temperature, humidity and lighting
o safe functioning of equipment
o availability of supplies and materials
o monitors aseptic practices to avoid breaks in technique while
coordinating the movement of related personnel (medical,
radiography, laboratory)
o monitors patient and documents specific activities throughout the
procedure to ensure patient’s safety and well-being
b. The Scrub Nurse

• Is a registered nurse or an LPN
• The scope of responsibilities include:
o scrubbing for surgery
o setting up the sterile tables
o preparing sutures, ligatures and special equipment
o assisting the surgeons during the procedure by anticipating the
required instruments, sponges, drains, and other equipment
o keeping the track of time the patient is under anesthesia and the time
the wound is open
o as the surgical wound is closed, scrub nurse counts all needles,
sponges, and instruments to be sure they are accounted for to ensure
patient’s well-being
o Collects and labels specimen for laboratory exam
• Other scope of nursing activities include:
o Starting and maintaining the IV infusion
o Administering intravenous medications
o Physiologic monitoring throughout the surgical procedure and
providing for patient’s safety.
o Provision of emotional support
o Assisting in positioning the patient on the operating room table
c. The Anesthesiologist / Anesthetist
Administers anesthetic agents and continually monitors patient status
Plans medications for anesthesia, analgesia, and blocks Monitors major
bodily functions (such as breathing, heart rate and rhythm, body
temperature, blood pressure, and blood oxygen levels) during surgery
Addresses any problems that might arise during surgery
d. The Surgeon
Manages the surgical procedure and makes surgical judgments about the
patient's care
Initiates, participates, and completes the essential components of the
surgical procedure
e. Surgical Assistant
Under the direction of the surgeon (and within the legal scope of
practice for each role/state), the assistant performs specific task during
the surgical procedure
The assistant may hold retractors, suction the wound, cut tissue, suture
and dress wounds
B. NURSING MANAGEMENT:
a. Assessment: Nursing Safety Priority
Verify patient’s identity
Validate surgical consent form, signed and witnessed
Review the most recent laboratory findings and test results
Perform final assessment to identify risk factors including medical and
physical examinations
Report any abnormalities or discrepancies to the surgeon or anesthesia
provider
Anticipate problems related to patient’s safety such as potential for
injury, potential for infection, decreased gas exchange due to anesthesia,
pain, reduced respiratory effort
b. Planning and Implementation

• Preventing injury
PLANNING: Expected Outcomes:
The patient is expected to be free of injury as indicated by:
Adequate capillary refill and peripheral pulses in all extremities
Sensory perception and motor function after surgery at the same
level as before surgery
Absence of injury to the skin (redness, open skin areas, bruising,
burns)
Absence of retained surgical items
INTERVENTIONS
Interventions are needed to prevent injury from positioning based on
patient risk factors, anesthesia method, and type and duration of the
surgical procedure. Proper positioning is critical. Pressure injuries and
nerve injuries can occur if attention is not paid to all areas of the body
that are in contact with the OR table. The circulating nurse pads the
operating bed with foam and/or silicone gel pads and coordinates the
patient's transfer to the operating table. The skin is assessed,
especially of older patients, for bruising or injury, and extra padding is
placed as indicated (Spruce & VanWicklin, 2015).
The patient is usually in a supine position after transfer to the

operating bed. Anesthesia may be initiated with the patient supine,
and the patient then may be repositioned for surgery Before or just
after anesthesia induction and before positioning begins, a time-out is
conducted to prevent wrong-site, wrong-side, wrong-procedure or
wrong-person surgery. A time-out is a critical pause in the progression
of care to confirm the patient's identity, the procedure and the site,
and other pertinent information. The time-out is initiated by a member
of the surgical team and is documented by the circulating nurse. Once
the time-out has been completed, patient care activities such as
positioning, skin preparation, and draping of the surgical site may
begin.
• Preventing Infection
PLANNING: Expected Outcomes
The patient is expected to have an uninfected surgical wound or
wounds. Indicators include:
Aseptic technique is maintained throughout the surgical
procedure.
Wound edges are closed and not excessively red or swollen.
Wound is free from purulent drainage.
White blood cell counts remain at expected levels after surgery.
Patient is afebrile.
INTERVENTION
Surgical wound infections interfere with recovery, delay wound
healing, contribute to rising health care costs, and are a source of
nosocomial infections. Observance and maintenance of aseptic
technique throughout the surgical procedure helps prevent infection.
• Preventing Hypoventilation
The patient is expected to be free of respiratory complications related
to impaired GAS EXCHANGE and hypoventilation as indicated by:
Maintenance of SaO2 , PaO2 , and blood pH within normal limits
Vital signs within normal limits
Return to presurgical level of cognitive function
INTERVENTIONS
The nurse, surgeon, and anesthesia provider monitor the patient
throughout the procedure to prevent respiratory and circulatory
complications resulting from the effect of anesthesia on breathing and
GAS EXCHANGE. Maintenance of SaO2 , PaO2 , and blood pH within
normal limits, Vital signs within normal limits, and return to presurgical
level of cognitive function are the best indicators of uncomplicated
and safe surgical procedure
c. Evaluation of care
• Evaluate the care of the intraoperative patient based on the identified patient
o Is free from complications of anesthesia care provided
o Remains injury free related to surgical positioning or equipment (no
skin tears, bruises, redness, or other injury over pressure points)
o Remains free of skin or tissue contamination and infection during
surgery
o Maintains normal thermoregulation and body temperature
o Is safely endorsed to Postoperative care
3. POST-OPERATIVE PHASE
Begins with the admission of the patient to the Post-anesthesia care unit and ends with a
follow-up evaluation in the clinical setting or at home.
Goal:
The priorities for Postoperative Nursing care are SAFETY, COMFORT and patient
advocacy by preventing, reducing, avoiding, and managing the risk factors in the
postoperative setting
Anticipated Nursing Problems:

In the post-operative phase, the patient is at risk for
• GAS EXCHANGE due to the effects of anesthesia, pain, opioid analgesics, and
immobility
• Potential for infection and delayed healing due to wound location, decreased
mobility, drains and drainage, and tubes
• Acute pain due to the surgical incision, positioning during surgery, and
endotracheal tube (ET) irritation
• Potential for decreased peristalsis due to surgical manipulation, opioid use, and
fluid and electrolyte imbalances
A. NURSING PLAN AND IMPLEMENTATION

• IMPROVING GAS EXCHANGE
The patient is expected to attain and maintain optimal lung
expansion and breathing patterns after surgery as indicated by:
▪ Partial pressure of arterial oxygen (Pao2) within normal range
▪ Partial pressure of arterial carbon dioxide (Paco2) within
normal range
▪ Oxygen saturation values within normal range
INTERVENTION
▪ AIRWAY MAINTENANCE. After assessing respiratory status,
an airway may need to be inserted if the patient does not
demonstrate adequate GAS EXCHANGE. An oral airway pulls
the tongue forward and holds it down to prevent obstruction.
If the patient had oral surgery or has clenched teeth, a large
tongue, or upper airway obstruction, insert a nasal airway
(nasal trumpet) to keep the airway open. A manual
resuscitation bag and emergency equipment for intubation or
tracheostomy should remain readily available in the PACU
area. For patients whose only airway is a tracheostomy or
laryngectomy stoma, alert other staff members by posting
signs in the room and notes on the chart. Monitoring.
Monitor the patient's oxygen saturation (SpO2) for adequacy
of GAS EXCHANGE with pulse oximetry with each set of vital
signs or at least every hour, according to the patient's
condition. Patients who normally have a low Pao2 such as
those with lung disease or older adults are at higher risk for
hypoxemia. An older adult is often prescribed low-dose
oxygen therapy for the first 12 to 24 hours after surgery to
reduce confusion from anesthesia and sedation. Patients who
received moderate sedation with a benzodiazepine such as
midazolam (Versed) or lorazepam (Ativan, Nu-Loraz ) may be
overly sedated or have respiratory depression sufficient to
need reversal with flumazenil (Romazicon). Hypothermia after
surgery causes shivering, which increases oxygen demand and
can induce hypoxemia. Many rewarming methods can be
used, although prevention is more important. The highest
incidence of impaired GAS EXCHANGE after surgery occurs on
the second postoperative day.
▪ POSITIONING. In the PACU immediately position the patient

in a semi-Fowler's position unless contraindicated. If the
patient cannot have the head of the bed raised, either place
him or her in a side-lying position or turn the head to the side
to prevent aspiration. Oxygen Therapy. Impaired GAS
EXCHANGE is prevented and managed with oxygen therapy.
Apply oxygen by face tent, nasal cannula, or mask to eliminate
inhaled anesthetic agents, increase oxygen levels, raise the
level of consciousness, and reduce confusion. After the
patient is fully reactive and stable, raise the head of the bed
to support respiratory function. For some patients oxygen
therapy may continue through the second day after surgery.
When hypoxemia occurs despite preventive care,
interventions such as respiratory treatments and mechanical
ventilation may be used to manage the cause of the
hypoxemia. Breathing Exercises. After the patient regains the
gag and cough reflexes and meets criteria for extubation (if
intubated), remove the airway or ET tube. Usual extubation
criteria include the ability to raise and hold the head up and
evidence of thoracic breathing. Help the patient splint the
incision, cough, and deep breathe to promote GAS EXCHANGE
and eliminate anesthetic agents. As soon as the patient is
awake enough to follow commands, urge coughing, using the
incentive spirometer, and breathing deeply hourly while
awake throughout the postoperative period. The patient who
is unable to remove mucus or sputum requires oral or nasal
suctioning. Perform mouth care after removing secretions.
▪ MOVEMENT. Assist the patient out of bed and to ambulate as

soon as possible to help remove secretions and promote
ventilation. Even when the patient has had extensive surgery,
the expectation may be to get out of bed the day of or the
first day after surgery. If this is not possible, help him or her
turn at least every 2 hours (side to side) and ensure that
breathing exercises and leg exercises are performed Early
ambulation reduces the risk for pulmonary complications,
especially after abdominal, pelvic, or spinal surgery. It
increases circulation to extremities and reduces the risk for
clotting and venous thromboembolism (VTE), especially deep
vein thrombosis (DVT). The patient may resist getting up, but
you must stress the importance of activity to prevent
complications. When indicated, offer the patient pain
medication 30 to 45 minutes in advance of scheduled
activities to allow for maximum effect of the analgesic agent.
• PREVENTING WOUND INFECTION AND DELAYED HEALING

The patient is expected to have incision healing without wound
complications as indicated by:
• Wound edges remaining together
• No purulent drainage, induration, or redness in, from, or
around the incision
INTERVENTIONS
• WOUND CARE. Reinforcing the dressing, changing the
dressing, and assessing the wound for healing and
infection; caring for drains, including emptying drainage
containers/reservoirs; measuring drainage; and
documenting drainage features
• DRUG THERAPY. Wound infection is a major complication
after surgery that may be managed by administering
antibiotics per doctor’s order.
• MANAGING PAIN
PLANNING: Expected Outcomes.
The postoperative patient is expected to attain or maintain optimal
COMFORT levels. Indicators include:
▪ Patient report that pain is controlled
▪ Absence of physiologic indicators of acute pain (increased
heart rate and blood pressure)
▪ Absence of behavioral indicators of pain (e.g., facial
grimacing, teeth clenching, guarding, rubbing the painful
area)
▪ Willingness to ambulate and participate in self-care
INTERVENTIONS
Pain management after surgery includes drug therapy and other methods
of management such as positioning, massage, relaxation techniques, and
diversion. Often the patient has better pain relief from a combination of
approaches. Assess the patient's comfort level and the effectiveness of the
therapies.
See Lesson 1, part 1 of Module 1 for discussion of pain assessment and
management.
• PROMOTING PERISTALSIS
Decreased intestinal peristalsis with the possible development of a
postoperative ileus (POI) can occur as a result of drug therapy,
anesthesia/analgesia, operative manipulation, and increased sympathetic
nervous system excitation from stress after any surgery but is most
common after open abdominal procedures. Thus, all postoperative
patients are at some risk for POI. This complication is unpleasant for the
patient, increases lengths of stay (Katrancha et al., 2014), and can lead to
other avoidable complications such as wound dehiscence, nausea,
vomiting, and deconditioning.
The patient is expected to have return of intestinal peristalsis after
surgery as indicated by:
▪ Presence of active bowel sounds in all four abdominal
quadrants
▪ Passage of flatus and/or stool
▪ No abdominal distention or rigidity
INTERVENTION
▪ Monitoring with accurate assessment of the abdomen is key
to determining recovery of intestinal peristalsis and
recognizing possible POI early. Assess the abdomen for the
presence and quality of bowel sounds, degree of distention,
and firmness whenever vital signs are taken. First observe for
distention and document whether this has increased or
decreased since the last observation. Auscultate for bowel
sounds in all four abdominal quadrants for up to 1 minute in
each quadrant. Gently palpate the abdomen to determine
degree of softness or whether any rigidity is present.
Although the presence of bowel sounds, especially lower in
the tract, does not indicate full peristalsis, the absence of
sound does correlate with hypomotility. Ask the patient
whether he or she has passed any flatus or stool. Although
passage of either indicates some intestinal motility, it does
not rule out POI.
▪ Ensuring adequate hydration helps promote peristalsis
because dehydration, fluid loss, and crystalloid excess can
potentially decrease intestinal motility, leading to POI.
Monitor IV fluid volume compared with urine output. Fluid
volumes infused should be sufficient (for the adult without
known kidney or cardiac problems) to maintain adequate
urine output that is dilute in appearance.
▪ Increased mobility, especially early ambulation, assists in
return of peristalsis. Help the patient ambulate at least once
per shift and increase the distance and time spent ambulating
with each intervention. Document both the time and distance
of each ambulation so progression can be continued by other
caregivers.
▪ Nonopioid pain management strategies can help reduce the
amount of opioids needed to manage pain adequately.
Opioids bind to GI receptors and contribute to decreased
peristalsis and POI development. Work with the
interprofessional team to use alternative pain control
measures in addition to opioids in the postoperative period.
See Chapter 4 for more discussion of nonopioid and
nonpharmacologic pain management strategies.
▪ Gum chewing in the early postoperative period has been
suggested to promote intestinal peristalsis. Chewing gum
stimulates digestive secretions, including gastric hormones
that trigger increased motility without adding bulk to the GI
system. A variety of nursing studies report this strategy to be
acceptable to patients, low-cost, and successful in returning
intestinal peristalsis after abdominal surgery (Katrancha et al.,
2014).
▪ Drug therapy can be useful both in preventing reduced
peristalsis and promoting increased intestinal peristalsis. The
opioid analgesics used for pain control work by binding to mu
opioid receptors in the brain. Similar mu receptors in the GI
system also are bound by opioids, which results in decreased
peristalsis. Drugs known as peripherally acting mu opioid
receptor antagonists (PAM-OR antagonists) can be given to
prevent opioids from binding to mu receptors in the GI tract
without interfering with the effectiveness of opioid pain
relief. Thus the action of these drugs facilitates return to
peristalsis after surgery. Two drugs approved for this purpose
are alvimopan (Entereg) and methylnaltrexone (Relistor).
Other drugs that have been tried to promote peristalsis by
directly stimulating GI motility are prokinetic agents. A
common drug in this class is metoclopramide (Reglan,
Maxeran). Because there is no evidence supporting its
effectiveness in preventing POI, it is used less often today.
B. EVALUATION OF CARE
Evaluate the care of the patient after surgery based on the identified priority patient
Attains and maintains adequate lung expansion and respiratory function
Has appropriate wound healing without complications
Has acceptable pain management
Has return of peristalsis
C. DISCHARGE PLANNING / REHABILITATIVE

a. Adherence to Treatment and Follow-ups
• MEDICATION: Instruct patient to strictly follow medication schedule to manage
pain, prevention of infection and promotion of wound healing process
• FOLLOW – UPS: Check-ups and regular monitoring of physical as well as
laboratory indicators should also be instructed to the patient for progress
monitoring
b. Home Care Management.
• Adequate rest and sleep. Fatigue exacerbates pain and slows down wound
healing.
• Wound care management
• Adequate exercise
• Adequate nutrition
• Pain management
• Support group
c. Health Care Resources
• Referral for physical therapy, especially to start or continue exercise regimens,
treatment with cutaneous stimulation, or heat or cold techniques.
• Referral to social worker to help them develop coping strategies or maintain
adequate family dynamics.
III. POST-TASK ACTIVITY
1. QUIZ – Link will be sent by the Clinical Instructor per schedule

2. VIDEO RECORDED of BASIC NURSING SKILLS and PROCEDURES on:
a. Artificial Airway
b. Chest Surgery
INSTRUCTIONS:
1. After studying and reviewing the Lesson 3 Module, the students are tasks to
demonstrate or at least discuss the basic nursing skills and procedures through a graded
video-recorded role playing. The skills shall cover care modalities on Artificial Airway
Management and Care of Client undergoing Lung Surgery
2. The length of the video that will cover the two care modalities shall not exceed 30
minutes.
3. RUBRICS or SKILLS CHECKLIST and PEER / GROUP EVALUATION on how each student are
to be graded will be as follows:
PART I: SKILLS CHECKLIST ON CARE MODALITIES:

Artificial Airway Management and Lung Surgery
ASSESSMENT CRITERIA CD ID ND REMARKS

(2) (1) (0)
SKILL BASED CRITERIA
I. PRE-PROCEDURE PHASE
1. Checks Doctor’s order
2. Verifies the right client for the procedure
3. Prepares all the necessary supplies and
equipment
4. Introduces self to client
5. Explains the procedure to the client
6. Assess / re-assess client’s need for the
procedure
7. Entertains queries from the client
8. Performs hand washing
9. Dons PPEs
10. Keeps room well lighted and warm
II. PROCEDURE PHASE
1. Observes privacy by closing doors and
curtains
2. Conducts procedure in chronological
sequence
3. Assists clients in assuming various positions
necessary for the procedure
4. Involves client with the procedure by giving
clear instructions or coaching
5. Observes client’s reaction / response to
procedure
6. Maintains proper posture and body
mechanics while performing procedure
7. Maintains IPR with client during the
procedure
8. Doffs PPE
III. POST PROCEDURE PHASE
1. Assists client in assuming position of
comfort after the procedure
2. Evaluates client’s response to the
procedure
3. Performs after care
4. Washes hands
5. Documents procedure and significant
observations
KNOWLEDGE BASED CRITERIA
• Narrator:
1. Explains essential points in the presentation
2. States rationale as needed
3. Clear and logical structure of presentation
4. Summarizes major points of the
presentation
5. Identifies indications/ contraindications of
nursing actions
6. Uses appropriate terminologies accordingly
• Members:
1. Answers questions post-video presentation
2. Offers additional information post-video
presentation
ATTITUDE BASED CRITERIA
1. Compliance
o Length of presentation within the
assigned time limits
o Observed due date
o Followed other essential
instructions
2. Creativity
3. Resourcefulness
4. Cooperativeness
5. Enthusiasm and Eagerness to learn
6. Appearance (decency and appropriateness
e.g. proper uniform)
PROCEDURAL POINTS 74
LEGEND:
CD – Correctly Done / Displayed / Demonstrated
ID – Incorrectly Done / Slightly Displayed / Slightly Demonstrated
ND – Not Done / Not Displayed / Not Demonstrated
Performed by: Evaluated by:
______________________________ ________________________________
Block and Group Clinical Instructor’s Name and Signature
PART II: PEER - GROUP EVALUATION
Instruction: Each member will rate each other including yourself according to the following rating scale:
1- Not executed
2- Poorly executed
3- Averagely executed
4- Excellently executed
Name Participation Cooperation Quality of Work TOTAL

(in planning & (interest, (Value & worth of (12)
developing enthusiasm, work output)
ideas) interest)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Note:
• Do not fill -up Part I-Skills Checklist Evaluation Form. That is for your Clinical Instructor’s guide on
how to rate you on your Video Output
o Part I – Skills Checklist Evaluation Form is presented to the students to serve as guide as to
how students will be graded
• Part II: Peer Group Evaluation Form is for you to fill up. Submission is after the video class
presentation
• Clinical Instructor will add your individual overall rate for peer group evaluation to Part I Rating
• TOTAL EXPECTED PERFECT SCORE: 156 POINTS
o Part I = 144 (72 points x 2 Basic Skills / Procedures: Airway Management, Lung Surgery)
o Part II = 12 points
• This is Prelim Culminating Activity for the group assigned to prepare the mentioned video

Lesson 3 Artificial Airway Chest Surgery

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Lesson 3 Artificial Airway Chest Surgery

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ARELLANO UNIVERSITY

STUDENT NAME: _______________________________________________________________________

Class Schedule / Section: ______________________________ Date: _________________________

SKILLS LAB WORKSHEET #2: Pre-Task Activity

DEFINITION OF WORDS FOUND: (use additional sheet / page as necessary)

WHILE TASK ACTIVITY – MODULE CONTENT:

a. ORAL AIRWAYS or OROPHARYNGEAL AIRWAY (OPA)

Considerations for Oropharyngeal Airway

PRE-SELECTED VIDEO FOR SKILLS DEMONSTRATION:

Considerations for Nasopharyngeal Airway

PRE-SELECTED VIDEO FOR SKILLS DEMONSTRATION:

TRACHEOSTOMY- is a surgical procedure done

A tracheostomy is a 51- to 76-mm (2- to 3-

• To maintain airway patency by removing mucus and encrusted secretions.

PARTS OF TRACHEOSTOMY TUBE

• Sterile cotton-tipped applicators

PRE-SELECTED VIDEO FOR SKILLS DEMONTRATION:

Unexpected Outcomes Related Interventions

• Call for assistance.

• Remove inner cannula if applicable

II. CHEST SURGERY

A procedure concerned with restoration, reconstruction, correction or improvement in the shape

Example: Lung Transplant

C. ACCORDING TO DEGREE OF RISK

D. ACCORDING TO THE EXTENT

b. Minimally Invasive Surgery (MIS)

E. SUFFIXES & TERMS RELATED TO SURGERY

c. SEGMENTAL / WEDGE RESECTION

THE PERIOPERATIVE NURSING

Anticipated Nursing Problems: Safety, lack of information, fear and anxiety

A. The Scope of Nursing Management:

c. Preadmission testing (Laboratories):

• Consent must be signed before administration of the premedication

f. Pre-operative Nursing Intervention:

Anticipated Nursing Problems:

A. The Surgical Team:

b. The Scrub Nurse

b. Planning and Implementation

The patient is usually in a supine position after transfer to the

Anticipated Nursing Problems:

A. NURSING PLAN AND IMPLEMENTATION

▪ POSITIONING. In the PACU immediately position the patient

▪ MOVEMENT. Assist the patient out of bed and to ambulate as

• PREVENTING WOUND INFECTION AND DELAYED HEALING

C. DISCHARGE PLANNING / REHABILITATIVE

1. QUIZ – Link will be sent by the Clinical Instructor per schedule

PART I: SKILLS CHECKLIST ON CARE MODALITIES:

ASSESSMENT CRITERIA CD ID ND REMARKS

Performed by: Evaluated by:

Name Participation Cooperation Quality of Work TOTAL

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Class Schedule / Section: ______ Date: _