MS1 Part 1

Care of Clients with Problems in the Oxygenation, Fluid & Electrolyte, Infectious, Inflammatory, Immunologic Response
Cruz, Larraine Jhasmine D.

BSN-3C0
Module 1 compulsion to take the drug

primarily to experience its psychic
Pain ●
effects
Algogenic
Pain is defined as an unpleasant sensory and ○ causing pain
emotional experience associated with actual or ● Allodynia
potential tissue damage or described in terms of such ○ Pain due to a stimulus that does
damage (American Pain Society, 2008 ). Pain can be not normally provoke pain, such
localized, affecting a specific area of the body, or it as touch; typically experienced in
can be general. Most of the time, pain is the reason the skin around area affects by
and the first manifestation that makes client seek nerve injury and commonly seen
medical attention. Pain sensation varies individually. with many neuropathic pain
It is influenced by beliefs, attitude and social factors. syndromes
● Breakthrough pain
As future nurses we need to understand the ○ sudden increase in pain despite the
pathophysiology, the physiologic and psychological administration of pain-relieving
consequences of acute and chronic pain and the medications
methods used to treat pain because nurse pend more ● Dependence
time with patients in pain than other health care ○ occurs when a patient who has been
providers do. taking opioids experiences a
Pain management is considered such an important withdrawal syndrome when the
part of care that it is referred to as “the fifth vital opioids are discontinued; often
sign” to emphasize its significance and to increase occurs with opioid tolerance and
the awareness among health care professionals of the does not indicate an addiction
importance of effective pain management (American ● Dysthesia
Pain Society, 2008). ○ the maximum amount and duration
of pain that an individual can
endure
● Endorphins and Enkephalins
○ Morphine-like substances produced
by the body. Primarily found in the
central nervous system, they have
the potential to reduce pain.
● Pain threshold/Pain sensation
○ amount of pain stimulation required
for a person to feel pain
Pain is the 5th vital sign
■ Different perceptions of
● Pain disables and distresses more people
pain from one person to
than any single disease
another
● Pain is a complex constellation of
■ Women tend to endure
unpleasant sensory, emotional,
pain more than men
psychological, and certain autonomic
● Example:
(involuntary) responses and behavioral
childbirth and
reactions provoked by a tissue damage
labor
● Pain Tolerance
Terms to remember/know:
○ the maximum amount and duration
● Addiction
of pain that an individual can
○ A behavioral pattern of substance
endure
use characterized by a
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● Hyperalgesia ○ chemical substances that increase

○ increased pain from a stimulus that the sensitivity of pain receptors by
usually provokes pain enhancing the pain-provoking
● Nociception effect of bradykinin
○ activation of sensory transduction ○ Dysmenorrhea is caused by the
in nerves by thermal, mechanical, release of prostaglandin
or chemical energy impinging on ■ Counteract its effect by
specialized nerve endings. The medication
Nerves involved convey info about ● Radiating pain
tissue damage to the CNS ○ a pain (under category of visceral
○ You must have an intact nervous pain) perceived in the source of
system to feel pain pain and extended to nearby tissue.
● Nociceptor ● Referred pain
○ a receptor preferentially sensitive to ○ a pain (under category of visceral
a noxious stimulus pain) perceived in a general area of
● Non- nociceptor the body, usually away from the
○ nerve fiber that usually does not site of stimulation. E.g., cardiac
transmit pain pain may be felt in the shoulder
● Opioid or left arm, with or without chest
○ A morphine-like compound that pain.
produces bodily effects including
pain relief, sedation, constipation, Types of pain according to duration
and respiratory depression. This
term is preferred over narcotic.
○ Count for respiratory rate because
it can induce respiratory depression
as well as sedation
● Placebo
○ any medication or procedure, that
produces an effect in a patient
because of its impact or explicit
intent and not because of it’s
specific physical or chemical
properties
○ Usually in sterile water form
Types of pain according to inferred pathology
● Placebo Effect
○ analgesia that results from the
expectation that a substance will
work, not from the actual substance
itself
● Phantom pain
○ Perceived pain (type of
neuropathic pain) when a person
with an amputated limb perceives
that the limb still exists and
feels burning, itching, deep pain
in tissues that have been
surgically removed.
● Prostaglandins
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○ nerve fiber that usually does not

transmit pain
Neurophysiological Transmission of Pain
1. Transduction
-When a pain threshold has been reached and there is
injured tissue, substances that stimulate the pain
Difference of the two: receptors called nociceptors, are released
● Nociceptive pain is different from -These pain receptors can be stimulated by serotonin,
neuropathic pain because nociceptive pain histamine, potassium ions, acids, and some enzymes
develops in response to a specific stimulus -Ibuprofen and local anesthetic can decrease pain
to the body, but neuropathic pain doesn't. ● Bradykinin
Neuropathic pain is pain that comes from ○ a powerful vasodilator is released
damage to the nerves or nervous system. It at the site of an injury
causes a shooting and burning type of pain ○ causes the release of inflammatory
or numbness and tingling. chemicals such as histamine.
Again, remember: ○ These two chemicals (bradykinin
● Nociception and histamine) cause the area to
○ activation of sensory transduction redden, swell, and become tender.
in nerves by thermal, mechanical, ○ Bradykinin also stimulates the
or chemical energy impinging on release of prostaglandins.
specialized nerve endings. The ○ Dolor (pain), calor (heat), functio
Nerves involved convey info about laesa (dysfunction), rubor (redness)
tissue damage to the CNS are existing
● Nociceptor ● Prostaglandin
○ a receptor preferentially sensitive to ○ These compounds sensitize the pain
a noxious stimulus receptors and enhance the effects of
● Non- nociceptor bradykinin and histamine.
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● Substance P areas controlling blood pressure, heart

○ act as a stimulant to the nociceptors rate, breathing, and emotions.
○ Known to be a neurotransmitter 3. Perception
that enhances the movement of ● when the client experiences pain
impulses across the nerve synapse ● believed to occur in cortical structures which
from the primary afferent neuron to allow for cognitive responses
the second-order neuron ● non-pharmacologic intervention can
decrease pain
● The pain stimuli transmitted along the nerve
fibers as described earlier, enter the spinal
cord, and the cord to the thalamus reticular
formation.
● Conscious perception of the pain occurs
initially at the brainstem and thalamic level.
● Interpretation and localization of the pain is
in the cerebral cortex
● Common non-pharmacological diversions
-Nociceptors are stimulated: ○ Massage
● directly - by damage to the receptor cell, ○ Diversional activities
● secondarily - by the release of chemicals ■ companionship
such as bradykinin. ○ Therapeutic positioning
-Three types of stimuli that excite corresponding ○ Cold and hot compresses
types of nociceptors: 4. Modulation
● mechanical ● neurons send signal back to dorsal horn of
● thermal SC
● Chemical ● causes release of endogenous opioids,
2. Transmission serotonin and NE
a. Transmission of impulse from the peripheral ● Tricyclic antidepressant
nerves to the spinal cord (SC)
● C fibers- larger, unmyelinated nerve
fibers, dull aching pain
● A delta – smaller, myelinated fibers,
sharp, localized pain
● Messages come out of the spinal cord
and travel via motor nerves to the arm
muscles, causing the arm to withdraw
quickly.
● This is an automatic reflex that does not
involve the brain or conscious thought
b. From the SC to brain stem and thalamus via
the spinothalamic tract
● pain signals are also sent upwards in the
spinal cord via the Spinothalamic tract
(amongst others) to an area in the brain
stem (base of the brain) called the
thalamus.
c. Thalamus to somatic sensory cortex
● Further processing occurs in the
thalamus with signals being sent to
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● The pain gate in the spinal cord can be shut

in several different ways:
○ Stimulation of touch fibers
Theory of Pain ○ Release of endogenous opioids
○ Electrical stimulation
○ Morphine and other opioid drugs
○ Normal and excessive sensory
stimuli
○ Cerebral cortex and thalamic
inhibition of pain
● The nervous system is made up of
stimulatory and inhibitory fibers. When
nociceptor is stimulated it will stimulate
transmission at the next fiber junction
(represented as +>–). The interneuronal
fiber is an inhibitory neuron (−>–). When it
● Gate Control Theory is stimulated it, in turn, inhibits or shuts off
The ﬁrst theory to suggest that psychological factors transmission at the next junction. So a
play a role in the perception of pain and guided placebo has a (+) stimulatory effect on the
research towards the: descending control system, which has a
1. cognitive behavioral approaches to pain stimulatory effect (+) on the interneuronal
management. fiber, which has an inhibitory effect (−) on
2. distraction and music therapy provide pain the ascending control system. A topical
relief. anesthetic has an inhibitory effect (−) on
Synapses in the dorsal horns act as gates that close to nerve transmission at the nociceptor level
keep impulses from reaching the brain or open to and a spinal anesthetic has the same impact
permit impulses to ascend to the brain. (−) on the ascending nociceptive fibers.
● According to the gate control theory:
○ small-diameter nerve fibers carry Pain Assessment
pain stimuli through a gate A. Comprehensive pain assessment must be
○ large diameter nerve fibers going conducted upon initial interview.
through the same gate can inhibit B. Physical examination of Pain
the transmission of those pain The following are components of a comprehensive
impulses-that is, close the gate pain assessment and ways on how to elicit the
information from the patient:
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1. Location- Ask the patient to point the A. NRS: Numeric Rating Scale
areas of pain on the body. - Uses number to assess a person’s
2. Intensity- mild, moderate, severe- Ask severity to pain from 0 to 10.
the patient to rate the severity of pain using - Score of 0 means that the patient
tools (example: pain scale 1-10 or face is not experiencing any pain, while
emoji tool) 10 means the worst pain.
3. Quality- Allow patient to describe how - Simple and works well for
the pain feels; “sharp”, ”shooting”, patients who can cognitively rate
“burning” pain intensity. But what about if the
4. Timing- onset, duration, pattern- Ask client is 5 yrs old, he might not
patient when the pain started and whether it understand how to score the pain
is constant or intermittent. on such an abstract scale therefore
5. Aggravating and alleviating (relieving) we use other tools.
factors- Ask patient what makes the pain B. Wong- Baker FACES pain rating scale:
worse and what makes it better; Effect of - Best tool for young patients.
pain on the ability to perform recover - Consists of six pictures of faces
activities should be regularly evaluated - The faces correlate to a number.
6. Comfort- function (pain intensity goal)- - ”0” - happy face that indicates no
Identification of short term functional goals pain.
and reinforce to the patient that good pain - “10” - tearful sad face and
control will more likely lead to successful indicates the worst pain.
achievement of goal. - The faces in between reflect
7. Personal Meaning differing levels of pain.
- To assess you will inform the
Pain Behaviors pedia client what each face
○ varies from one person to another represents.
○ verbal, non-verbal and behavioral Then he can pick the face that best
expressions may not be reliable represents how he is feeling.
C. Faces Pain Scale – Revised (FPS-R)
- a self-report measure of pain
intensity developed for children
- Has 6 faces range from neutral
facial expressions to one of
intense pain and are numbered
0,2,4,6,8,10.
D. Verbal Descriptor Scale (VDS)
Tools To Assess Intensity of Pain: - uses different words or phrases to
There are many different tools available to help describe the intensity of pain,
nurses assess a client's level of pain. It is important to such as “no pain, mild pain,
choose the tool that will work best for the client. moderate pain, very severe pain &
worst possible pain”
- the patient is asked to select the
phrase that best describes pain
Intensity.
E. Visual Analog Scale (VAS)
- A 10cm line with word anchors at
the ends. “no pain” & “pain as
bad as it could possibly be”
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- Patient is asked to mark on the

line to indicate the intensity of pain
- Impractical for use in daily
clinical practice & rarely used
Factors that Influence Pain Response:

● Past experience
○ Once a person experiences severe
pain, that person knows just how
severe it can be. Conversely,
someone who has never had severe
pain may have no fear of such pain.
● Anxiety
○ anxiety that is relevant or related
to the pain may increase the
patient’s perception of pain ;
Anxiety that is unrelated to the
pain may distract the patient and
may actually decrease the
perception of pain.
● Depression
○ Longer durations of pain are
associated with an increased
incidence of depression
● Culture
○ Beliefs about pain and how to
respond to it differ from one culture
to the next
● Age
○ The way an older person responds
to pain may differ from the way a
younger person responds. If pain
perception is diminished in the
elderly person, it is most likely
secondary to a disease process
(eg, diabetes) rather than to
aging (American Geriatrics
Society, 1998)
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● Gender ● Anxiety r/t past experiences of poor pain

○ Women had higher pain intensity, control and anticipation of pain
pain unpleasantness, frustration, ● Self care deficit r/t poor pain control
and fear compared to men.
Robinson, Riley, Meyers et al. Management of Pain
(2001); men being more anxious Nurse’s Role:
about their pain ( Edwards, 1. Administering Pain relieving
Auguston and Fillingim (2000) intervention
● Intensity 2. Assessing effectiveness of
○ none to mild discomfort to intervention
excruciating. 3. Monitoring for adverse effects
● Timing 4. Advocate for the patient when the
○ onset, duration, relationship prescribed treatment is ineffective
between time and intensity, and ● Identifying the Goals of Pain Management:
changes in rhythmic patterns; ○ to determine the type of
sudden or gradual increase intervention needed and to establish
● Location a target
○ have the patient point to the area of ● Consider the ff:
the body involved ○ Severity of Pain as judge by the
● Quality patient
○ patient describes the pain in his or ○ Anticipated harmful effects of pain
her own words without offering ○ Anticipated duration of pain
clues
● Personal meaning Pain Management Interventions
○ effect of pain in person’s daily life. I. Pharmacologic
● Aggravating, alleviating factors A. Premedication Assessment
○ anything makes the pain worse ● ask for allergies
and what makes it better; ● medication history
relationship between activity and ● other health problems
pain ● Approaches for using analgesic
● Pain behaviors agents:
○ nonverbal and behavioral ○ Balanced Anesthesia
expressions of pain are not ■ refers to the use
consistent or reliable indicators of of more than one
the quality or intensity of pain, analgesia to
and they should not be used to obtain more pain
determine the presence of or the relief and fewer
degree of pain experienced side effects
(grimace, cry, rub the affected ○ Pre Re Nata (PRN)- as
area, guard the affected area, or needed
immobilize it, moaning , ○ Preventive Approach
groaning, grunt, or sigh.) ○ Individualized dosage
○ Patient Controlled
Sample Nursing Diagnoses Analgesia (PCA)
● Acute Pain ■ for post-operative
● Chronic Pain and chronic pain
● Ineffective airway clearance r/t poor ■ allows patients to
coughing secondary to incisional pain control
administration of
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their pain o platelet aggregation and

medication with increase mucosal blood flow
in predetermined ● COX-2
safety limits o mediates prostaglandin
1. ANALGESIC AGENTS formation that results in
o symptom of pain,
inflammation and fever
B. Opioid (Narcotic)Analgesic Agents
● Act on CNS to inhibit activity of
ascending nociceptive pathways
● goal is to relieve pain and improve
quality of life
● can be administered by various routes
● Side Effects:
o Respiratory depression and
sedation
▪ Most serious adverse
effects
▪ increases with age
and concomitant use
of other opioids
▪ decrease RR and
shallow respiration
o Nausea and vomiting
▪ occur after the initial
dose
● Adverse Effects of Analgesic Agents ▪ triggered by sudden
o Respiratory depression change in position
o Sedation o Constipation
o Nausea, vomiting ▪ occur in patients over
o Constipation large doses of opioids
o Pruritus ▪ tolerance does not
● It can be categorized into 3 main groups occur
A. Non - opioid o Inadequate pain relief
● Includes Paracetamol and NSAIDS ▪ due to inadequate
● NSAIDS: Decrease pain by inhibiting dose or shifting route
cyclo-oxygenase (enzyme involved in of administration
production of prostaglandin) o Tolerance and addiction
o decrease pain by inhibiting ▪ the need to increase
COX pathway; the rate the dose to achieve
o limiting step in prostaglandin same effect
production combined with o Other effects
opioids nephrotoxic ▪ pruritus, urinary
● COX-1 retention
o mediates prostaglandin ▪ decreased excretion in
formation involved in liver and kidney
o maintenance of physiologic disease
function
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▪varying effects in ● EMLA (eutectic mixture of local

patients with thyroid anesthetic)
disease ● Intraspinal (epidural)
▪ hypotension in o local anesthetic is directly applied
dehydrated patients to the nerve root through an
▪ may be potentiated by epidural catheter
other medications e.g.
▪ MAO inhibitors, Routes:
Phenothiazines ● Oral
C. Approaches for Using Analgesic Agents o preferred route of analgesic
● Balanced analgesia – use of more than one administration higher dose.
form of analgesia concurrently to obtain o Easiest route, least expensive; best
more pain relief with fewer side effects. tolerated
● “PRN” medications (pro re nata(PRN), or ● Rectal
“as needed.” o alternative when oral and IV is not
● Routine administration: around the clock an option
(ATC) or preventive approach; analgesic o rectum allows passive diffusion of
agents are administered at set intervals so medications and absorption into the
that the medication acts before the pain systemic circulation
becomes severe and before the serum opioid o Keep in mind: drug absorption is
level falls to a subtherapeutic level. unreliable due to rectal tissue
● Individualized dosage - The dosage and the health and administration technique
interval between doses should be based on ● Topical and Transdermal Route
the patient’s requirements rather than on an o absorbed through the skin and fat
inflexible standard or routine. People layer slowly
metabolize and absorb medications at ● Parenteral Route
different rates and experience different o IM, IV or SQ
levels of pain. o Rapid onset with shorter duration
● PCA: patient-controlled analgesia ● Transmucosal
o lozenges or nasal spray
D. Local Anesthetic Agents - ( Topicals, patches, ● Intraspinal- intrathecal/spinal or epidural
sprays ) o for persistent, severe, unresponsive
● Rapidly absorbed into the bloodstream, pain
resulting to dec. availability at the surgical o may cause spinal h/a, respiratory
or injury site and an inc anesthetic level in depression, vomiting
the blood, increasing the risk of toxicity
● Blocks nerve conduction when applied
directly to the nerve fibers.
● A vasoconstrictive agent (eg, epinephrine or
phenylephrine) is added to the anesthetic
agent to decrease its systemic absorption and
to maintain its concentration at the surgical
or injury site.
● Local Anesthetic Agents
● Topical
o applied to the site of injury w/ a
vasoconstricting agent
o Intraspinal analgesics
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▪ Act directly on opiate all injection parts connected to the

receptors in the dorsal epidural line to avoid inadvertent
horn of the spinal cord. injections of other substances
▪ Intrathecal space contains intended for IV lines into the
cerebrospinal fluid (CSF) epidural space.Secure temporary
and directly surrounds the catheters with tape. Limit the
spinal cord, opiates act client's activity.
q ● Maintain catheter placement
u o Provide assistance in moving into
i nd out of a bed or chair.
c ● Maintain catheter patency
k o Inspect the insertion or exit for
l signs of leakage, infection, and
y bleeding with each dose
administered or at least every 12
o hours.
n ● Prevent infection
the dorsal horn. o Use strict aseptic technique when
▪ Very little drug is handling the catheter
absorbed by blood vessels o Change tubing every 24 hours
into the systemic o Ensure that the insertion site is
circulation. covered with a sterile, transparent
o Two commonly used medications occlusive dressing
are preservative-free morphine ● Maintain urinary and bowel function
sulfate and fentanyl. o Monitor intake and output
o The major benefit of intraspinal o Assess for bowel and bladder
drug therapy is that it exerts a distention
lesser sedative effect than do ● Prevent respiratory depression
systemic opiates. o Assess sedation level and
o Epidural analgesics - The epidural respiratory status every hour for the
space is most commonly used first 24 hours and thereafter every 4
because the dura mater acts as a hours
protective barrier against infection, o Do not administer other opioids or
including meningitis. central nervous system depressants
unless ordered
o Keep an ampule of naloxone
hydrochloride (0.4 mg) at the
bedside. Notify the clinician in
charge if the respiratory rate falls
below 8 bpm per minute or if the
client is difficult to rouse
E. Tricyclic antidepressants and anticonvulsants
Nursing Considerations in epidural analgesics ● For neurologic pain and unresponsive to
● Maintain client safety opiods
o Label the tubing, the infusion bag, ● tricyclic antidepressant agents (
and the front of the pump with tape amitriptyline (Elavil) or imipramine
marked "EPIDURAL to prevent (Tofranil ) - therapeutic effect may not
confusion with other similar- occur before 3 weeks.
looking IV lines. Apply tape over
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● Antiseizure medications (phenytoin painful sensations can

(Dilantin) or carbamazepine (Tegretol ) block or decrease pain
used in lower doses indicated for Pain transmission impulses
of neurologic origin ( causalgia, tumor ● Ice and Heat Therapies
impingement on a nerve, postherpetic ○ ice should be applied no
neuralgia, dysesthesia (burning or longer than 20 minutes at
cutting pain) a time
● Placebo effect ○ Heat
o Any medication/ procedure
that produces an effect in a
patient because of it’s implicit
or explicit intent & not bec of
it’s specific physical or
chemical properties.
o Occurs when a person
responds to the medication or
other treatment because of an
expectation that the treatment
will work rather than because
it actually does so
o The placebo effect results from
the natural (endogenous)
production of endorphins in
the descending control system.
It is a true physiologic
response that can be reversed
by naloxone, an opioid
antagonist (Wall, 1999).
● Placebos (tablets or injections with no
active ingredients) should not be used to
assess or manage pain in any patient
regardless of age or diagnosis” The
American Society of Pain Management
Nurses (1996)
● Gerontologic considerations ● Transcutaneous Electrical Nerve
o More likely to have adverse stimulation-
drug effects, drug interactions ○ uses battery operated unit
o Increased likelihood of chronic with electrodes applied to
illness the skin to produce a
o May need to have more time tingling, vibrating or
between doses of medication buzzing sensation in the
due to decreased excretion, area of pain
metabolism related to aging ● Distraction
changes ○ focusing the patient’s
II. Non- Pharmacologic attention on something
● Cutaneous stimulation and other than the pain
Massage (cognitive techniques) TV,
○ proposes stimulation of music, mental exercises
fibers that transmit non-
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● Relaxation Techniques electrical pulses to the

○ abdominal breathing at a different parts of the NS
slow, rhythmic rate. ● thought to relieve pain by
rhythmic inhalation an blocking painful stimuli
exhalation ● spinal cord or deep brain
● Guided Imagery stimulation
○ using one’s imagination in ● Reversible
a special way to achieve a 2. Interruption of pain pathways
specific positive effect; ● Permanent
consist of combining slow, ● Cordotomy
rhythmic breathing with a ○ Division of
mental image of relaxation certain tracts of
and comfort the SC
● Hypnosis ○ Interrupts the
● Alternative therapies transmission of
○ Music therapy, touch pain
therapy, reflexology,
magnetic therapy,
electrotherapy,
acupressure,
aromatherapy)
● Rhizotomy
○ Sensory nerve
roots are
destroyed when
they enter the SC
reducing
nociceptive input
III. Neurologic and Neurosurgical Interventions

● Indicated for intractable pain (pain
that cannot be relieved
satisfactorily by the usual
approaches, including medications;
usually is the result of malignancy
(especially of the cervix, bladder,
prostate, and lower bowel)
● Indicated for prolonged and severe
intractable pain
1. Stimulation procedures - intermittent Nursing Process Framework for Pain
electrical stimulation of a tract or center to Management
inhibit the transmission of pain impulses ( ● Factors to consider for pain management
TENS, Spinal Cord stimulation) ○ Severity of the pain, as judged by
● pain suppression by the client.
application of low-voltage ○ Anticipated harmful effects of pain.
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■ A high risk patient is at ● EXPLORATORY

much greater risk for the ○ to estimate the extent of
harmful effects of pain the disease
than a young healthy ● ABLATIVE
patient. ○ to remove a diseased
○ Anticipated duration of the pain. organ
● PALLIATIVE
Remember: ○ done to relieve symptoms
○ Always establish nurse-patient of a disease without
relationship, teaching treating or correcting the
○ Provide physical care disease itself
○ Manage anxiety/ related to pain ● RECONSTRUCTIVE
○ Evaluate all the pain management ○ to repair tissue/organs
strategies done to patient whose function and
appearance has been
Module 2 damage
● CONSTRUCTIVE
Surgery ○ to repair a congenitally
malformed tissue/organ.
Perioperative ● COSMETIC/AESTHETIC
● which spans the entire surgical experience, ○ to improve personal
consists of three phases that begin and end at appearance
a particular points in the sequence of ● CURATIVE
surgical experience events. The preoperative ○ elimination or repair of
phase, intra-operative phase, and post pathology
operative phase. Each phase includes diverse ● PROCUREMENT FOR
activities a nurse performs. Patients TRANSPLANT
scheduled for surgery from varied settings; ○ Diseased or damaged
ambulatory, outpatient, or in-patient require body organs and structures
a comprehensive assessment, diagnoses, replaced with donated or
planning, interventions, and evaluation artificial organs.
The three phases of perioperative nursing ● REMOVAL
1. PREOPERATIVE PHASE - The time beginning ○ removal of foreign body
with the patient’s decision to have surgery and 2. Risk involved
ending at the time of the induction of anesthesia ● Classification of Surgery Based on
2. INTRAOPERATIVE PHASE - The time the Degree of Risk involved
beginning with the induction of anesthesia and ○ Minor surgery
ending with the admission of the patient to the post ■ Less important
anesthesia care unit (PACU) body structure –
3. POSTOPERATIVE PHASE - The time removed/involve
beginning with the admission of the patient to the d
PACU and ending with follow up visit and/or ■ Risk - less risk
discharge of the patient ■ Complications -
few
Surgical procedures are classified according to: ■ Done under local
1. Purpose anesthesia
● DIAGNOSTIC ■ Often performed
○ removal and study of in a day surgery
tissue to make a diagnosis. ■ Examples:
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● Excision
of breast
mass
● Circumc
ision
● D and C
● Debride
ment
○ Major surgery
■ Major organ –
removed /surgical
manipulated
■ Risk - high
degree
■ Prolonged
/complicated
■ Blood loss - ↑
■ Examples:
● Cesarea
n section
● M.R.M.
● Cholecy
stectom
Surgical settings:
y
● Elective Surgery
● T.A.H.B
○ carefully planned event
.S.O.
● Emergency Surgery
3. Urgency
○ may arise with unexpected urgency
● Categories of Surgery Based on
● Same-day admission
Urgency
○ patient most often admitted on the
day of surgery for in patient
surgery.
● Ambulatory Surgery
○ is done on an out-patient basis.
○ Advantages:
■ Less stress to the patient
■ Less risk of nosocomial
infection.
■ Less decrease in patient’s
productivity.
■ Less costly to the patient
○ Disadvantages:
■ Less time to monitor and
assess patient
■ Less time to establish
holistic care
■ Patient will be
responsible for assessing
complications
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PREOPERATIVE PHASE ● Upper respiratory infection

○ Increases risk of respiratory
Goals:
complications
● Assess and correct physiologic and
○ If there’s pneumonia or TB, resolve
psychological problems - surgical risk.
first of the condition
● Give the person and significant others
● Liver disease
complete learning/teaching guidelines
○ Alters metabolism and elimination
regarding surgery.
of drugs
● Instruct and demonstrate exercises - benefit
○ Impairs wound healing and clotting
(post operative)
time
● Plan for discharge /any projected changes in
● Fever
lifestyle due to surgery.
○ Predisposes - fluid and electrolyte
imbalances
Risk Assessment
○ May indicate underlying infection
● Bleeding Disorders
● Chronic respiratory disease (emphysema,
○ Thrombocytopenia - ↓ platelet
bronchitis, asthma)
count
○ Anesthetic agents reduce
■ This condition sets in if
respiratory function
the patient has dengue,
● Immunological disorders (leukemia, AIDS,
liver cirrhosis, might as
bone marrow depression and use of
well in concern with
chemotherapeutic drugs or
anemia
immunosuppressive agents)
■ Know the bleeding time of
○ Increased risk of infection and
the patient
delayed wound healing after
○ Haemophilia - ability of the blood
surgery.
to clot is severely reduced (little or
● Drug abuse
no clotting factor)
○ Person abusing drugs - ↑ risk of
■ Get the patient’s CBC
HIV/Hepatitis, which affects
■ It increases the risk of
wound healing
hemorrhage
● Chronic pain
● Diabetes mellitus
○ Higher tolerance
○ Increases susceptibility to infection
○ Impaired wound healing
Assessment Considerations for Clients undergoing
○ Diabetes Mellitus
Surgery
■ Strict glycemic control
● Age
(80-110 mg/dl)
○ Infant - normal body temperature
● Heart Disease (Recent MI, dysrhytmias,
must be maintained
CHF) and peripheral vascular disease
○ Elderly patients – are at risk during
○ Stress of surgery - ↑ cardiac
surgery because of declining
demands
physiological status
○ General anesthetic agents -
○ Fragile skin
↓cardiac functions.
■ Precaution-positioning.
○ Chances of death is higher than
○ Decreased subcutaneous fat
usual
■ risk for hypothermia.
■ The healthcare team can
○ Bone loss
try but inform the s/o and
■ Risk for fracture.
patient the risk
■ Careful positioning
BSN-3C0
● Nutritional Status ○ General anesthesia is usually

○ Post-op: needs at least 1500 preferred in eclamptic patients with
kcal/day to maintain energy convulsions.
reserves. ○ General Anesthesia is administered
○ Increase in CHON, Vitamin A & C with caution.
and Zinc to facilitate healing. ● Previous Surgery
○ Malnutrition ○ Client’s past experience with
■ Weight loss of 10% within surgery can influence physical and
6 weeks before surgery psychological responses to a
must be investigated procedure.
■ Brittle nails – indicate ● Perception and understanding of surgery
poor nutrition ○ The client is misinformed or
■ Optimum nutrition is unaware of the reason for surgery
required for wound and has inaccurate perception or
healing and preventing knowledge of the surgical
infection. procedure.
■ Both obese and ● Medication history
underweight is considered ○ Antibiotics
malnutritioned ■ potentiate action of
○ Check the patient’s BMI in order to anesthetic agents.
assess the nutritional status ■ MOST EFFECTIVE IN
● Obesity or bariatric PREVENTING
○ Reduced ventilator and cardiac INFECTION IF IT IS
function. CAD, DM, CHF GIVEN 30 – 60 MIN
○ Postoperative complications : before the operative
○ Embolus incision is made.
● Immunocompetence ■ Ex. If surgery scheduled at
○ Cancer patients: Surgeon waits for 7:00 am/give it 6:30 am
4-6 weeks (ideally) ○ Antidysrhythmias
○ after completion of radiation ■ Can reduce cardiac
treatments before surgery. contractility and impair
● Fluid and electrolyte imbalance cardiac conduction during
○ Excess body fluid can overload the anesthesia.
heart ○ Anticoagulants
○ Normal serum potassium ■ alter normal clotting
concentration is 3.5 – 5.0 mEq/L factors and thus increase
○ Notify anesthesiologist ↓ or ↑ risk of hemorrhaging.
serum potassium concentration ■ They should be
(risk for arrhythmia when under discontinued at least 48
general anesthesia ) may hours prior to surgery.
cancel surgical procedure. ■ Aspirin is a commonly
● Pregnancy used medication that can
○ CESAREAN SECTION- emergent alter clotting
or urgent basis. mechanisms.– would
○ General Anesthesia increases the ALERT the nurse if used
risk for fetal death and preterm by the patient days before
labor. surgery for pain
management.
BSN-3C0
○ Anticonvulsants ● Grapes
■ Long term use - e.g. ● Guava
Phenytoin [Dilantin] and ● Hazelnuts
Phenobarbital can alter ■ ADHESIVE TAPE
metabolism of anesthetic ■ ANESTHESIA MASKS
agents ■ TOURNIQUET
○ Antihypertensions ■ IRRIGATION
■ interact with anesthetic SYRINGES
agents to cause ■ CATHETERS
bradycardia, hypotension ■ Goal:
and impaired circulation ● Provide a atex-
○ Corticosteroids free environment
■ With prolonged use, may ● Smoking habits
cause adrenal ○ Increase amount and thickness of
hypertrophy, which mucous secretions- smokers.
reduces the body’s ability ○ General Anesthesia - ↑ airway
to withstand stress. irritation and stimulates pulmonary
○ Insulin secretions (retained ↓ciliary activity
■ Diabetic client’s need for during anesthesia).→ Ineffective
insulin after surgery is Airway Clearance
altered ○ Post- operative deep breathing and
○ Diuretics coughing is vital.
■ Diuretics potentiate ● Family support
electrolyte imbalances ○ Identify client’s source of support.
(particularly potassium) ○ Family presence should be
after surgery. encouraged (client’s coach)
● Allergies ● Review of emotional health
○ An allergy to shellfish is also ○ Surgery is psychologically
allergic to- IODINE SKIN stressful.
PREPARATIONS (Iodophor and ○ Feelings about the surgery.
Betadine) or any other products ○ Fears and concerns.
containing iodine such as dyes. ○ Anger and anxiety.
○ Note: allergic to shellfish do not ○ SPEND TIME LISTENING TO
necessarily have an allergy to THE CLIENT
seafood ○ ANSWER QUESTIONS
○ Latex allergy
■ allergic reactions to Fears of surgery at different
natural rubber latex and developmental stages
synthetic rubber At risk Age Group
for latex allergy, if allergic ● Toddler
to: (LATEX FRUIT ○ Specific Fears
SYNDROME) ■ Fear of
● Bananas separation
● Avocados ○ Nursing Actions
● Kiwi ■ Teach parents to
● Apricots expect
● Peaches regression, e.g. in
● Potatoes toilet training,
● Tomatoes
BSN-3C0
and difficult ○ Response is determined by culture,

separations self concept, degree of self esteem.
● Preschooler ○ Nurse should encourage
○ Specific Fears expressions of concerns about
■ Fear of sexuality.
Mutilation ● Coping resources
○ Nursing Actions ○ Be aware of the responses
■ Allow child to ○ Assist in stress management
play with models ○ Identify sources of support.
of equipment. ● Culture
■ Encourage ○ The nurse should acquire
expression of knowledge of the client’s cultural
feelings(.e.g. and ethnic heritage.
anger) ● Client expectations
● School-age ○ Assess expectations
○ Specific Fears ○ Provide accurate information and
■ Loss of control clarify misconceptions
○ Nursing Actions
■ Explain Preparing clients for surgery
procedures in ● Preoperative preparation of the patient
simple terms. ○ Preoperative history
■ Allow choices ○ Physical examination
when possible. ○ Completed and documented before
● Adolescence the patient arrives in the OR
○ Specific ○ Common tests are:
■ Fears Loss of ■ CBC to check for
independence abnormalities.
being different ■ Electrolytes to assess for
from peers e.g. imbalances.
alterations in ■ PT/PTT( Prothrombin
body image. time ; partial
○ Nursing Actions thromboplastin time) to
■ Involve avoid bleeding problems.
adolescence in ■ Urinalysis
procedures and ○ Blood type & cross match
therapies. ■ If a transfusion is
■ Expect anticipated
resistance. ■ If the patient refuses to
■ Express accept blood transfusions,
understandings of documentation it.
concerns. ■ Example: NO BLOOD
■ Point out TRANSFUSION –
strengths. Jehovah’s Witnesses
○ Chest X-ray
● Self concept ■ to assess patient with
○ Assess and identify personal cardiac or pulmonary
strengths and weaknesses. disease
● Body image ■ for smokers
■ person age 60 and older
BSN-3C0
■ for cancer patients ○ Visual Impairment/Blindness

○ ECG ■ Make some noise as you
■ known suspected heart approach so as not to
disease. startle the patient.
■ 40 years of age or older by ■ Eyeglasses should be
policy permitted to be worn
● If a general
● Nursing interview anesthetic is
○ to make a preoperative assessment. used, glasses
○ to provide emotional support should be sent to
○ teaches how to prepare for – PACU.
postoperative recovery – videotape ● Contact lenses
○ Review the patient’s chart and must be removed
records. before the
○ Biographic information administration of
○ Physical findings a general
○ Special therapy anesthetic,
○ Emotional status because they may
○ Choose an optimal time and place dry on the cornea
without interruptions or become
● Preoperative Visit (O.R Nurse) dislodged.
○ Walk in, sit down, maintain eye ● Informed consent
contact, and introduce yourself. ○ It is an agreement by a client to
○ Explain - purpose accept a course of treatment or
○ Assess - understanding of the procedure after being provided
surgical procedure. complete information The surgeon
○ Orient to the environment of the has the ultimate responsibility for
OR suite and interpret policies and obtaining informed consent
routines ○ The witness signing a consent
○ Review the preoperative document attest only to the
preparations following:
○ Anesthesia provider will visit ■ Identification of the
○ Encourage patient /family to patient or legal substitute
discuss their feelings or anxieties. ■ Voluntary signature,
○ Identify any special needs of the without coercion.
patient. - A pad of paper and pencil ■ Mental state of signatory
- unable to speak or hear. - Ask - (i.e. not coerced, sedated,
wears any type of prosthetic device. or confused) at the time of
○ Preoperative vital signs signing.
○ Elevated temperature (underlying ○ Purposes
infection) - postpone the surgery ■ Understands the nature of
until infection has been treated. the treatment including the
● Patient with individual needs potential complications
○ Language Barrier and disfigurement.
■ Get an interpreter ■ decision was made
■ Hearing without pressure.
Impairment/Deafness ■ is protected against
■ sign language unauthorized procedure.
■ hearing aid
BSN-3C0
SURGEON AND ■ Permission for a lifesaving

HOSPITAL procedure - by telephone,
■ protected against legal fax, or other written
action by a client who communication.
claims that an ■ TELEPHONE – 2 nurses
unauthorized procedure should monitor the call
was performed. and sign the form
○ Circumstances requiring a ● Written preoperative instructions
permit ○ NPO before the surgical procedure
■ Any surgical procedure (“NPO after midnight”) to prevent
where scalpel, scissors, regurgitation or emesis and
suture, hemostats of aspiration of gastric contents.
electrocoagulation may be ○ NPO after 5 am:
used. ■ Can eat gelatin desert at
■ Entrance into a body 4:30am
cavity- thoracic ■ Can brush his teeth at 5am
parecentesis, (do not swallow water)
bronchoscopy ○ NOTE: CAN NOT SMOKE AT 7:
■ Use of general anesthesia, 00 AM
local infiltration, regional ■ Smoking increases
block production of gastric HCl,
○ Validation of consent which can increase the
If the patient is risk of aspiration in an
■ Legal age -18 y/o ,if anesthesized client.
minor, a parent or legal ○ Shower with antibacterial soap to
guardian should sign. cleanse the skin
■ An emancipated minor ○ The physician may want the patient
(not subject to parental to take any essential oral
control), married, or medications that she/he normally
independently earning a takes, with a minimal fluid intake.
living he/she may sign. ○ Jewelry and valuables should be
(not in the Philippines) left at home to ensure safekeeping
■ Unconscious, a ○ Nail polish and acrylic nails should
responsible relative or be removed - inhibit contact
guardian should sign. between these devices and the
■ Illiterate, he/she may sign vascular bed. – TO ASSESS
it with an X, after which HYPOXIA
the witness writes ○ Uncover at least one finger nail
“Patient’s mark”. ○ Patients should be given other
■ Mentally incompetent, the instructions about what is expected
legal guardian should sign. ■ When to arrive at the
■ Mentally incapacitated by surgical facility.
alcohol or other chemical ■ Where to wait
substance the spouse or ■ Where the patient will be
responsible relative of taken after the surgical
legal age may sign procedure.
○ Consent in Emergency ■ Who will take the patient
Situations. home if the procedure,
medication or anesthesia
BSN-3C0
renders the patient ■ Muscle pumping exercises

incapable of driving. ● Contract and
● Preoperative teaching relax calf and
○ Implementing the Teaching thigh muscles at
Program least 10 times
■ Begin at the patient’s level consecutively.
of understanding ■ Leg exercises
■ Include family members ● Moving the legs
and significant others in improve
teaching process. circulation and
■ Use of Audiovisual aids if muscle tone.
available ● This is taught to
○ Instruct patient - postoperative the client who is
activities. at risk for
■ Diaphragmatic developing
(Abdominal) breathing thrombophlebitis
● To promote lung (inflammation of
expansion and the vein), which
ventilation and is associated with
enhance blood the formation of
oxygenation. blood clots.
● Patient - lie on
■ Incentive Spirometers back.
● Preoperatively - ● Bend his knee
measures deep and raise his
breaths (inspired foothold it a few
air) while seconds
exerting ● Extend the leg,
maximum effort. and lower it to
● Postoperatively – the bed.
used 10 -12 times ● Repeat above
an hour. about 5 X with
■ Coughing one leg and then
● Promotes the with the other.
removal of chest (Repeat the set 5
secretions to X every 3-5
prevent hours).
complications ● Then have the
(pneumonia, patient lie on
obstruction) side; exercise the
■ Turning legs by
● Stimulates pretending to
circulation, pedal a bicycle.
encourages deep ■ Ankle and foot exercises
breathing, and ● Rotate both
relieves pressure ankles by making
areas. complete circles,
● Turn every 2 first to the right
hours as ordered then to the left.
BSN-3C0
●Repeat 5 X and ○ Anxiolytic agents (e.g. alprazolam

then relax. [Xanax]) - to relieve anxiety.
● With feet ● Eliminating wrong site and wrong procedure
together, point surgery
toes toward the ○ Site has been marked by the
head and then to surgeon.
the foot of the ○ Indelible ink is used to mark left
bed. 4.Repeat this and right distinction multiple
pumping action structures (e.g.fingers), and levels
10 X, and then of the spine.
relax. ○ If the patient refuses a mark,
■ Pain management document and note on the
● Physical preparation procedure checklist
○ Preoperative diet:
■ High CHON, sufficient
CHO, fats and vitamins
Preparing the patient on the day of the surgery

Early morning care
1. Awaken the patient one hour before
preoperative medications will be given to
him.
2. Morning bath, mouth wash.
○ Reduction of Risks for Surgical
3. Provide a clean hospital gown. Sanitary
Wound Infection
napkin for menstruating patients
● Bowel cleansing
4. Remove hairpins, braid long hair, cover hair
○ 3 Purposes
with cap. Remove wigs or hair pieces.
■ Reduces the risk of
5. Remove dentures - to prevent aspiration.
contamination from fecal
Dentures allowed in local anesthesia and for
matter during operation.
some plastic surgery procedures to retain
■ Prevents postoperative
facial contours
distention until normal
6. Remove colored nail polish
bowel functions return
○ to permit observation/access to the
■ Prevents constipation and
nail bed during the procedure.
straining in the
○ PULSE OXIMETER at least one
postoperative period.
fingernail should be uncovered.
● Recheck
7. Removed jewelry for safekeeping.
potassium levels
○ If wedding ring cannot be removed,
after bowel
it is taped loosely or tied securely
preparation
to prevent loss.
● Promotion of Rest and Comfort
○ The patient may be permitted to
○ Rest is essential for normal healing
keep a religious symbol
○ Sedative – Hypnotics
8. Removed all removal prostheses
(diazepam[Valium]) to promote
sleep
BSN-3C0
○ There are chances that patients are ● Relieve apprehension and anxiety
permitted to wear eyeglasses or ● Prevent autonomic reflex response
hearing aids in the OR ● Decrease respiratory and gastrointestinal
○ Antiembolic stockings or elastic secretions
bandages Preoperative medications
● Oral medications – given 60-90 minutes
(with a minimal amount of water)before the
patient goes to the OR.
● IM and SC injections- should be given 30-
60 minutes before arrival at the
OR(minimally 20 min)
● IV medications - are usually administered
to the patient after arrival in the preoperative
● Antiembolic stockings or elastic bandages
holding area or OR.
may be ordered for the lower extremities to
● Anticholinergics-reduces respiratory tract
prevent embolic phenomena.
secretions and prevents severe reflex
● The stockings are applied slowing of the heart during anesthesia.
○ before abdominal or pelvic ○ Given less than an hour before the
procedures
patient’s trip to the OR.
○ if patient have varicosities, are
○ Examples: - Atropine Sulfate -
prone to thrombus formation Scopolamine
○ If patient have a history of emboli
Frequently Used Preoperative Medications
○ for some geriatric patients
● Narcotic analgesics (Demerol & Morphine
○ for long procedures.
Sulfate)
9. Take baseline VS before preoperative ● Sedatives
medication. ● Anticholinergic (Atrophine Sulfate)
10. Check hospital patient ID wristband - ● Histamine
barcode ● H2-receptor antagonist
11. Check for special orders- enema, GI tube ● Antacids
insertion, IV line. ● Antiemetics
12. Check NPO
13. Have the client void before preoperative
15. Administer pre-op medication as ordered
medication to prevent over distention of the
● Warn the client to expect
bladder or incontinence during drowsiness and dry mouth
unconsciousness ● NOTE: HAVE THE CLIENT
14. Continue to support emotionally VOID FIRST BEFORE
ADMINISTERING IT.
Medication ● Consent form needs to be signed
● Antibiotic is given 1 hour preoperatively
before the administration of
● If cultures or specimens are obtained during
preoperative medications.
the surgical procedure, a notation should be
● Elevate side rails & provide quiet
made on the pathology specimen sheet to environment
indicate antibiotic use.
Purposes of Preoperative Medications
Transporting patient to the OR
● Provide analgesia ● Maintain comfort and safety of the patient.
● Prevent nausea and vomiting ● Accompany OR attendants to the patient’s
● Promote sedation and amnesia bedside for introduction and proper
● Decrease anesthesia requirements
identification.
● Facilitate the induction of anesthesia
BSN-3C0
● Assist in transferring the patient from bed to

stretcher (unless bed goes to the OR floor).
● Complete chart
INTRAOPERATIVE PHASE
Surgical terminologies
Only by knowing the terms can the nurse prepare the
proper instruments and supplies for a particular
procedure
● Coordinate - arrival of the patient in the OR
Prefix Meaning
Preoperative holding area A or An Without or not
Ante Before or forward
Anti Against or opposite
Hemi Half
Hyper Above or over or

excessive
Retro Behind or posterior to

Surgical waiting area
Supra above
Root Meaning
Arthro Joint
Blepharo Eyelids
Cardio Heart
Cholecys Gallbladder
Operating room Colon Colon
Cranio Brain
Suffix Meaning
Ectomy Removal or surgical

incision of
BSN-3C0
Itis Inflammation
Operating room team members
Lith Stone, calculus ● Sterile or scrubbed
○ Operating surgeon
Centesis To puncture or aspirate ○ Assistant(s) to the surgeon
○ Scrub nurse(s)
Lysis Freeing of
● Unsterile or unscrubbed
Rrhapy Repair ○ Anesthesiologist
○ Circulating nurse
Oscopy Examination of an ○ pathologist
organ by viewing
Ostomy Creation of an artificial/

new opening through
the wall of an organ
Otomy Cutting into an organ/

tissue
Pexy Fix/ suture in place
Plasty Restoration of a lost

part/ piece of tissue; ● Robotic surgery, or robot-assisted
reconstruction surgery, allows doctors to perform many
types of complex procedures with more
Common abbreviations precision, flexibility and control than is
possible with conventional techniques.
AAA Abdominal aortic ○ Robotic surgery is usually
aneurysm, “triple A”
associated with minimally invasive
AKA Above knee amputation surgery — procedures performed
through tiny incisions.
BKA Below knee amputation ● The da Vinci Surgical System consists of an
ergonomic surgeon console, a patient-side
APR Abdominal perineal cart with four interactive arms, a high-
resection
performance vision system and proprietary
APR Anterior posterior repair
Sterile team
AXR Abdominal x-ray ● Surgeon
○ Performs the surgical procedure
Surgical team ○ Responsible for the preoperative
diagnosis and care.
○ Informs all team members of what
are needed in the procedure
○ Responsible for the postoperative
management of care.
● First assist or SROD
● Scrub nurse
● Surgical technologist
Non-sterile team
● Anesthesiologist
BSN-3C0
○ A medical doctor trained to ● The tip of the ESU pencil becomes hot and
administer anesthesia and manage could burn the patient or a team member →
the medical care of patients before, attach to a container (holder/holster).
during, and after surgery ● The ESU tip should not be cleaned with a
○ Determines when to position the scalpel blade. The char should not be
patient permitted to fall into the patient
○ Gives the go signal when to ● Prepare sutures in the sequence in which the
transfer the patient to the post- surgeon will use them
anesthesia care unit ● Place a ligature in the surgeon’s hand.
● Circulating nurse ● Prepare 3 working needles in advance
○ Coordinates care of the patient with ● If the instrument towel on the sterile field
the surgeon, scrub nurse/tech, and becomes bloody, do not remove it but cover
anesthesia provider. it with a fresh, sterile towel.
○ Provides assistance to the surgical ● Specimen designated as left or right be kept
team throughout the surgical separately in clearly marked containers.
procedure. ● Specimen - hand it in a basin or appropriate
● Pathologist container; never place it on a surgical
○ Consulted by the surgeon during or sponge.
after surgery for a diagnosis by ● Tell exactly what the specimen is, or if the
gross or microscopic examination specimen is to have special testing (e.g.
of any tissue removed. frozen section – NO FORMALIN
SOLUTION ADDED).
Duties and responsibilities of a scrub nurse ● Any counted sponge should be unfolded and
● Preparation dropped into the sponge bucket for counting
○ Surgeon’s preference card ● Counting
○ Room setup
○ Establish baseline counts
○ Establish sterile ground/field
—TIME OUT—
● A brief pause before starting a significant procedure
● Verify:
○ Right procedure
○ Right patient
○ Right side
● “Time Out” for prevention of wrong site injury
○ Correct patient?
○ Correct position?
○ Correct site? Correct procedure? Duties and responsibilities of a circulating nurse
○ Correct equipment? ● Greet and identify the patient (pre-op
○ Correct images? (scans or radiographs in holding area) introduce self, and identify
proper orientation) title and role.
○ Correct implants? (as appropriate)
● Check - CHART
—CUTTING TIME—
● The surgical time, or cut time, is from the first ● Check the wristband
incision until the end of the surgery. ● Offer blanket - patient
○ First knife - initial skin scalpel is ● Room setup
contaminated. ● Clear path for emergency
● Do not remove towel clip on a drape
equipment.
○ points are contaminated and the drape
now has holes.
○ All necessary positioning
aids are available
BSN-3C0
● Position - Anesthesiologist ●The person who

● Check the OR bed . assembles and
● Make sure lights are in working wraps items for
order. sterilization will
○ Plan setup for position of count them in
instrument table in standardized
relation to surgical field. multiple units.
● Cap – cover hair ■ Baseline count during
● Transfer - OR bed, safety belt applied over setup for the surgical
the thighs 2-3 inches above the patient’s procedure
knees ● The scrub person
● Arms on arm boards and the
● Preparation circulating nurse
○ Surgeon’s preference card together count all
○ Room setup items before the
● Assist the anesthesia provider surgical
○ Assist with positioning during procedure.
regional anesthesia. ■ Closing counts(First
○ Stand at patient’s side during Closing count) Counts are
induction of general anesthesia taken in 3 areas
○ Help anesthesia personnel with IV ● Field Count
or intubation if needed. Prepare to ● Table Count
apply cricoid pressure as needed ● Floor Count
during intubation ■ Final count (Second
● Assist scrub person to move sterile table closing count) during
adjacent to surgical field. subcuticular or skin
● Attach cords, cables, and tubings to closure.
appropriate devices. ■ Purpose of Counting
● Place suction canister in direct view of ● To account for all
anesthesia provider. surgical and
● Provide standing platforms/steps as needed nonsurgical
● Monitor: items.
○ Vital Signs ● To ensure that the
○ I and O – urine output patient is not
● Anticipates injured as a result
○ Sequence of the procedure of a retained
○ Needs of the sterile team foreign body.
○ Breaches of sterile technique ● To promote an
○ Hemostatic needs optimal
○ Radiation protection for sterile perioperative
team patient care
● Counting outcome.
○ A counting procedure is a method ○ Incase of incorrect count
of accounting for items put on a ■ The surgeon is informed
sterile table for use during the immediately.
surgical procedure. ■ The entire count is
○ Counting procedures: repeated.
■ Initial count when the tray ■ The circulating nurse
is assembled. searches the trash
BSN-3C0
receptacles, under the ● Cultures are obtained under sterile

furniture, on the floor, in condition. The tips of swabs must not be
the laundry hamper, and contaminated by any other source.
throughout the room. ● Smears and fluids should be taken to the
■ The scrub person searches laboratory as soon as possible - placed on
the drapes and under items glass slides - evacuation tubes.
on the table and Mayo ● Stones are placed in dry container so they
stand. will not dissolve.
■ The surgeon searches the ● A foreign body may be given to the police,
surgical field and wound. surgeon or patient depending on its legal
■ Immediate supervisor implications, policy or surgeon’s wishes.
notified. ● Amputated extremities (wrapped in plastic)
■ Radiograph film be taken SENT to the laboratory.
before the patient leaves ● Avoid placing the amputated limb on the
the OR. patient’s field of vision to prevent emotional
■ Incident report and distress.
document on the OR ● Give hand - off report to RN in post
record what happened procedural area.
○ Medical error ○ Patient name and age
■ When a surgery is ○ Allergies and sensitivities
completed, the team ○ Current procedure and type of
waves the SURGICAL anesthesia
WAND around the patient ○ Location of incisions, dressing, and
and surrounding areas. drains
This process ensures the ○ Pertinent comorbidity
surgical item counts are ○ Special needs(language, vision,
correct by both manual hearing)
counting and ○ Location of family or significant
radiofrequency scanning. other
This 15 to 30 seconds of ○ Any procedure specific information
scanning at the end of all
surgical procedures Asepsis
provides safe patient care ● Asepsis - absence of microorganisms that
you can count on. cause disease, freedom from infection;
exclusion of microorganisms.
Reminders for the Circulating Nurse ● Aseptic technique – methods by which
● Prepare and label specimens for transport to contamination with microorganism is
the laboratory. prevented.
○ Histopathology - Saline or a ● Sterile technique- methods by which
solution of aqueous of contamination with microorganisms is
formaldehyde (10% formalin) is prevented to maintain sterility
commonly used as a fixative. THROUGHOUT THE SURGICAL
● Fresh tissue and frozen section tissue PROCEDURE.
examination are not place in preservative
solution Infection
● Cultures should be refrigerated or sent to the ● Community-acquired - Infectious disease
laboratory immediately. process that developed or was incubating
BEFORE patient entered the health care
facility.
BSN-3C0
● Cross infection - Infection contracted by a and should be changed

patient from another patient or staff after caring for each
member, and/or contracted by a staff patient.
member from a patient. ■ HANDLE MASK BY
● Caused by: THE STRING.
○ unsterilized medical equipment ■ Coughing and sneezing
○ bacteria from coughing and explodes droplets into the
sneezing - DROPLET environment, and
○ the transmission of viruses through therefore persons with a
human contact respiratory infection
○ touching contaminated objects should NOT be permitted
○ dirty bedding in the OR suite.
● Sources of contamination ○ Human error
○ SKIN ■ Failure to follow the
■ Sebaceous (oil) and principles and applications
sudoriferous (sweat) of sterile and aseptic
glands techniques places the
■ Shedders are individuals patient and personnel at
who shed contaminated risk.
skin cells in the ● Modes of contamination
environment. ○ Direct Contact between a non
● Head sterile and sterile surface
● Neck ■ The surgeon’s back
● Axilla touching sterile wash
● Hands basin.
● groin, perineum, ■ Bacterial seepage through
legs and feet moist linen.
○ SCRUB’S TEAM HAIR AND ■ A puncture in a sterile
PATIENT’S HAIR glove.
■ all hair must be carefully ■ Possible contact by the
tucked under a cap. circulating nurse with any
■ all hair must be removed sterile item passed to the
from operative site scrub nurse
(mechanical irritant in ○ Anesthesiologist touching the top
wound healing) of the anesthesia screen
○ Infected fluids from the patient
wetting sterile gloves or
instruments.
○ Surgeon touching the exposed skin
of the patient
Sterility
● Sterile persons are gowned and gloved.
● Gowns are considered sterile only from the
chest to the level of the sterile field in front,
○ Nasopharynx
and from 2 inches above the elbows to the
■ Masks are worn in all
cuffs on the sleeves.
restricted areas to cover
the nose and the mouth
BSN-3C0
-All articles must be

properly wrapped. -
Rubber tubing should not
be kinked
-Articles must be free
from oil or grease
-Glass jars/containers
placed on their sides with
lids remove
-Basins and any solid
containers are tilted.
● Sterile persons keep their hands in sight at Advantages
all times and at or above waist level or the •Fast – 20 min. ( most
level of the sterile field. common)
● Hands are kept away from the face •Economical – uses only
● The hands are never folded under the arms water and electricity.
● Tables are sterile only at table level.
○ Tables are sterile at table level, OR
personnel must adhere to the
following:
○ Only the top of a sterile, draped
table is considered sterile.
○ Edges and sides of the draped
extending below table level are
considered contaminated.
● The sterile field is created as close as
possible to the time of use.
● Sterile persons keep well within the sterile
area.
○ Sterile persons pass each other ● Chemical sterilization
back to back at a 360 degree turn. ○ Prolong gas exposure -
○ Sterile persons turn their backs to occupational carcinogen,
an unsterile person or area when causing leukemia
passing. ○ For heat or moisture
● Disinfection – the chemical or physical sensitive items PLASTICS
process of destroying all pathogenic Items – dry (EO + water =
microorganism except the spore bearing ethylene glycol (toxic) For
ones. It is used for inanimate objects but not packaged, pre sterilized
on tissue. items
● Sterilization – the process by which all
pathogenic and non pathogenic
microorganisms including spores, are killed.
● Saturated steam under pressure
○ Autoclaving
■ Hospital supplies -
Pressurized steam
penetrates the supplies
better.
BSN-3C0
●Cold sterilization department and hospital

○ is used when gas or steam personnel.
sterilization is not ■ Examples
possible, but sterilization ● Operating room
is required. supervisor’s
○ Cidex is a liquid chemical office.
sterilant and a high level ● Locker rooms.
disinfectant: ● Surgical
■ Materials must be scheduling office
kept in the ○ Semi restricted
solution for 10 ■ attire consist of scrub suit
hours to and caps to enter in this
eliminate all area.
microorganisms. ■ This area includes the
■ Disinfection – all support areas of the
pathogens surgical suite
destroyed, except ■ Examples:
sporeformers ● Clean cores and
● 10 sub-sterile rooms
minutes- as designated by
disinfect the facility
ion - ● Corridors outside
● 20 the operating
minutes- room
high ● Storage areas for
level clean and sterile
disinfect supplies
ion ○ Restricted zone
■ Catheters, ■ scrub suits, caps, shoe
delicate covers and masks are
instruments, worn.
endoscopic ■ Areas where unwrapped
instruments sterile supplies are
Surgical Environment provided to carry out
procedures are carried out
are included in this
section.
■ Examples:
● Procedure room
● Operating room
● Three (3) zones ● Scrub area
○ Unrestricted ● Personal Protective Equipment (PPE)
■ street clothes are allowed ○ Apron
■ area is separated by doors ■ Decontamination –
from the main hospital decontamination of
corridor. instruments
■ area allows access for ■ Fluid proof – worn during
communication with surgeries when excessive
bleeding is expected
BSN-3C0
● C-arm machine is a piece of medical ● Gowning

imaging equipment that operates on the
basic principle of X-ray technology. This
fluoroscopy device is used to visualize
patients' anatomy in the operating room
during surgery.
○ Lead apron – worn during surgeries
requiring radioactive materials
● Serving gloves
● Surgical scrub
○ 2-5 minutes
● Surgery in progress
● Removing gown after surgery
○ The gown is removed before the
gloves.
○ In pulling gown off arms be sure
that gown sleeve is TURNED
INSIDE OUT to prevent
contamination of scrub attire.
● Open method of gloving technique
BSN-3C0
Anesthesia
Surgical Loss of Regular Position
● Before giving ANESTHESIA the Anesthesia reflexes; respiratio patient
anesthesiologist must assess the condition of Relaxation Depressio n and prep
the patient especially his vital signs through n of vital Contracte skin only
the cardioscope. functions d pupils when
● General anesthesia Reflexes anesthesio
○ Produce loss of consciousness disappear logist
Muscle indicates
○ Result is an immobile, quiet patient
relax this stage
who does not recall the procedure. Auditory is reached
● Propofol sensation
○ Milk of amnesia loss
○ Michael jackson drug
Danger Respirator Not Prepare
stage y failure, breathing for
Vital Possible Little or cardiopul
functions cardiac no pulse monary
too arrest or resuscitati
depressed heartbeat on
○ Stages of general anesthesia

From To Patient’s Nursing
reaction actions
Analgesia Loss of Drowsy, Close

Induction conscious dizzy suite doors
Stage ness Keep
● General endotracheal anesthesia
room quiet
and stand ○ Sellick's Maneuver of Cricoid
by to Pressure (to minimize aspiration)
assist ○ Cricoid pressure to control
regurgitation of stomach contents
Excitement Relaxatio May be Secure during induction of anesthesia.
/ Delirium, n excited patient
Loss of with properly
consciousn irregular remain at
ess breathing the side of
and the patient
movemen of the
ts of the patient
extremitie quietly but
s. ready to
Susceptib assist
le to anesthesio
external logist as
stimuli needed
(e.g.
Noise)
BSN-3C0
● Halothane (Flouthane)
○ Pleasant sweet, non-pungent odor
which made it an agent of choice
for pediatric anesthesia.
Cardiovascular and respiratory
depressant
● Isoflurane (Forane) ● Spinal or subarachnoid block
○ Administration-inhalation ○ The solution is injected into the
Induction and particularly recovery subarachnoid space, desensitization
are rapid(rapid excretion of spinal nerve roots
● Bronchoscopy ■ Pontocaine- main
○ Topical application - The anesthetic anesthetic agent
agent is applied directly to the ■ Dextrose 10% in water
mucosal membrane or into an open ■ Ephedrine Vasoconstrictor
wound. It blocks the peripheral Prolongs the effect of
nerves around spinal anesthesia by
causing constriction of the
blood vessel
○ The sitting position is preferable in
the obese whereas the lateral is
better for uncooperative or sedated
patients
● Simple local infiltration

○ The agent is injected into the tissue
around the incisional area.
● Advantages
○ A local infiltration anesthesia can
○ Patient is conscious
last up to 3 hours.
○ Easy administration
○ Example: xylocaine (with
○ Non irritating to
epinephrine
respiratory passages
vasoconstrictor,prolongs local
○ Muscular relaxation
anesthesia)
○ No effect on childbirth
○ Contraindicated – when used on the
○ Minimal toxicity
fingers,toes & penis may cause
○ For patient who has eaten
ischemia/necrosis from
and needs emergency
vasoconstriction)
surgery
BSN-3C0
○ For alcoholics extremities from dangling over the

● Disadvantages side of the bed
○ Psychic strain ○ TO PREVENT NERVE DAMAGE
○ Conscious
○ No control of the drug Skin preparation
once injected ● ABDOMINAL SX. – clean the umbilicus
○ Danger of trauma and ● Shave – follow the hair growth
infection due to poor ● Chest and breast operations
technique
○ Respiratory and
circulatory depressant
○ ↓ BP
○ N and V
○ Headache - loss of spinal
fluid
● Complications of spinal anesthesia ● Abdominal and pelvic operations
During surgery
○ Hypotension- paralysis of
the vasomotor nerve
○ Respiratory failure-
anesthesia reaches the T3
level (diaphragm muscle)
○ Nausea and vomiting- due
to vagal
stimulation,traction placed
on various organs.
○ Cardiac arrest- due to
cerebrovascular collapse
and interference in venous ● Stoma
return ○ Intestinal stoma are contaminated
○ Urinary retention- may with fecal material and intestinal
need to be catheterised. florae.
○ Infection ○ The stoma should be isolated with a
○ CVA- due to hypotension clear plastic adhesive dressing and
○ Spinal Headache- loss of surgical dressing and prepped last.
CSF through the dural ● Other contaminated areas
hole ■ Draining sinuses
■ Skin ulcers
Positioning ■ Vagina
● POSITIONING is putting the patient in ■ Anus
proper body alignment to expose the ○ In all these, the general rule of
operative area. scrubbing the most contaminated
● Objectives: areas last with separate sponge
○ Optimize surgical site exposure for applies.
the surgeon
○ Facilitate physiologic monitoring
by the anesthesia provider
○ Promote safety and security for the
patient Prevent the patient’s
BSN-3C0
● Rectoperineal and vaginal area Phase I

● is the level of care in which close
monitoring is required and basic life-
sustaining needs are of the highest priority.
● Nurses - conduct assessments, engage in
monitoring, and intervene to maintain
airway patency and hemodynamic stability
as well as manage pain, fluids, thermal
comfort, and other aspects of patient care.
● Phase I emphasizes ensuring the patient's
full recovery from anesthesia and return of
Surgical incisions vital signs to near baseline.
Importance ● The primary goal is to facilitate the
-Circulating Nurse transition of the patient from this level of
● To know the extent of area to be prepared care to Phase II
● To prepare the gadgets for positioning
-Scrub Nurse Phase II
● To serve as a guide for draping the operative ● Clinical care and strategic planning are
site aimed at preparing the patient for return
● To have the correct instruments and supplies home or for transition to extended care for
available further observation.
● To be able to assist the surgeon effectively ● In this phase, the patient has a
and efficiently ○ stable airway with good ventilatory
status on room air
POST OPERATIVE PHASE ○ satisfactory pain management and
Post-anesthesia Care Unit control of postoperative nausea and
● The PACU is a critical care unit where the vomiting
patient's vital signs are closely observed, ○ appropriate ambulatory ability for
pain management begins, and fluids are procedure and baseline, among
given. The nursing staff is skilled in other things
recognizing and managing problems in ● Phase II recovery focuses on preparing
patients after receiving anesthesia. The patients for hospital discharge, including
PACU is under the direction of the education regarding the surgeon's
Department of Anesthesiology. postoperative instructions and any
prescribed discharge medications.
Post operative Care ● Goal: Preparing patient for transfer to Phase
● Depends on the type of surgery and health III, home, extended care facility
history, pain management and wound care.
● 3 phases Phase III
○ Phase I: Immediate Recovery Phase ● Extended care /observation unit - Step down
(intensive care) unit, sit up unit or progressive care unit
○ Phase II: Intermediate, Less Goal: preparing patient for discharge, self
intensive care (preparing for self care
care or transfer) ● Note: In many hospitals Phase 2 and phase 3
○ Phase III: Extended units are combined
care/Observation Unit - preparing
for D/C
BSN-3C0
● Verbal report
Preparing for transfer of Patient ○ Medications given preoperatively
● Do not move quickly patient from one and intraoperatively, as well as
position to the other (lithotomy→ those taken by prescription or self
supine/lateral→ Orthostatic hypotension medication.
● Ex. Status post: D and C, T.U.R.P. ○ Medical history, including previous
● Orthostatic hypotension, also called postural surgical procedures.
hypotension, is defined as a sudden drop in ○ Allergies and responses to
blood pressure caused by a change in allergens, substance sensitivity.
posture ○ Positioning on the OR bed and
devices attached to the skin.
○ Complications during the surgical
procedure
○ Intake and output, including IV
fluids and blood.
○ Location of the waiting family or
significant others
● To prevent skin shearing (ELDERLY)
○ Special considerations.
○ With two people, one at each side
○ Sensory and/or physical
using a draw sheet, one person at
impairments; eyewear, hearing
the head, and one person at the feet
aids, dentures, or other personal
property brought to the OR is
returned to the patient when the
level of consciousness is
appropriate.
○ Language barrier and level of
understanding
○ Use of tobacco, alcohol and/or
addictive drugs
○ Orders such as “no code”, do not
resuscitate (DNR),”or do not
attempt resuscitation.
● A concise verbal report of the anesthesia
● The basic responsibilities of PACU staff
provider and /or circulating nurse to the
○ airway management and oxygen
PACU nurse includes the following
administration for patients who
○ Name and age of the patient
have undergone general anesthesia
○ Type of surgical procedure and the
○ monitoring vital signs (heart rate,
name of the surgeon.
blood pressure, temperature, and
○ Type of anesthesia and name of
respiratory rate)
anesthesia provider.
○ managing postoperative pain
○ Vital signs (baseline, preoperative,
○ treating postoperative nausea and
and intraoperative) including
vomiting
current body temperature.
○ treating postanesthetic shivering
○ Types and locations of drains,
○ monitoring surgical sites for
packing and dressing.
excessive bleeding, mucopurulent
○ Preoperative level of consciousness
discharge, swelling, hematomas,
and current status.
wound healing, and infection
● Initial Assessment
○ Airway patency
BSN-3C0
○ Effectiveness of respiration
○ Presence of artificial airways
○ Mechanical ventilation, or
supplemental oxygen
○ Circulatory status
○ Vital signs
○ Wound condition, including
dressings and drains
○ Fluid balance, including IV fluids, ● Administer oxygen as ordered
output from catheters and drains ● Assess rate, depth, & quality of respirations
and ability to void ● Check vital signs every 15mins until stable,
○ Level of consciousness and pain then, every 30 mins
○ Assess for & maintain patent ● Note level of consciousness; reorient client
airway. to time, place, & situation
■ Position unconscious & ● Assess color & temperature of skin, color of
conscious client on side nail beds,& lips
(unless contraindicated) or ● Monitor IV infusions
on back with head to side ● Check all drainage tubes & connect to
& chin extended forward suction or gravity drainage
■ Position patient that he is ● Encourage client to cough & deep breath
not lying on and after airway is removed – helps mobilize
obstructing secretions and prevents atelectasis.
drains/drainage tubes. ○ Coughing is
○ Check for presence or absence of CONTRAINDICATED in patients
gag reflex who have:
○ Maintain artificial airway in place ■ Head injury – inc ICP
until gag & swallow reflex have ■ Eye surgery – inc IOP
returned ■ Plastic sx –inc. tension on
○ Watch out for delicate tissues
HYPOPHARYNGEAL ● Assess dressing for intactness, drainage &
OBSTRUCTION S/S - choking; hemorrhage
noisy and irregular respirations; ○ First dressing is changed by the
decreased oxygen saturation scores; physician
and within minutes, a blue, dusky ○ Wound drainage
color (cyanosis) of the skin ■ bright red (sanguineous)
■ Tilting the head back to ■ pinkish (serosanguineous)
stretch the anterior neck ■ serous ( straw colored or
structure lifts the base of clear)
the tongue off the
posterior pharyngeal wall.
■ OROPHARYNGEAL
AIRWAY - prevents the
tongue to fall backward
and obstruct passages
BSN-3C0
● Monitor & maintain client’s temperature; ● Provide wound care

May need extra blankets to keep patient ○ Management of wound drains
comfortable. ○ Changing the dressing
● If spinal anesthesia is used, maintain flat ○ First post operative dressing is
position & check for sensation and usually changed by the surgeon or
movement in lower extremities surgical resident
○ Spinal headaches are caused by ● Post operation exercises
leakage of spinal fluid through a ○ Coughing is necessary to clear
puncture hole in the tough secrets that may accumulate in your
membrane (dura mater) that lungs.
surrounds the spinal cord. This ○ By breathing deep lungs as fully as
leakage decreases the pressure possible for any secretions to come
exerted by the spinal fluid on the out more easily
brain and spinal cord, which leads ● Postop complications
to a headache ○ Shock
○ Hemorrhage
○ Deep Vein Thrombosis
○ Pulmonary Embolism
○ Pulmonary Complications :
Atelectasis, Aspiration, Pneumonia
○ Intestinal Obstruction
○ Wound Infections
○ Wound Dehiscence
○ Urinary Retention
○ Psychological Disturbances -
Depression - Delirium
Complications
Shock
Transfer Responsibilities
● response of the body to a decrease in the
1. Endorse condition; point out significant
circulating blood volume - tissue hypoxia
needs
BP=blood loss (if blood loss500 ml, blood
2. Assist in the transfer
transfusion is indicated.
3. Orient to room, nurses, call light, and
● Clinical Manifestations
therapeutic devices
○ Anxiety or agitation
Care in surgical floor
○ Cool, clammy skin
● Maintain good respiratory status
○ Confusion
● Monitor cardiovascular status
○ Decreased or no urine output
● Promote adequate fluid & electrolyte
○ General weakness
balance
○ Pale skin color (pallor)
● Promote optimum nutrition Clear liquid diet
○ Rapid breathing
● Monitor & promote return of urinary
○ Sweating ,moist skin
function
○ UNCONSCIOUSNESS
● Promote bowel elimination
● Nursing Considerations
○ Early ambulation
○ Assess wound dressing
○ Improved dietary intake
○ Report excessive drainage or
○ Stool softener (if prescribed)
bleeding
○ Pain management –analgesics
○ Monitor vital signs every 15 min
○ Provide additional comfort
until stable
measures
○ Note early changes in vital signs
BSN-3C0
○ Report tachycardia, tachypnea,

hypotension
○ Monitor input and output
○ Keep intravenous fluid rate on
schedule
○ Assess respirations before giving
opioids
○ Fluid or blood replacement-
TIMELY REPLACEMENT
○ Vasopressors (drugs to raise blood
pressure as ordered)
○ Additional surgery may be needed ● Clinical manifestations
to control bleeding ○ Apprehension
○ Place in a shock position ○ Restlessness
■ Flat on back, legs elevated ○ Thirst, cold, clammy, moist, pale
at 20 degree angle, knees skin
kept straight ○ Deep, rapid RR, low body
temperature
○ Low CO(cardiac output)
○ Decreased BP, low hemoglobin
● Nursing considerations
○ Monitor vital signs
○ Replace blood- blood transfusion,
IV fluids
○ Use pressure dressing
○ Give vitamin K (aquamephyton),
Hemostan
Hemorrhage ○ Ligation of bleeders
● Copious escape of blood from the blood
vessels. Atelectasis
● Capillary- slow, generalized oozing
● Venous- dark in color and bubble out
● Arterial- spurts and is bright red in color
● Classification of hemorrhage
○ Primary – hemorrhage during
surgery
○ Intermediate – hemorrhage within
24 hours after primary bleeding has
been controlled.
○ Secondary - hemorrhage that ● Collapse of lung tissue affecting part or all
occurs at any time after the first of one lung → incomplete expansion of the
post op day. - If a suture slips lung (experienced 2nd day postop)
because a blood vessel was not ● Clinical manifestations
securely tied, it becomes infected ○ Dyspnea, cyanosis, cough,
or eroded by a drainage tube.
○ Elevated temperature
○ Pain on affected side
○ Tachycardia
BSN-3C0
○ Reinforce deep breathing,

coughing, turning exercises
○ Suctioning, Postural drainage,
Antibiotics as ordered
○ Change position at least every 2
hours
○ Rest , incentive spirometry
○ Administer oxygen as ordered
Paralytic ileus
● Obstruction of the intestine due to paralysis
of the intestinal muscles. The paralysis does ● Clinical manifestations
not need to be complete to cause ileus, but ○ Dyspnea, cyanosis,
the intestinal muscles must be so inactive ○ cough, restlessness
that it prevents the passage of food and leads ○ ABG-low Oxygen, high CO2
to a functional blockage of the intestine ● Diagnostic tests
● Peristalsis stops completely – gas builds up ○ Chest x-ray
● Clinical manifestations ■ Watermark’s sign- an
○ Absent bowel sounds abrupt tapering or
○ Cramping pain narrowing of a vessel
○ No flatus or stool caused by pulmonary
○ Distension embolism
○ Nasogastric suctioning
○ Use of decompression tubes
○ Give IV fluids
○ ABG- respiratory alkalosis

○ ECG – to detect dysrhythmias
○ Ventilation and perfusion scan
Pulmonary embolism ○ Pulmonary angiography –
● An occlusion of the pulmonary vasculature confirmatory test. Outlines the
causing blood flow obstruction. It is a pulmonary vasculature to show the
problem with perfusion not ventilation.The location of emboli.
blockage can be life threatening. ● Nursing considerations
● Experienced 2nd day post op ○ give oxygen
● Most common cause - prolonged bed rest. ○ anticoagulants (heparin) to be given
Blood pools or collects in the veins and ○ IV fluids to be infused
blood clots can form.
Wound infection
● experienced 3-5 days postop
● Causes
BSN-3C0
○
Staphylococcus aureus, E.coli, ● Risks
Pseudomonas aerogenosa ○ Poor wound healing (e.g., poor
● Clinical manifestations nutritional status, infection, or
○ Elevated WBC and temperature, obesity) is at risk for dehiscence.
chills ○ Obesity - constant strain placed on
○ Pus or other discharge on the their wounds and the poor healing
wound-Positive cultures qualities of fat tissue
○ Foul smell from the wound Evisceration
○ Redness,swelling,pain,warmth ● With total separation of wound layers,
● Nursing considerations evisceration (protrusion of visceral organs
○ Antibiotic therapy through a wound opening) occurs. The
○ Aseptic technique –change of condition is an emergency that requires
dressing surgical repair.
○ Good nutrition ● Nursing Considerations
● Rule of thumb ○ Apply abdominal binder
○ Fever - 1 st 24 hours-pulmonary ○ Encourage proper nutrition-high
infection CHON,vit C
■ within 48 hours-UTI ○ Keep in bed rest
(urinary tract infection) ○ Stay with the client,have someone
■ within 72 hours-wound call for the doctor
infection ○ Supine or semi-fowlers position,
● Kinds bend knees to relieve tension on
○ Hemorrhage/hematoma abdominal muscles
○ Wound dehiscence ○ Evisceration-cover exposed
■ separation of wound intestine with sterile moist saline
edges(5-6 days postop) dressing.
■ feeling that wounds are ○ Reassure, keep him quiet and
“pulling apart” relaxed.
○ Wound evisceration ○ Prepare for surgery and repair of
■ externalization of wound
bowel(experienced 5-6
days postop) Urinary retention
Wound dehiscence ● occurs most frequently after operation of the
rectum, anus, vagina and lower abdomen
caused by spasm of the bladder sphincter.
Experienced 8-12 Hours postop.
● Clinical manifestations
○ Unable to void after surgery
○ Bladder distension
○ Catheterized the patient
● A strategy to prevent dehiscence is to place Deep vein thrombosis

a folded thin blanket or pillow over an ● Formation of a blood clot (thrombus) in a
abdominal wound when the patient is deep vein, predominantly in the legs.
coughing. This provides a splint to the area, Experienced 6-14 days up to 1 year later
supporting the healing tissue when coughing ● Clinical manifestations
increases the intraabdominal pressure. ○ calf pain(+ Homan’s sign)
○ edema, tenderness
BSN-3C0
○ Prevention
■ Hydrate adequately to
prevent
hemoconcentration.
■ Encourage leg exercises
and ambulate early
■ Avoid any restricting
devices that can constrict
and impair circulation Post op psychological Disturbances
■ Prevent use of bed rolls ● Post-operative delirium
dangling over the side of ○ Delirium is an abrupt change in the
the bed with pressure on brain that causes mental confusion
the popliteal area. and emotional disruption. It makes
it difficult to think, remember,
sleep, pay attention, and more.
● Acute Confusional State
○ A clinical syndrome characterized
by disturbed consciousness,
cognitive function, or perception.
● Causes
○ Dehydration, insufficient
oxygenation, anemia, trauma
(especially in nervous persons)
drugs, infection, electrolyte
imbalance, and not being able to
move around (immobilization).
● Clinical manifestations
○ poor memory, restlessness,
disoriented, sleeps disturbances
● Active intervention ○ Sedatives - quiet and comfortable.
○ Bed rest; elevate the affected leg ○ Explain reasons for interventions
with pillow support. ○ Listen and talk to the client and
○ Wear antiembolic support hose significant others.
from the toes to the groin. ○ Provide physical comfort
○ Avoid massage on the calf of the
leg Wound Care
○ Initiate anticoagulant therapy as Types of wound healing
ordered(Heparin ○ First Intention
○ Second intention
○ Third intention
First Intention
● an aseptically made wound with minimal
tissue destruction and minimal tissue
reaction
BSN-3C0
● heals as edges are approximated by close ● Physiologic mechanisms to

sutures or staples. maintain hemostasis and promote
● no open areas or dead spaces are left to blood clotting are activated
serve as potential sites of infection 2. Proliferative Phase (Proliferation,
● granulation tissue not visible Granulation and Contraction)
● scar formation minimal ● Begins within 2-3 days after
● covered with sterile dressing surgery.
Second Intention ● Sutures and staples are removed
● an infected wound/chronic wound/extensive during this phase.
tissue damage wound is left open and 3. .Remodeling or Maturation Phase
allowed to heal from inside out. ● Begins about 3 weeks after surgery
● periodically cleaning and assessing of and can continue for 6 or more
wound for healthy tissue production months.
● scar tissue is extensive - healing is ● Scar tissue is remodeled by a
prolonged process of collagen synthesis and
● Wound edges not approximated breakdown to increase its strength.
● Pressure ulcers
● Surgical wounds that have tissue loss
● Wound heals by granulation tissue
formation, wound contraction, and
epithelialization.
Third Intention
● a potentially infected surgical wound may be
left open for several days. If no clinical
signs of infection occur, the wound is then
closed surgically.
Module 3
Inflammatory
response
• An inflammatory response is your body’s
attempt to fight invaders.
Three phases of surgical
1. Inflammation phase Stress and adaptation
● Begins with the surgical incision. Stress is a natural feeling of not being able to cope
with specific demands and events. However, stress
BSN-3C0
can become a chronic condition if a person does not Major complex occurrences involving large
take steps to manage it. groups
These demands can come from work, relationships, • These include events of history, such as
financial pressures, and other situations, but anything terrorism and war. The demographic,
that poses a real or perceived challenge or threat to a economic, and technologic changes
person’s well-being can cause stress. occurring in society
Stress can be a motivator, and it can even be essential • The tension produced by any stressor is
to survival. The body’s fight-or-flight mechanism a result not only of the change itself, but
tells a person when and how to respond to danger. also of the speed with which the change
However, when the body becomes triggered too occurs.
easily, or there are too many stressors at one time, it Stressors that occur less frequently and
can undermine a person’s mental and physical health involve fewer people
and become harmful. • This category includes the influence of
When the body is threatened or suffers an injury, its life events such as death, birth,
response may involve functional and structural marriage, divorce, and retirement. It
changes; these changes may be adaptive (having a also includes the psychosocial crises
positive effect) or maladaptive (having a negative that occur in the life cycle stages of the
effect). The defense mechanisms that the body uses human experience.
determine the difference between adaptation and • Chronic illness and its effect
maladaptation—health and disease.
Classifications of stress according to duration
Stress • Acute or time-limited
• A state produced by a change in the o Example:
environment that is perceived as ▪ Studying
challenging, threatening or damaging to a ▪ Examination
person’s dynamic balance or equilibrium. • A stressor sequence; a series of stressful
events resulting from an initial event
Types of stressors: o Example:
• Physical stressors ▪ Job loss
o Cold ▪ Divorce
o Heat ▪ Break-up
o Chemical agents • Chronic intermittent stressor
• Physiologic stressors o Daily hassles
o Pain • Chronic enduring stressor that persists over
o Fatigue time
• Psychosocial stressors o Chronic illness
o Fear of failing an examination o Disability
o Losing a job o Poverty
o Waiting for a diagnostic test result
Classification of stress Adaptation

Day-to-day stressors • a change or alteration designed to assist in
• includes such common occurrences as adapting to a new situation or environment
getting • This is the process of coping with the stress,
caught in a traffic jam, experiencing a compensatory process that has physiologic
computer downtime, and having an and psychological components
argument with a spouse or roommate • Adaptation is a constant, ongoing process
have a greater health impact that requires a change in structure, function,
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or behavior so that a person is better suited Models of Stress

to the environment; it involves an interaction
between the person and the environment.
Homeostasis
• a steady state within the body; the stability
of the internal environment
• When a change or stress occurs that causes a
body function to deviate from its stable
range, processes are initiated to restore and
• Stimulus-based model
maintain dynamic balance.
o Holmes and Rahes advanced this
• When these adjustment processes or
theory
compensatory mechanisms are not adequate,
o It proposed that life changes (LIFE
steady state is threatened, function becomes
EVENTS) or (STRESSORS),
disordered, and dysfunctional responses
either positive or negative, are
occur
stressors that tax the adaptation
capacity of an individual, causing
The constellation of systems
physiological and psychological
• The goal of the interaction of the body’s
strains that lead to health problems.
subsystems is to produce a dynamic
o They developed the Social
balance or steady state (even in the
Readjustment Rating Scale
presence of change), so that all
(SRRS).
subsystems are in harmony with each
o They hypothesized that people with
other.
higher scores in the SRRS, -that is
• Four concepts — key to the understanding
major life changes-are more likely
of steady state
to experience physical or mental
o constancy,
illness.
o homeostasis
o stress, and
Sample of the Social Readjustment Rating Scale
o adaptation
(SRRS)
• Response-based model
o It is represented in the well known
theory of Hans Selye
o It is similar to the “Fight or Flight”
response, which occurs in situation
that perceived as very threatening.
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o The response is a physiological one Pathophysiology of stress and disease

in which arousal of the sympathetic
nervous system results in many
physiological and somatic changes
and finally disruption of
homeostasis.
▪ Psychological Response to
Stress
▪ Physiologic Response to
Stress
o General adaptation syndrome
(GAS)
▪ Triggers:
• Trauma
• Sudden change
• Positive stress
• Daily stress
• Local Adaptation Syndrome (LAS)

o Response of a body
tissue, organ or part to the stress of trauma,
illness or other physiological change
o Characteristics
▪ The response is localized,
it does not involve entire
body systems
▪ The response is adaptive,
meaning that a stressor is
necessary to stimulate it
▪ The response is short
term. It does not persist
indefinitely
▪ The response is
restorative, meaning that
the LAS assists in
restoring homeostasis to
the body region or part
o Two Localized Responses
▪ Reflex Pain Response is a
localized response of the
central Nervous system to
pain. It is an adaptive
response and protects
tissue from further
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damage. The response social support or help, knowledge,

involves a sensory and skills to reduce this threat.
receptor, a sensory nerve
from the spinal cord, and Physiological Adaptation
an effector muscle. How does the brain interpret stressful Stimuli?
▪ Inflammatory Response • Limbic System
is stimulated by trauma or o Contains amygdala, hippocampus
infection. This response and septal nuclei
localizes the o Cerebral hemisphere – concern
inflammation, thus with cognitive functions
revenging its spread and o Reticular Activating System (RAS)
promotes healing. The network of cells that forms a two
inflammatory response way communication system
may produce localized o Example:
pain, swelling, heat, ▪ Eating, drinking,
redness and changes in temperature control,
functioning. reproduction, defense,
aggression)
The Transactional Model of Stress
• Lazarus and Folkman
o They believe that people have the
capacity to think, evaluate, and
then react.
o Thinking can make stress either
better or worse.
o Lazarus developed an interaction
theory that proposed two- stage
process of appraisal:
▪ A Primary Appraisal
Process: Determine
whether the event
represents a threat to the
individual. It has three
outcomes
• Events regarded
as irrelevant.
• Events regarded
as positive to
well being
• Events regarded
as negative to
well being.
o This negative appraisal leads to:
o A Secondary Appraisal Process:
Here the individuals assess their
coping resources. These resources
include environmental factors,
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Psychological adaptation
• Mediating Process – after recognizing a
stressor, a person consciously or
unconsciously reacts to manage the
situation.
How does cognitive appraisal happen?
• Coping with the stressful event
o Consists of the cognitive and
behavioral efforts made to manage
the specific external or internal
demands that tax a person’s
resources and may be emotion-
focused or problem-focused
Psychological adaptation to anxiety

How does this happen?
Anxiety Fear
Source of anxiety is not The source if
identified identifiable
Related to the future, Related to the present
anticipated event
Vague Definite
Result of psychologic Result of a discrete
or emotional conflict physical or
psychological entity
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▪ Ways people describe,

o
Level of Anxiety monitor and interpret
▪ Mild their symptoms, take
▪ Moderate remedial actions and use
▪ Severe the health care system
▪ Panic ▪ Affected by:
Stress Management 1. Age
• Promoting Healthy Lifestyle 2. Sex
• Enhancing Coping Strategies 3. Occupation
• Teaching Relaxation Techniques 4. socioeconomic
• Educating About Stress Management status
• Enhancing Social Support 5. Religion
6. ethnic origin
Inflammation Process 7. psychological
Inflammation is part of the body’s defense stability
mechanism and plays a role in the healing process. 8. Personality
When the body detects an intruder, it launches a 9. education
biological response to try to remove it. 10. modes of coping
The attacker could be a foreign body, such as a thorn, ▪ 4 aspects of the sick role:
an irritant, or a pathogen. Pathogens include bacteria, 1. Clients are not
viruses, and other organisms, which cause infection held responsible
to an individual. for their
condition
Disease and Illness 2. Clients are
• Disease excused from
o an alteration in body function certain social
resulting in reduction of capacities roles and tasks
or a shortening of the lifespan. 3. Clients are
obliged to get
• Illness
well as quickly as
o a highly personal state in which the
possible
person’s physical, emotional,
4. Clients or their
intellectual, social, developmental,
families are
or spiritual functioning is thought
obliged to seek
to be diminished
competent help
o Types of illness/disease acc. to
▪ 5 Stages of Illness
duration:
according to Suchman
▪ Acute- abrupt onset and
1. Symptom experience
short duration, may not
require intervention • person comes to
Ex. Common colds believe that
▪ Chronic – insidious onset something is
and usually last for an wrong
extended period of time • consults others
usually characterized by about the
remissions and symptoms
exacerbations • may self
o Illness Behavior medicate
• 3 Aspects:
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o Physical • the client is

experien expected to
ce of relinquish the
sympto dependent role
ms and resume
o Cognitiv former roles and
e aspect responsibilities
o Emotion • Effects of Illness/disease
al o Impact on the Client
response ▪ Behavioral or emotional
2. Assumption of the sick changes
role ▪ Change in body image
• person accepts the ▪ Vulnerability for loss of
sick role and seeks autonomy
confirmation from ▪ Changes in lifestyle
family members and
friends Cellular Responses to Stress and Toxic Insults:
• often continue self Adaptation, Injury, and Death
treatment and delay Introduction to Pathology
consultation as long • Pathology is the study (logos) of disease
as possible (pathos). It is devoted to the study of the
• may have anxiety, structural, biochemical, and functional
fear or depression changes in cells, tissues, and organs that
• may be excused from underlie disease
normal roles or duties • Four aspects of a disease process
3. Medical care contact 1. cause (etiology),
• seeking medical help 2. the mechanisms of its development
either by own (pathogenesis),
initiative or at the 3. the biochemical and structural
urging of others alterations induced in the cells and
• Information usually organs of the body (molecular and
sought by patients: morphologic changes)
• Validation of real 4. the functional consequences of these
illness changes (clinical manifestations)
• Explanation of the
symptoms in Stages of the cellular response to stress and
understandable terms injurious stimuli
• Reassurance or
prediction of
condition
4. Dependent Client Role
• acceptance of the
client role
• may vary from one
client to another
5. Recovery or
Rehabilitation
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▪ Disuse of a body part is

often associated with the
aging process and
immobilization.
▪ Cell size and organ size
decrease, and the
structures principally
affected are the skeletal
muscles, the secondary
sex organs, the heart, and
• Adaptations of Cellular Growth & the brain.
Differentiation o Hyperplasia
▪ is an increase in the
number of new cells in an
organ or tissue. As cells
multiply and are subjected
to increased stimulation,
the tissue mass enlarges.
This mitotic response (a
change occurring with
mitosis) is reversible when
o Hypertrophy the stimulus is removed.
▪ refers to an increase in the This distinguishes
size of cells, resulting in hyperplasia from
an increase in the size of neoplasia or malignant
growth, which continues
the organ.
after the stimulus is
▪ can be physiologic or
removed.
pathologic and is caused
▪ may be hormonally
by increased functional
induced. An example is
demand or by stimulation
by hormones and growth the increased size of the
factors thyroid gland caused by
▪ Compensatory thyroid stimulating
hormone (secreted from
hypertrophy is the result
the pituitary gland) when a
of an enlarged muscle
deficit in thyroid hormone
mass and commonly
occurs.
occurs in skeletal and
o Dysplasia
cardiac muscle that
experiences a prolonged, ▪ is bizarre cell growth
increased workload. One resulting in cells that
example is the bulging differ in size, shape, or
muscles of an athlete. arrangement from other
cells of the same tissue
o Atrophy
type.
▪ can be the consequence of
▪ Dysplastic cells have a
disease, decreased use,
decreased blood supply, tendency to become
loss of nerve supply, or malignant; dysplasia is
inadequate nutrition. seen commonly in
epithelial cells in the
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bronchi of people who blood (decreased

smoke hemoglobin),
o Metaplasia • a ventilation–
▪ is a cell transformation in perfusion or
which one type of mature respiratory
cell is converted into problem that
another type of cell. reduces the
▪ This serves a protective amount of arterial
function, because less- oxygen available,
transformed cells are more • a problem in the
resistant to the stress that cell’s enzyme
stimulated the change. system that
• Cell injury makes it unable
to use oxygen.
• The usual cause
of hypoxia is
ischemia or
deficient blood
supply. Ischemia
is commonly
seen in
o Injury is defined as a disorder in myocardial cell
steady-state regulation. Any injury in which
stressor that alters the ability of the arterial blood
cell or system to maintain optimal flow is decreased
balance of its adjustment processes because of
leads to injury. atherosclerotic
o Causes of disorder and injury in narrowing of
the system (cell, tissue, organ, blood vessels.
body) Ischemia also
▪ Hypoxia results from
▪ Nutritional imbalance intravascular
▪ Physical agents clots (thrombi or
▪ Chemical agents emboli) that may
▪ Infectious agents form and
▪ Immune mechanisms interfere with
▪ Genetic defects blood supply.
o Hypoxia o Nutritional imbalance
▪ Inadequate cellular ▪ refers to a relative or
oxygenation (hypoxia) absolute deficiency or
interferes with the cell’s excess of one or more
ability to transform essential nutrients. This
energy. may be manifested as
▪ Causes: undernutrition (inadequate
• decrease in blood consumption of food or
supply to an area, calories) or overnutrition
• decrease in the (caloric excess)
oxygen-carrying
capacity of the
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▪ Protein deficiencies and ▪ The severity of the

avitaminosis (deficiency infectious disease depends
of vitamins) are typical on the number of
examples. An energy microorganisms entering
deficit leading to cell the body, their virulence,
injury can occur if there is and the host’s defenses
insufficient glucose or (e.g., health, age, immune
insufficient oxygen to responses).
transform the glucose into o Immune mechanisms
energy. ▪ The immune response
o Physical agents detects foreign bodies by
▪ Physical agents, including distinguishing non self
temperature extremes, substances from self
radiation, electrical shock, substances and destroying
and mechanical trauma, the non self entities.
can cause injury to the ▪ The entrance of an antigen
cells or to the entire body. (foreign substance) into
▪ The duration of exposure the body evokes the
and the intensity of the production of antibodies
stressor determine the that attack and destroy the
severity of damage. antigen (antigen–antibody
o Chemical agents reaction).
▪ Chemical injuries are ▪ The immune system may
caused by poisons, such as function normally, or it
lye, that have a corrosive may be hypoactive or
action on epithelial tissue, hyperactive. When it is
or by heavy metals, such hypoactive,
as mercury, arsenic, and immunodeficiency
lead, each of which has its diseases occur; when it is
own specific destructive hyperactive,
action. hypersensitivity disorders
▪ Drugs, including occur
prescribed medications, o Genetic defects
can also cause chemical ▪ Many of these defects
poisoning. Some people produce mutations that
are less tolerant of have no recognizable
medications than others effect, such as lack of a
and manifest toxic single enzyme; others
reactions at the usual or contribute to more
customary dosages obvious congenital
▪ Alcohol (ethanol) is also a abnormalities, such as
chemical irritant. Down syndrome
o Infectious agents
▪ Biologic agents known to
cause disease in humans
are viruses, bacteria,
rickettsiae, mycoplasmas,
fungi, protozoa, and
nematodes.
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Morphologic alterations in cell injury only one of several agents that may
trigger an inflammatory response.
o It is useful to describe the basic

alterations that occur in damaged
cells before we discuss the
biochemical mechanisms that bring
o Body defenses against injury
about these changes. All stresses
Normal Defenses of the Body
and noxious influences exert their
▪ First Line: (non-specific
effects first at the molecular or
immune response)
biochemical level. There is a time
• Skin and Mucous
lag between the stress and the
Membrane
morphologic changes of cell injury
• Cellular and
or death; the duration of this delay
chemical factors
may vary with the sensitivity of the
methods used to detect these • Microbial
changes Antagonism
• Cellular Response to Injury

Inflammation
o Cells or tissues of the body may be
injured or killed by any of the
agents (physical, chemical,
infectious). When this happens, an
inflammatory response (or
inflammation) naturally occurs in
the healthy tissues adjacent to the
site of injury.
o Inflammation is a localized reaction ▪ Second Line (non-specific
intended to neutralize, control, or immune response)
eliminate the offending agent to • Inflammation
prepare the site for repair. It is a • Phagocytosis
nonspecific response (not Pathophysiology of Acute
dependent on a particular cause) Inflammation:
that is meant to serve a protective • Injury
function. • Damage cells
o Inflammation is not the same as release chemical
infection. An infectious agent is mediators-
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histamine, o Attachment
serotonin, o Ingestion
prostaglandin, o Digestion
leukotrienes
• Vasodilation
• Increased
capillary
permeability-
leak of plasma
into the
interstitial space
• Leukocyte moves
to the site of
injury
• Phagocytosis ▪ Third Line (specific
immune response)
• Humural
Immunity
• Cell-Mediated
Immunity
• Local Signs of Inflammation

▪ pain
▪ swelling
▪ redness
▪ heat
▪ loss
• Systemic effects of inflammation

o fever- usually develops if
inflammation is extensive and if
there is infection
o Development of fever:
• Phagocytosis
o Chemotaxis
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o Infection→ toxin in blood → 4. Others nutritional, High iron levels, Stress,

ingestion by phagocytes→ Age, Cancer and chemo tx, HIV/AIDS, Drugs
production of interlukin by and Genetics
macrophages→ production of
prostaglandin by Hypothalamus → • Chronic Inflammation
set higher temp. for the o may develop after acute
hypothalamus→ signal to blood inflammation or insidiously
vessels to constrict and conserve o less swelling and exudates
heat → vasoconstriction continuous formation but more
until blood supply matches the lymphocyte, macrophage and
thermostat set at the fibroblast are present
hypothalamus→ fever, malaise, o more tissue destruction occurs
headache, anorexia o Ex. Rheumatoid arthritis,
granuloma formation in
tuberculosis
• Purposes of inflammatory response

o Localize an infection
o Prevent spread of pathogens
o Neutralize toxins
o Aid in repair of damage tissues
Disorders and conditions that adversely affect

Phagocytic and Inflammatory Process
1. Leukopenia vs Neutropenia
▪ radiation, drugs, nutritional,
congenital
2. Conditions affecting Leukocyte Motility and
chemotaxis
▪ due to defect in production of actin,
steroids, conditions like Chediak-
Higashi syndrome
3. Disorders affecting Intracellular killing by
phagocytes
▪ due to deficiencies in
myeloperoxidase or inability to
generate superoxide anion,
hydrogen peroxide or hypochlorite
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Third line of defense • Primary function of the immune system

• Humural Immunity o Differentiate between self and non-
• Cell-Mediated Immunity self
2 Major types of Immunity: o Destroy that which is non-self
o 2 Major arms of the Immune
System:
▪ Humoral immunity
▪ Cell-mediated immunity
• Natural Immunity
o also called native or innate
resistance; the skin and
mucous membranes, cellular
and chemical factors
• Acquired Immunity- result from the
active production or receipt of Ab
during a person’s lifetime
o Active
o Passive
Supplemental:
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• Cell-mediated immunity
• Alterations in immunity
o a complex system of interactions
o Three types of Inappropriate
between many cell types and
Responses:
cellular secretions
▪ Allergy
o directed towards infection by
▪ Autoimmunity
intracellular pathogens
▪ Alloimmune diseases
o involves T-H, T-C, T-D, NK, KC
o Allergy is the deleterious effects of
and granulocyte
hypersensitivity to environmental
o Ab play only a minor role
antigens. It can be immediate or
delayed. Has four distinct types:
▪ Type I- Ig E-mediated
▪ Type II- Cytotoxic
▪ Type III- Immune
Complex
▪ Type IV- Cell-
mediated/Delayed type
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o Type I- Ig E-mediated
▪ Rapidly developing
immunologic reaction
occurring within minutes
after combination of an
antigen with antibody
bound to mast cells or
basophils.
▪ An allergen stimulates B-
lymphocytes production of
Ig E.
▪ Ig E antibodies formed in
response to an antigen
have strong tendency to
attach to mast cells and
basophils through cell
surface receptor
▪ When mast cells or
basophil armed with
cytophilic Ig E antibodies,
is re-exposed to the same
allergen, a series of
reaction takes place
resulting in release of
chemical mediators.
▪ Primary mediators are:
Histamine, Eosinophilic
chemotactic factor of
anaphylaxis, neutrophil
chemotactic factor, and
granule-matrix-derived
mediators such as heparin
and trypsin. o Type II (Tissue specific reaction/
▪ Diagnostic procedure: cytotoxic reaction)
• Skin Testing or ▪ Mediated by antibodies
prick test directed toward antigens
• Radioimmunosor present on the surface of
bent testing cells or other tissue
(RIST) measures components.
total level of IgE ▪ Destruction of a target cell
in the body through the action of
• Radioallergosorb antibody against an
ent antigen on the cell’s
testing(RAST) plasma membrane.
measures the ▪ It can destroy or alter cells
specific Ig E by these mechanisms:
• antibodies against
many allergens.
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• Complement- o Type IV (Cell-Mediated/Delayed

dependent Hypersensitivity)
reactions ▪ It is initiated by
• ADCC(Antibody specifically sensitized T-
-dependent Cell- lymphocytes and do not
mediated involve antibody.
Cytotoxicity) ▪ Delayed type is initiated
• Target cells tend by specifically sensitized
to malfunction. T-lymphocytes, generated
during the initial contact
with antigen.
▪ Memory T-cells after the
first exposure was formed
and will remain in the
circulation.
▪ During the second
exposure, the T-memory
cells will secrete
lymphokines that will
amplify the response by
recruiting inflammatory
o Type III (Immune-complex cells, activating them and
mediated response) keeping them in the site
▪ Caused by antigen-
antibody complexes
formed in the circulation
and deposited later in the
vessel walls or
extravascular tissues.
▪ This is induced by Ag-Ab
complexes that produce
tissue damage as a result
of their capacity to
activate variety of serum
mediators, principally the
complement system.
▪ Examples:
Glomerulonephritis,
arthritis
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Autoimmunity Module 4
• Breakdown of tolerance in which the body’s
immune system begins to recognize self-
antigens as foreign.
Immunologic
• Example: Systemic Lupus Erythematosus- a
chronic progressive systemic inflammatory
disease that can cause major organ systems
response
to fail. Foreign antigens which
originate from outside the body,
such as the substances produced
by microorganisms (eg. bacteria,
viruses, fungi, and protozoa), as
well as substances in snake
venom, certain proteins in foods,
and components of serum and
red blood cells from other
individuals can cause damage by
entering and attacking the
internal milieu of the human body.
The body develops an immune response
Alloimmunity whenever it recognizes foreign substances. Immune
• Occurs when an individual’s immune responses serve three functions: defense (involves
system reacts against antigens on the tissues resisting infection), homeostasis (involves removing
of other members of the same species. worn out “self” components), and surveillance (deals
• Examples: Transient Neonatal disease, with identification and destruction of mutant cells). A
Transplant rejection. person’s ability to elicit a normal immune response
depends on the individual genetic make-up, age,
General Nursing Measure for Hypersensitivity metabolism, health, and environment.
• Assessment
o History of exposure to allergens Overview of the Immune System
o Difficulty of breathing • The immune system is the body's natural
o Difficulty of swallowing defense system that helps fight infections.
o Complaints of swollen tongue The immune system includes the following.
o Itching, tearing and burning of eyes o The tonsils. These are on either
o Itching and burning of Skin side of the back of the throat. The
o Rashes tonsils help make antibodies.
o Nose twitching nasal stuffiness. o The thymus gland. This is found in
• Implementation the upper chest at the bottom of the
o Establish a patent airway. neck, behind the breastbone. The
o Prepare to administer epinephrine thymus also helps make antibodies.
(Adrenaline), diphenhydramine o Bone marrow This is a soft tissue
hydrochloride (Benadryl) or that is found mainly inside the long
corticosteroid. bones of the arms and legs, the
o Provide measures to control shock vertebrae, and the pelvic bones.
(Trendelenburg position) The marrow makes white blood
o Salves, wet compresses and cells that destroy bacteria, viruses,
soothing baths for local reactions. and other organisms that cause
o Provide emotional support. infection.
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o The spleen. This organ is found in ▪ The skin and mucous

the upper left side of the abdomen. membrane provide non-
It filters the blood by removing old specific immunity as an
or damaged blood cells and external barrier against
platelets. The spleen helps the infection. The skin acts as
immune system by destroying a first-line defense against
bacteria and other foreign organisms; white blood
substances. cells phagocytize
o Lymph nodes and vessels (the microorganisms; gastric
lymphatic system). This system is secretions and digestive
found throughout the body. It enzymes destroy
carries fluid, nutrients, and waste organisms that are
material between the body tissues swallowed.
and the bloodstream. The lymph ▪ Natural immune
nodes filter lymph fluid as it flows mechanisms can be
through them. The nodes trap divided into two stages:
bacteria, viruses, and other foreign immediate (generally
substances, which are then occurring within minutes)
destroyed by special white blood and delayed (occurring
cells. These cells are called within several days after
lymphocytes. exposure) (Levinson,
• Immune Function 2014).
o The basic function of the immune o ACQUIRED IMMUNITY usually
system is to remove foreign develops as a result of prior
antigens such as viruses and exposure to an antigen through
bacteria to maintain homeostasis. immunization (vaccination) or by
There are two general types of contracting a disease, both of which
immunity: generate a protective immune
▪ Natural (innate) response. Weeks or months after
immunity or nonspecific exposure to the disease or vaccine,
immunity is present at the body produces an immune
birth. response that is sufficient to defend
▪ Acquired (adaptive) or against the disease on re-exposure.
specific immunity In contrast to the rapid but
develops after birth. nonspecific natural immune
• Each type of immunity has a distinct role in response, this form of immunity
defending the body against harmful relies on the recognition of specific
invaders, but the various components are foreign antigens.
usually interdependent (Levinson, 2014). ▪ The acquired immune
o NATURAL IMMUNITY which is response is broadly
nonspecific provides a broad divided into two
spectrum of defense against and mechanisms:
resistance to infection. It is • (1) The CELL
considered the first line of host MEDIATED
defense following antigen exposure IMMUNE
because it protects the host without RESPONSE,
remembering prior contact with an involving T-cell
infectious agent (Levinson, 2014). activation
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• (2) HUMORAL • An assessment of immune function begins

IMMUNE during the health history and physical
RESPONSE, examination. Areas to be assessed include
involving B-cell nutritional status; infections and
maturation and immunizations; allergies; disorders and
production of disease states, such as autoimmune
antibodies disorders, cancer, and chronic illnesses;
(Haynes et al., surgeries; medications; and blood
2015). transfusions. In addition to inspection of
▪ The two types of acquired general characteristics, palpation of the
immunity are known as lymph nodes and examinations of the skin,
active and passive and are mucous membranes, and respiratory,
interrelated. gastrointestinal, musculoskeletal,
▪ Active acquired immunity genitourinary, cardiovascular, and
refers to immunologic neurosensory systems are performed.
defenses developed by the
person’s own body. This Health history (Hx)
immunity typically lasts • The history should note the patient’s age
many years or even a along with information about past and
lifetime. present conditions and events that may
▪ Passive acquired provide clues to the status of the patient’s
immunity is temporary immune system.
immunity transmitted • Gender
from a source outside the o There are differences in the
body that has developed immune system functions of men
immunity through and women. For example, many
previous disease or autoimmune diseases have a higher
immunization. incidence in females than in males,
a phenomenon believed to be
Assessment of the Immune System correlated with sex hormones. Sex
hormones play definitive roles in
lymphocyte maturation, activation,
and synthesis of antibodies and
cytokines. In autoimmune disease,
the expression of sex hormones is
altered, and this change contributes
to immune dysregulation.
• Gerontologic Considerations
o Immunosenescence is a complex
route in which the aging process
stimulates changes in the immune
system Some of the changes that
occur in immunosenescence
include, but are not limited to, bone
marrow defects, dysfunction of the
thymus gland, and impaired
lymphocytes.
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• Nutrition prescribed and over-the-counter

o The relationship of infection to medications that the patient has
nutritional status is a key taken or is currently taking for
determinant of health. these allergies and the effectiveness
Traditionally, this relationship of the treatments, is obtained.
focused on the effect of nutrients
on host defenses and the effect of Nursing Assessment
infection on nutritional needs. This Health Assessment Family History Assessment
has expanded in scope to Specific to Immunologic Disorders
encompass the role of specific • Collect a family history for both maternal
nutrients in acquired immune and paternal relatives for three generations.
function • Assess family history for other family
• Immunization members with histories of immunologic
o The patient is asked about disorders.
childhood and adult immunizations, • Obtain information about family members
including vaccinations to provide with a history of recurrent infections or
protection against influenza, illnesses.
pneumococcal disease • Recognize ethnic risk (non-Ashkenazi
(Pneumovax), pertussis, herpes Jewish, Armenian, Arab, and Turkish are at
simplex, and the usual childhood greater risk for Familial Mediterranean
diseases (e.g., measles, mumps). fever; Caucasians have a higher incidence of
• Infection Crohn’s disease)
o Recent exposure to any infections • Patient Assessment
and the exposure dates are elicited. o Assess for symptoms such as
The nurse must assess whether the changes in respiratory status
patient has been exposed to any associated with asthma (e.g.,
sexually transmitted infections wheezing, or airway hyper-
(STIs) or blood-borne pathogens responsiveness; mucosal edema;
such as hepatitis B, C, and D and mucus production).
viruses and human immune o Gather information regarding
deficiency virus (HIV). A history immunizations and whether an
of past and present infections and altered response to any
the dates and types of treatments, immunization has occurred.
along with a history of any multiple o Assess for symptoms of
persistent infections, fevers of immunodeficiency disorders, such
unknown origin, lesions or sores, or as unexplained weight gain, or loss,
any type of drainage, as well as the skin rashes, changes in hair texture
response to treatment, are obtained. or distribution, joint or muscle
• Allergy pain, intolerance to cold, irregular
o The patient is asked about any menstrual periods, abdominal
allergies, including types of discomfort, or the presence of
allergens (e.g., pollens, dust, plants, diarrhea.
cosmetics, food, medications, o Identify the pattern of sickness with
vaccines, latex), the symptoms regard to frequency of colds,
experienced, and seasonal respiratory infections, or history of
variations in occurrence or severity illness that tends to linger.
in the symptoms. History of testing
and treatments, including
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o Obtain a history of childhood o B-cell quantification with

illnesses and details of the illness monoclonal antibody
experience. o In vivo immunoglobulin synthesis
o Assess for the medical history of with T-cell subsets
frequent or recurrent infections o Specific antibody response
o Learn about susceptibility to o Total serum globulins and
infections, assess for patterns individual immunoglobulins
(frequency, length of illness, the • Cellular (Cell-Mediated) Immunity Tests
severity of symptoms), and o Total Lymphocyte Count
recognize infections that would be o T-cell and T-cell subset
atypical for age. quantification with monoclonal
o Inquire about environmental antibody
exposures (e.g., smoke, chloroform, o Delayed hypersensitivity skin test
metal or dust particles, paint). Ask o Cytokine production
about exposure to other viruses o Lymphocyte response to mitogens,
such as Epstein Barr or Influenza. antigens, and allogenic cells
o Helper and suppressor T-cell
Physical Assessment functions
• Assess the skin and mucous membranes for
lesions, dermatitis, purpura (subcutaneous Management of Patients with Immune Deficiency
bleeding), urticaria, inflammation, or any Disorders
discharge. Immunodeficiency disorders impair the immune
• Note any signs of infection. system’s ability to defend the body against foreign or
• Record Vital signs and observe patient for abnormal cells that invade or attack it (such as
chills and sweating bacteria, viruses, fungi, and cancer cells).
• Palpate the anterior and posterior cervical, Immunodeficiency disorders can be classified as
supraclavicular, axillary, and inguinal lymph either primary or secondary and by the affected
nodes for enlargement; if palpable nodes are components of the immune system
detected, their location, size, consistency, • Primary Immunodeficiency
and reports of tenderness on palpation are o These disorders are usually present
noted. at birth and are genetic disorders
• Assess joints for tenderness, swelling, that are usually hereditary. They
increased warmth, and limited range of typically become evident during
motion. Evaluate patient’s respiratory, infancy or childhood. However,
cardiovascular, genitourinary, some primary immunodeficiency
gastrointestinal, and neurosensory systems disorders until adulthood.
for signs and symptoms indicative of o Primary immunodeficiency
immune dysfunction. disorders may be caused by
• Assess for any functional limitations or mutations, sometimes in a specific
disabilities the patient may have. gene. If the mutated gene is on the
X (sex) chromosome, the resulting
Diagnostic Evaluation disorder is called an X-linked
• A series of blood tests and skin tests, as well disorder. X-linked disorders occur
as bone marrow biopsy, may be performed more often in boys. About 60% of
to evaluate the patient’s immune people with primary
competence. immunodeficiency disorders are
• Humoral (Antibody-Mediated) Immunity male.
Tests o Primary immunodeficiency
disorders are classified by which
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part of the immune system is o Other conditions that may cause

affected: secondary immunodeficiency
▪ Humoral immunity, which disorder
involves B-cells ▪ Cancer that affects the
(lymphocytes), a type of bone marrow (such as
white blood cell that leukemia and lymphoma)
produces antibodies can prevent the bone
(immunoglobulins) marrow from producing
▪ Cellular immunity, which normal white blood cells
involves T- (B cells and T cells)
cells(lymphocytes), a type ▪ Undernutrition from
of white blood cell that nutrients can impair the
helps identify and destroy immune system
foreign or abnormal cells ▪ Age (older people)
▪ Both humoral and cellular ▪ Immunosuppressant drugs
immunity (B cells and T (given to prevent rejection
cells) of a transplanted organ or
▪ Phagocytes (cells that tissue or to people with an
ingest and kill autoimmune disorder to
microorganisms) suppress the body's attack
▪ Complement proteins against its own tissues)
(proteins that help ▪ Chemotherapy and
immune cells kill bacteria radiation therapy
and identify foreign cells • Clinical Manifestations
to destroy) o People with an immunodeficiency
▪ The affected component disorder tend to have one infection
of the immune system after another.
may be missing, reduced o Respiratory infections
in number, or abnormal o Infections of the mouth, eyes, and
and malfunctioning. digestive tract
• Secondary Immunodeficiency o Thrush - a fungal infection of the
o These disorders generally develop mouth,
later in life and often result from o Gingivitis
the use of certain drugs, radiation o Ear and skin infections
therapy, or from almost any o Large, noticeable warts (caused by
prolonged serious disorders, such viruses).
as diabetes or human o Fever and chills
immunodeficiency virus (HIV) o Weight loss and loss of appetite
infection. In diabetes, it can result o Abdominal pain possibly because
in an immunodeficiency disorder the liver or spleen is enlarged.
because white blood cells do not o Chronic diarrhea in infants and
function well when the blood sugar young children and failure to thrive
level is high. Human o Physical Assessment: enlarged
immunodeficiency virus (HIV) spleen, swollen lymph nodes and
infection results in acquired tonsils.
immunodeficiency syndrome • Diagnostic Tests
(AIDS), the most common severe o Serologic levels of immune cells
acquired immunodeficiency and proteins (lymphocytes,
disorder.
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neutrophils, complement, ▪ Lesions on the face, lips,

immunoglobulin levels) or perianal area
o Tests to check functions of B- ▪ Redness, swelling, or
lymphocytes (ex. Schick Test), T- drainage from skin lesions
lymphocytes (ex. PPD, mumps skin ▪ Persistent vaginal
test), granulocytes (ex. nitroblue discharge with or without
tetrazolium, and complement perianal itching
proteins ▪ Persistent abdominal pain
o Genetic Testing o Observe for subtle and unusual
o Biopsy (tissue from lymph nodes or signs and changes in physical status
bone marrow) o Monitor vital signs and the
• Treatment development of pain, neurological
o General measures and certain signs, cough, and monitor and
vaccines to prevent infections report skin and oral lesions
o Antibiotics and antivirals when immediately
needed o Monitor laboratory values (white
o Immune globulin blood cells and differential cell
o Stem cell transplantation count) for changes indicative of
o Transplantation of thymus tissue infection
o Gene therapy o Monitor culture and sensitivity
• Nursing Management reports from wound drainage,
o Determine history of past lesions, sputum, stool, urine, and
infections, particularly the type and blood to identify pathogenic
frequency of infections, methods, organisms and appropriate anti-
and response to past treatments, microbial therapy.
signs, and symptoms of any skin, o Assess nutritional status, stress
respiratory, oral, gastrointestinal, or level, and coping skills; use of
genitourinary infection, and alcohol, drugs, and tobacco, and
measures taken by the patient to general hygiene practices
prevent infection o Reduce patient’s risks for infection,
o Assess and monitor the patient for assist with medical measures aimed
signs and symptoms of infection at improving the immune status and
▪ Fever with or without treating infection, achieving
chills optimal nutritional status,
▪ Cough with or without maintaining respiratory, bowel, and
sputum bladder function.
▪ Shortness of breath o Assess the patient’s ability to
▪ Difficulty of breathing demonstrate acceptable hand
▪ Difficulty swallowing hygiene
▪ White patches in the oral o Encourage patient to cough and
cavity perform deep breathing exercises at
▪ Swollen lymph nodes regular intervals
▪ Nausea with or without o Teach good dental hygiene
vomiting measures to reduce the potential
▪ Persistent diarrhea oral lesions and do instructions on
▪ Frequency, urgency, or measures to protect to protect the
pain on urination integrity of the skin
▪ Change in the character of o Attention to strict aseptic technique
urine when performing invasive
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procedures, such as dressing Anaphylaxis

changes, venipunctures, bladder • A clinical response to an immediate (Type 1
catheterization. hypersensitivity) immunologic reaction
o Assist patient to manage stress, to between a specific antigen and antibody.
incorporate lifelong patterns of The reaction results from a rapid release of
physiologic safety, and to adopt Ig E Mediated chemicals, which can induce
behaviors that strengthen immune a severe, life threatening allergic reaction.
system function • Anaphylaxis causes the immune system to
o Inform the family about the release a flood of chemicals that can cause a
potential risks and benefits of the person to go into shock.
treatment regimen (ex. gene
therapy, bone marrow
transplantation, and
immunomodulators
Management of Patients with Allergic Reactions

An allergic reaction is a manifestation of tissue injury
resulting from interaction between an antigen and an
antibody. Allergy is an inappropriate and often
harmful response of the immune system to normally
harmless substances, called allergens (e.g., dust,
weeds, pollen, dander).
Allergy is a hypersensitive reaction to a specific
allergen that is initiated by immunological Pathophysiology
mechanisms and usually mediated by • Anaphylaxis occurs in an individual after re-
immunoglobulin E (IgE) antibodies, which are exposure to an antigen to which that person
produced in response to allergens has produced a specific IgE antibody.
When the body encounters an antigen, usually a • Upon reexposure to the sensitized allergen,
protein that the body’s defenses recognize as foreign, the allergen may cross-link the mast cell or
a series of events occurs in an attempt to render the basophil surface-bound allergen-specific IgE
invader harmless, destroy it, and remove it from the resulting in cellular degranulation as well as
body. When lymphocytes respond to the antigens, de novo synthesis of mediators.
antibodies (protein substances that protect against • IgE binds to the antigen
antigens are produced. Common allergic reactions • Antigen-bound IgE then activates Fc epsilon
occur when the immune of a susceptible person RI (high-affinity IgE receptor) or FcεRI
responds aggressively to a substance that is normally (Links to an external site.)receptors on mast
harmless (e.g. dust, weeds, pollen, dander) chemical cells and basophils.
mediators released in allergic reactions may produce • This leads to the release of inflammatory
symptoms from mild to life threatening. mediators such as histamine.
• Many of the signs and symptoms of
anaphylaxis are attributable to binding of
histamine to its receptors; binding to
H1receptors mediates pruritus, rhinorrhea,
tachycardia, and bronchospasm.
• Prostaglandin D2 mediates bronchospasm
and vascular dilatation, principle
manifestations of anaphylaxis.
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• Leukotriene C4 is converted into LTD4 and • Histamine and Tryptase assessment (done
LTE4, mediators of hypotension immediately after the onset to confirm the
bronchospasm, and mucous secretion during diagnosis)
anaphylaxis in addition to acting as • 5-hydroxyindoleacetic acid levels
chemotactic signals for eosinophils and • Skin Testing and In Vitro IgE Tests (to
neutrophils. determine the stimulus causing the
Etiology anaphylactic reaction (eg, food allergy,
• Food allergies, such as to peanuts, and tree medication allergy , or insect bite or sting).
nuts, fish, shellfish and milk. Medical Management
• Medications, including antibiotics and • Remove the causative antigen such as
aspirin other over-the-counter pain relievers, discontinuing an antibiotic agent could stop
and the intravenous (IV) contrast used in the progression of shock.
some imaging tests. • Administer medications that restore vascular
• Stings from bees, yellow jackets, wasps, tone and provide emergency support of basic
hornets and fire ants. life functions.
• Latex allergy develops after many previous • Cardiopulmonary resuscitation if cardiac
exposures to latex. arrest and respiratory arrest are imminent or
Clinical Manifestations have occurred
• MILD: (Onset of symptoms begins within • Endotracheal intubation or tracheostomy to
the first 2 hours after exposure) establish an airway.
o peripheral tingling and a sensation • IV lines are inserted to provide access for
of warmth, possibly accompanied administering fluids and medications.
by a sensation of fullness in the Pharmacologic Therapy
mouth and throat • Epinephrine is given for its vasoconstrictive
o nasal congestion, periorbital reaction; for emergency situations, an
swelling, pruritus, sneezing, tearing immediate injection of 1:1, 000 aqueous
of the eyes solution, 0.1 to 0.5 ml, repeated every 5 to
• MODERATE: (Onset of symptoms begins 20 minutes is given.
within the first 2 hours after exposure) • Diphenhydramine (Benadryl) is
o flushing, warmth, anxiety, and administered to reverse the effects of
itching in addition to milder histamine, thereby reducing capillary
systemic manifestations permeability.
o More serious reactions: • Albuterol (Proventil) may be given to
bronchospasm and edema of the reverse histamine-induced bronchospasm
airways or larynx with dyspnea, Nursing Management
cough and wheezing. • Nursing Assessment
• SEVERE: (Onset of symptoms is abrupt) o Assess all patients for allergies or
o mild/moderate signs and symptoms previous reactions to antigens.
o rapid progression of bronchospasm, o Assess the patient’s understanding
laryngeal edema , severe dyspnea, of previous reactions and steps
cyanosis, and hypotension. taken by the patient and the family
o dysphagia, abdominal cramping, to prevent further exposure to
vomiting, diarrhea and seizures can antigens.
also occur o Advise the patient to wear or carry
o cardiac arrest and coma may follow identification that names the
Diagnostic Tests specific allergen or antigen.
• Nursing Diagnosis
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o Impaired gas exchange related to promoting maximum chest

ventilation perfusion imbalance. expansion and is the position of
o Ineffective peripheral and tissue choice during respiratory distress.
perfusion related to decreased o Encourage adequate rest and limit
blood flow secondary to vascular activities to within client’s
disorders due to anaphylactic tolerance.
reactions. o Monitor the client’s central venous
o Ineffective breathing pattern related pressure (CVP), pulmonary artery
to the swelling of the nasal mucosa diastolic pressure (PADP),
wall. pulmonary capillary wedge
o Acute pain related to gastric pressure, and cardiac output/cardiac
irritation. index.
o Impaired skin integrity related to o Monitor urine output. The renal
changes in circulation. system compensates for low blood
• Planning pressure by retaining water, and
o Goals of Care: The patient will oliguria is a classic sign of
maintain an effective breathing inadequate renal perfusion.
pattern, as evidenced by relaxed • Expected Outcomes:
breathing at normal rate and depth o The patient maintained an effective
and absence of adventitious breath breathing pattern
sounds. o The patient demonstrated improved
o demonstrate improved ventilation ventilation.
as evidenced by an absence of o The patient displayed
shortness of breath and respiratory hemodynamic stability.
distress. o The patient and significant others
o display hemodynamic stability as verbalized understanding of
evidenced by normal vital signs, allergic reaction, its prevention, and
urine output, and state/level of management.
consciousness. o The patient and significant others
o verbalize understanding of allergic verbalized understanding of need to
reaction, its prevention, and carry emergency components for
management. intervention, need to inform health
o verbalize understanding of need to care providers of allergies, need to
carry emergency components for wear medical alert
intervention, need to inform health bracelet/necklace, and the
care providers of allergies, need to importance of seeking emergency
wear medical alert care.
bracelet/necklace, and the
importance of seeking emergency Allergy
care. • Also known as hay fever, seasonal allergic
• Intervention rhinitis is the most common form of
o Assess the client for the sensation respiratory allergy presumed to be mediated
of a narrowed airway. by an immediate (Type 1 Hypersensitivity)
o Monitor oxygen saturation and immunologic reaction
arterial blood gas values. • Allergic rhinitis in children is most often
o Instruct the client to breathe slowly caused by sensitization to animal dander,
and deeply. house dust, pollen, and molds.
o Position the client upright as this
position provides oxygenation by
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• Pollen allergy seldom appears before 4 or 5 • CBC count with differential. CBC count
years of age. may reveal an increased number of
• Sensitization to outdoor allergens can occur eosinophils; an eosinophil count within the
in allergic rhinitis in children older than 2 reference range does not exclude AR;
years; however, sensitization to outdoor however, an elevated eosinophil count is
allergens is more common in children older suggestive of the diagnosis.
than 4-6 years. Medical Management
Pathophysiology • Avoidance of allergens or environmental
• Sensitization begins by ingestion or controls, medications, and allergen-specific
inhalation of an antigen. On re-exposure, the immunotherapy (sublingual or allergy
nasal mucosa reacts by slowing the ciliary shots).
action, edema formation, and leukocyte Pharmacologic Management
(primarily eosinophil) infiltration. Histamine • 2nd generation antihistamines:
is the major mediator of allergic reactions in Antihistamines are classified in several
the nasal mucosa. Tissue edema results from ways, including sedating and non-sedating,
vasodilation and increased capillary newer and older, and first- and second-
permeability. generation antihistamines (most widely
Etiology accepted classification); first-generation
• The most common allergens include dust antihistamines are primarily over-the-
mites, pet dander, cockroaches, molds, and counter OTC) and are included in many
pollen. combination products for cough, colds, and
Clinical Manifestations allergies.
• sneezing and nasal congestion • Intranasal antihistamines: These agents are
• clear, watery nasal discharge and nasal an alternative to oral antihistamines to treat
itching allergic rhinitis
• itching of the throat and soft palate • Intranasal corticosteroids: This class of
• dry cough and hoarseness medications is most effective; intranasal
• headache, pain over the paranasal sinuses corticosteroids are potent anti-inflammatory
• epistaxis agents shown to decrease allergic rhinitis
• fatigue, loss of sleep, and poor concentration symptoms
Assessment and Diagnostic findings • Intranasal antihistamine and corticosteroids:
• Skin-prick testing.This test is highly Combination products are emerging on the
sensitive and specific for aeroallergens; market for patients who require an intranasal
however, a false positive reaction can occur antihistamine and corticosteroids.
without corresponding clinical features, • Intranasal decongestants: Decongestants are
especially when skin mast cells are easily effective for short-term symptom control;
activated by pressure or other physical they decrease nasal discharge and
stimuli. congestion and are available without a
• Serum allergen-specific IgE testing.The prescription.
main limitations are that patients may be • Leukotriene receptor agonists. Montelukast
sensitive on a molecular level before IgE has been approved as monotherapy for
response is clinically seen on standard skin allergic rhinitis; it has been shown to be
testing; this may lead to positive results on most effective in patients in whom
laboratory tests that are not triggering significant congestion is a primary
clinical symptoms. complaint.
• Nasal smear. Eosinophils usually indicate • Allergen immunotherapy: Immunotherapy
allergy. with daily sublingual tablets may be able to
replace weekly injections in some
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individuals, depending on the offending by blowing the nose first then

allergens; depending on the particular administering the medication.
sublingual tablet, therapy must be initiated o Encourage a routine cleaning of the
at least 3-4 months before the allergen house, furniture, and equipment
season that is being treated. which may house dust and other
• Intranasal mast cell stabilizers. they produce pollen.
mast cell stabilization and anti-allergic o Administer pharmacologic
effects by inhibiting mast cell degranulation. treatment as ordered by the
Nursing Management physician.
• Nursing Assessment • Expected Outcomes
o Assess history to identify seasonal o Patient no longer breathes through
variations, provocative elements in the mouth.
the environment, and the timing of o Airway is back to normal,
events that lead to symptoms especially the nose.
• Nursing Diagnosis o Patient sleeps 6-8 hours a day.
o Ineffective airway clearance related o Patient and significant others
to obstruction or presence of describe the level of anxiety and
thickened secretions. coping patterns.
o Disturbed sleep pattern related to o Patient and significant others know
obstruction of the nose. and understand about the disease
o Anxiety related to lack of and treatment.
knowledge about the disease and
medical action procedure. Contact dermatitis
• Planning • A type IV delayed hypersensitivity reaction,
o The major goals for a patient with is an acute or chronic skin inflammation that
allergic rhinitis are: results from direct skin contact with
▪ Patient will no longer chemicals or allergens.
breathe through the • Often sharply demarcated inflammation and
mouth. irritation of the skin caused by contact to
▪ Airway will be back to substances by which the skin is sensitive.
normal, especially the Basic types/classifications:
nose. • Allergic dermatitis (results from direct
▪ Patient will sleep 6-8 contact with substances called allergens.)
hours a day.
▪ Patient and parents will • Irritant contact dermatitis (develops
describe the level of when skin comes into contact with an
anxiety and coping irritating substance.)
patterns.
▪ Patient and significant • Phototoxic contact dermatitis. (sunburn-
others will know and like skin disorder resulting from direct
understand about the tissue damage following the ultraviolet
disease and treatment. light-induced activation of a phototoxic
• Nursing Interventions agent).
o Identification and elimination of
the allergen. • Photoallergic contact dermatitis. (a
o Teach the patient and significant delayed-type hypersensitivity
others on how to use nasal sprays cutaneous reaction in response to a
photo-antigen applies to the skin in
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subjects previously sensitized to the same • Thin-layer Rapid Use Epicutaneous (TRUE)
substance. test -a patch test most commonly used
Pathophysiology Medical Management
• Involves pathogens that irritate the skin. • Avoiding the irritant.
• The hapten (small hydrophobic molecules)- • Photo therapy (light therapy to calm their
protein complex enters the stratum corneum immune system)
and binds to epidermal antigen-presenting • Medicated baths
Langerhans cells. Pharmacologic Therapy
• These cells process the antigen and travel to • Hydrocortisone/Corticosteroid (to combat
regional lymph nodes where they present the inflammation in a localized area).
antigen to naive CD4 T cells. • Antihistamine
• These T cells then proliferate into memory • Barrier cream. (to provide a protective layer
and effector T cells, which elicit contact for the skin.)
dermatitis within 48 to 96 hours of re- • Antibiotic (to treat secondary infection)
exposure to the allergen. Nursing Management
Causes • Nursing Assessment
• Water can aggravate contact dermatitis, o Assess skin, noting color, moisture,
through frequent hand washing and texture, and temperature.
prolonged contact with water. o Note erythema, edema, tenderness,
• All kinds of soaps, detergents, shampoos presence of erosions, excoriations,
and other cleaning agents have harmful fissures, and thickening.
substances that could possibly irritate the o Assess the patient’s perception of
skin. and behavior related to changed
• Solvents such as turpentine, kerosene, fuel, appearance
and thinners are strong substances that are • Nursing Diagnosis
harmful to the sensitive skin. o Impaired skin integrity related to
• Extremes of temperature. contact with irritants or allergens.
Clinical Manifestations o Disturbed body image related to
• Once the patient is exposed to an irritating visible skin lesions.
substance, severe itching would occur. o Risk for infection related to
• Skin turns red as a result of the irritation. excoriations and breaks in the skin.
• Vesicle type of skin lesion, weeping, which o Risk for impaired skin integrity
can be a pus or watery substance. Then later related to frequent scratching and
will start to form crust as it slowly becomes dry skin.
dry and peels off • Planning
Complications o The patient will
• Neurodermatitis starts with a patch of itchy ▪ maintain optimal skin
skin, which, when scratched habitually, may integrity within limits of
result in a thick,leathery, and discolored the disease, as evidenced
skin. by intact skin.
• If a rash is scratched habitually, it may turn ▪ verbalize feeling about
into an open wound wherein bacteria could lesions and continues
enter and cause infection. daily activities and
Assessment and Diagnostic Findings interactions.
• The location of the skin eruption and the ▪ remain free of secondary
history of exposure infection.
• Patch test on the skin with suspected
offending agents may clarify the diagnosis.
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▪ report increased comfort

level and skin remains
intact.
• Nursing Interventions
o Encourage the patient to bathe in
warm water using a mild soap, then
air dry the skin and gently pat to
dry.
o Application of topical steroid
creams and ointments is twice a
day, spread thinly and sparingly.
o Prepare the patient for photo
therapy, because this method uses
ultraviolet A or B light waves to
promote healing of the skin.
o Allow patient to verbalize feelings
regarding their skin condition.
o Encourage the patient to keep the
skin clean, dry, and well lubricated
to reduce skin trauma and risk for
infection.
• Expected Outcomes Pathophysiology
o Patient maintained optimal skin
• Inside-out : Immunological disturbance
integrity within limits of the
causes IgE mediated sensitization, epithelial
disease, as evidenced by intact
barrier dysfunction is secondary
skin.
• Outside-in: Epidermal barrier dysfunction
o Patient verbalized feeling about
allows irritants and allergens into the skin,
lesions and continues daily
with immunological disturbance secondary
activities and interactions.
Etiology
o Patient remained free of secondary
• Genetic: A family history of atopic
infection.
dermatitis (AD) is common. The strongest
o Patient reported increased comfort
known genetic risk factor for developing AD
level and skin remains intact.
is the presence of a loss-of-function
mutation in filaggrin (is a filament-
Atopic dermatitis
associated protein that binds to keratin fibers
• It is a Type I Immediate Hypersensitivity
in epithelial cells)
disorder characterized by inflammation and
• Infection: The skin of patients with AD is
hyperactivity of the skin.
colonized by Staphylococcus Aureus.
• It is a chronic, pruritic inflammatory skin
• Hygiene: The hygiene hypothesis is touted
condition that typically affects the face
as a cause for the increase in AD. This
(cheeks), neck, arms, and legs but usually
attributes the rise in AD to reduced exposure
spares the groin and axillary regions.
to various childhood infections and bacterial
• Usually starts in early infancy, but also
endotoxins.
affects a substantial number of adults.
• Climate: AD flares occur in extremes of
• Commonly associated with elevated levels
climate. Heat is poorly tolerated, as is
of immunoglobulin E (IgE).
extreme cold. A dry atmosphere increases
xerosis. Sun exposure improves lesions, but
sweating increases pruritus. These external
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factors act as irritants or allergens, other conditions (eg, cutaneous T-cell

ultimately setting up an inflammatory lymphoma)
cascade. Medical Management
• Food antigens: The role of food antigens in • Guidelines for treatment includes
the pathogenesis of AD is controversial, o Decreasing itching and scratching
both in the prevention of AD and by the by wearing cotton fabrics, washing
withdrawal of foods in persons with with a mild detergent
established disease. Because of the o Humidifying room temperature at
controversy regarding the role of food in 20C to 22C (68F to 72F)
AD, most physicians do not withdraw food o Avoiding animals, dusts, sprays
from the diet. and perfumes.
Clinical Manifestations o Keeping skin moisturized with
• Incessant pruritus (itchiness) daily baths to hydrate the skin and
• Xerosis (dry skin) the use of topical skin moisturizers
• Lichenification (thickening of the skin and is encouraged
an increase in skin markings) o Avoiding specific foods as
• Eczematous lesions (skin inflammation) appropriate if there is concomitant
• The eczematous changes and its morphology food allergy
are seen in different locations, depending on Pharmacological Management
the age of the patient (ie, infant, child, or • Moisturizers: Petrolatum, Aquaphor, or
adult). newer agents such as Atopiclair and Mimyx
• The following is a constellation of • Topical steroids (current mainstay of
symptoms and features commonly seen in treatment; commonly used in conjunction
AD: with moisturizers): Hydrocortisone,
o Pruritus triamcinolone, or betamethasone; ointment
o Early age of onset bases are generally preferred, particularly in
o Chronic and relapsing course dry environments
o IgE reactivity • Broad immunomodulators: Tacrolimus and
o Peripheral eosinophilia pimecrolimus (calcineurin inhibitors;
o Staphylococcus aureus generally considered second-line therapy)
superinfection • Targeted biologic therapies: Dupilumab
o Personal history of asthma or hay (anti-IL-4Ra monoclonal antibody)
fever or a history of atopic diseases Other treatments
in a first-degree relative • Ultraviolet (UV)-A, UV-B, a combination of
Assessment and Diagnostic Findings both, psoralen plus UV-A (PUVA), or UV-
• B1 (narrow-band UV-B) therapy
• Essential features/manifestations must be • In severe disease, methotrexate,
present azathioprine, cyclosporine, and
• Complete blood cell count can be useful to mycophenolate mofetil
exclude immune deficiency; an IgE level • Everolimus
can be helpful to confirm an atopic pattern; a • Probiotics
swab of skin can be helpful to identify S • Antibiotics for clinical infection caused by S
aureus superinfection aureus or flares of disease
• Allergy and radioallergosorbent testing is of • Intranasal mupirocin ointment and diluted
little value bleach (sodium hypochlorite) baths
• Biopsy shows an acute, sub-acute, or Nursing Management
chronic spongiotic dermatitis pattern that is • Nursing Assessment
nonspecific but can be helpful to rule out
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o Assess patient’s skin, noting open o Assist with allergy testing,

areas, drainage, or signs of including patient/parent education:
infection; Bacterial skin infections Allergy patch testing may be done
are common due to excoriation to determine allergens and triggers
from scratching. Crusting of broken for atopic dermatitis. Education
blisters may be present should be provided on how to
o Obtain history from patient and prepare for the patch test (no
significant others to determine lotions, creams) and when to return
triggers to be evaluated.
• Nursing Diagnosis o Apply topical medications and
o Impaired Skin Integrity related to bandages as appropriate. Topical
Contact with irritants or allergens corticosteroids are the first line of
o Disturbed Body Image related to treatment for eczema flare ups.
visible skin lesions o Administer oral medications as
o Risk for Infection secondary to required. Oral antihistamines may
Impaired skin integrity related to be given to help relieve symptoms
severe inflammation/Excoriation of itching and manage allergies. Be
o Risk for impaired Skin Integrity mindful of sedative effects of
related to severe pruritus, scratches antihistamines.
skin frequently, dry skin o Oral steroids may be given short-
• Planning term for severe symptoms.
o Goal of Care: o Provide resources and referral
▪ Patient will be free of rash information and education for
and pain; patient’s skin prevention
will be free from o Make sure that the patient’s nails
excoriation and infection are short and clean.Itching is the
• Nursing Interventions most prevalent symptom. Long,
o Routinely monitor skin to sharp or dirty nails can cause
determine effectiveness of secondary infections to develop on
interventions. Most flare-ups are the skin.
related to sensitivities to foods, • Expected Outcomes
items that contact the skin, hygiene o Patient maintains optimal skin
products, changes in weather and integrity within limits of the
immune response. disease, as evidenced by intact
o Encourage proper skin care skin.
including bathing and regular use o Patient verbalizes feeling about
of emollient creams (petroleum lesions and continues daily
jelly, etc.) Over washing and using activities and social interactions.
harsh soaps can make symptoms o Patient remains free of secondary
worse. Dry skin is prone to cracks infection.
and infection. o Patient reports increased comfort
o Encourage fragrance and dye free level and skin remains intact.
soaps when bathing.
o Avoid frequent baths. Infants do Management of Patients with Rheumatic
not need daily baths unless visibly Disorders
dirty. Rheumatic disorders
o Apply emollient creams frequently • Commonly called arthritis (inflammation of
to keep skin soft and hydrated. a joint), primarily affect skeletal muscles,
BSN-3C0
bones, cartilages, ligaments, tendons, and

joints in males and females in all ages.
Rheumatic or musculoskeletal conditions comprise
over 200 diseases and syndromes, which are usually
progressive and associated with pain. These
conditions can affect the joints, connective tissue,
cartilage, and tendons. Many of these conditions that
are considered autoimmune diseases, which arise Pathophysiology
from an abnormal immune response of the body • The autoimmune reaction primarily occurs
against it’s own tissues. in the synovial tissue.
Over 46 million people in the United States are living
• Phagocytosis produces enzymes within the
with some sort of rheumatic disease that has been
joint.
found to be the most common cause of reduced
• The enzymes break down collagen, causing
mobility.
edema, proliferation of the synovial
• Common Rheumatic Diseases and
membrane, and ultimately pannus formation
Musculoskeletal Conditions
(hypertrophied synovium)
o Ankylosing Spondylitis
• Pannus destroys cartilage and erodes the
o Osteoarthritis
bone.
o Rheumatoid Arthritis
• The consequences are loss of articular
o Lupus (Systemic Lupus
surfaces and joint motion.
Erythematous)
• Muscle fibers undergo degenerative
o Sjogren’s Syndrome
changes, and tendon and ligament elasticity
o Osteoporosis
and contractile power are lost.
o Steroid-Induced Osteoporosis
o Scleroderma
o Psoriatic Arthritis
o Fibromyalgia
o Polymyalgia Rheumatica
o Sarcoidosis
o Inflammatory Myositis
o Inflammatory Eye Disease
(particularly Uveitis)
o Autoimmune-related lung disease
o Vasculitis
o Dermatomyositis
o Behcet’s Disease Etiology
o Gout • Diffuse connective tissue diseases have
o Tendinitis and Bursitis unknown causes, but they are also thought to
o Osteonecrosis of the Jaw be the result of immunologic abnormalities.
• Researchers have shown that people with a
Rheumatoid arthritis specific gene marker called the HLA
• is an autoimmune disease of unknown (Human leukocyte antigens) shared epitope
origin. have a fivefold greater chance of developing
• It is classified as a diffuse connective tissue rheumatoid arthritis than do people without
disease and is chronic in nature. the marker.
• It is characterized by diffuse inflammation • Infectious agents. (bacteria and viruses)
and degeneration in the connective tissues • Female hormones.
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• Environmental factors. (exposure to • Serum complement: C3and C4 increased in

cigarette smoke, air pollution, and acute onset (inflammatory response).
insecticides.) Immune disorder/exhaustion results in
• Occupational exposures ( exposure to silica depressed total complement levels.
and mineral oil may harm the worker and • Erythrocyte sedimentation rate (ESR):
result in contact dermatitis.) increased in RA
Clinical Manifestations • C-Reactive protein: elevated in RA
• Joint pain. • CBC: Usually reveals moderate anemia.
• Swollen joints WBC is elevated when inflammatory
• Warmth in the affected joint and upon processes are present.
palpation, the joints are spongy or boggy. • Immunoglobulin (Ig) (IgM and IgG):
• Erythema (Redness of the affected area). Elevation strongly suggests autoimmune
• Lack of function due to pain. process as cause for RA.
• Deformities of the hands and feet (may be • X-rays of involved joints: Reveals soft-
caused by misalignment resulting in tissue swelling, erosion of joints, and
swelling). osteoporosis in adjacent bone (early
• Rheumatoid nodules may be noted in changes) progressing to bone-cyst
patients with more advanced RA, and they formation, narrowing of joint space, and
are non-tender and movable in the subluxation. Concurrent osteoarthritic
subcutaneous tissue. changes may be noted.
• Radionuclide scans: Identify inflamed
synovium.
• Direct arthroscopy: Visualization of area
reveals bone irregularities/degeneration of
joint.
• Synovial/fluid aspirate: May reveal volume
greater than normal; opaque, cloudy, yellow
appearance (inflammatory response,
bleeding, degenerative waste products);
elevated levels of WBCs and leukocytes;
Complications
decreased viscosity and complement (C3and
Medications used for treating rheumatoid arthritis
C4).
may cause serious and adverse side effects.
• Synovial membrane biopsy: Reveals
• Bone marrow suppression. Improper use of
inflammatory changes and development of
immunosuppresants could lead to bone
pannus (inflamed synovial granulation
marrow suppression.
tissue).
• Anemia. (when taking Immunosuppressive
Medical Management
agents such as as methotrexate (Links to an
• Balance of rest and exercise plan
external site.)and cyclophosphamide)
• Biologic response modifiers, consist of
• Gastrointestinal disturbances (when taking
molecules produced by cells of the immune
Non Steroidal Non Inflammatory Drugs
system participate in the inflammatory
NSAIDS).
reactions.
Assessment and Diagnostic Findings
• Occupational and physical therapy is
• Antinuclear antibody (ANA) titer: elevated
prescribed to educate the patient about the
in RA patients
principles of joint protection, pacing
• Rheumatoid factor (RF): Positive in RA
activities, work simplification, range of
• Latex fixation: Positive in RA
motion, and muscle-strengthening exercises.
• Agglutination reactions: Positive in RA
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• Nutrition (Basic food groups, with emphasis • Tenorrhaphy (suturing of a tendon).

on foods high in vitamins, protein, and iron • Arthrodesis (surgical fusion of the joint.)
for tissue building and repair) • Arthroplasty (surgical repair and
Pharmacologic Therapy replacement of the joint).
• Early Rheumatoid Arthritis Nursing Management
o COX-2 medications block the • Nursing Assessment
enzyme involved in inflammation o History and physical
while leaving intact the enzyme exam.(manifestations: bilateral and
involved in protecting the stomach symmetric stiffness, tenderness,
lining. swelling, and temperature changes
o Methotrexate is currently the in the joints.)
standard treatment of RA because • Extra-articular changes. ( include weight
of its success in preventing both loss, sensory changes, lymph node
joint destruction and long-term enlargement, and fatigue).
disability. • Nursing Diagnosis
o Additional analgesia may be o Acute and chronic pain related to
prescribed for periods of extreme inflammation and increased disease
pain. activity, tissue damage, fatigue, or
• Moderate, Erosive Rheumatoid Arthritis lowered tolerance level.
o Neoral, an immunosuppressant is o Fatigue related to increased disease
added to enhance the disease activity, pain, inadequate sleep/rest,
modifying effect of methotrexate. inadequate nutrition, and emotional
• Persistent, Erosive Rheumatoid Arthritis stress/depression
o Systemic corticosteroids are used o Impaired physical mobility related
when the patient has unremitting to decreased range of motion,
inflammation and pain or needs a muscle weakness, pain on
“bridging”medication while movement, limited endurance, lack
waiting for slower DMARDs to or improper use of ambulatory
begin taking effect. devices.
• Advanced, Unremitting Rheumatoid o Self care deficit related to
Arthritis contractures, fatigue, or loss of
o Immunosuppressive agents are motion.
prescribed because of their ability o Disturbed body image related to
to affect the production of physical and psychological changes
antibodies at the cellular level and dependency imposed by
o Short term use of low-dose chronic illness.
antidepressants (such as o Ineffective coping related to actual
amitriptyline, paroxetine, or or perceived lifestyle or role
sertraline) to reestablish an changes.
adequate sleep pattern and to • Planning
manage chronic pain. o Goals of Care: The patient will
Surgical Management ▪ Have an improvement in
• Reconstructive surgery (indicated when pain comfort level.
cannot be relieved by conservative measures ▪ Incorporate pain
and the threat of loss of independence is management techniques
eminent.) into daily life.
• Synovectomy (excision of the synovial ▪ Incorporate strategies
membrane.) necessary to modify
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fatigue as part of the daily affected joints; promote use of

activities. assistive ambulatory devices;
▪ Attain and maintain explain use of safe footwear; use
optimal functional individual appropriate
mobility. positioning/posture.
▪ Adapt to physical and o Assist to identify environmental
psychological changes barriers.
imposed by the rheumatic o Encourage independence in
disease. mobility and assist as needed:
▪ Use of effective coping Allow ample time for activity;
behaviors for dealing with provide rest period after activity;
actual or perceived reinforce principles of joint
limitations and role protection and work simplification.
changes. o Assist patient to identify self-care
• Nursing Interventions deficits and factors that interfere
o Teach comfort measures(eg, with ability to perform self-care
application of heat or cold; activities.
massage, position changes, rest; o Develop a plan based on the
foam mattress, supportive pillow, patient’s perceptions and priorities
splints; relaxation techniques, on how to establish and achieve
diversional activities). goals to meet self-care needs,
o Administer anti-inflammatory, incorporating joint protection,
analgesic, and slow-acting energy conservation, and work
antirheumatic medications as simplification concepts
prescribed. o Provide appropriate assistive
o Encourage verbalization of feelings devices; reinforce correct and safe
about pain and chronicity of use of assistive devices; allow
disease. patient to control timing of self-
o Assist in identification of and care activities; explore with the
assess for subjective changes in patient different ways to perform
pain. difficult tasks or ways to enlist the
o Develop and encourage a sleep help of someone else.
routine (warm bath and relaxation o Monitor for medication side
techniques that promote sleep); effects, including GI tract bleeding
explain importance of rest for or irritation, bone marrow
relieving systematic, articular, and suppression, kidney or liver
emotional stress. toxicity, increased incidence of
o Identify physical and emotional infection, mouth sores, rashes, and
factors that can cause fatigue. changes in vision. Other signs and
o Facilitate development of symptoms include bruising,
appropriate activity/rest schedule. breathing problems, dizziness,
o Encourage adequate nutrition, jaundice, dark urine, black or
including source of iron from food bloody stools, diarrhea, nausea and
and supplements. vomiting, and headaches.
o Encourage verbalization regarding o Monitor closely for systemic and
limitations in mobility. local infections, which often can be
o Assess need for occupational or masked by high doses of
physical therapy consultation: corticosteroids.
Emphasize range of motion of
BSN-3C0
• Expected Outcome least one first-degree family member

o The patient (parent, sibling, child) with the disease.
▪ Improved comfort level. • Environmental factors, susceptibility to
▪ Incorporated pain certain viruses, and an immune system
management techniques dysfunction with production of auto-
into daily life. antibodies are possible causes.
▪ Incorporated strategies • Hormonal abnormality and ultraviolet
necessary to modify radiation are considered possible risk factors
fatigue as part of the daily for the development of SLE.
activities. • Some drugs have been implicated as
▪ Attained and maintained initiating the onset of lupus-like symptoms
optimal functional and aggravating existing disease; they
mobility. include hydralazine hydrochloride,
o Adapted to physical and procainamide hydrochloride, penicillin,
psychological changes imposed by isonicotinic acid hydrazide, chlorpromazine,
the rheumatic disease. phenytoin, and quinidine.
o Used effective coping behaviors for • Possible childhood risk factors include low
dealing with actual or perceived birth weight, preterm birth, and exposure to
limitations and role changes. farming pesticides.
Medical Management
Systemic Lupus Erythematosus • Involves regular monitoring to assess
• is a chronic autoimmune disease that causes disease activity and therapeutic effectiveness
a systemic inflammatory response in various Assessment and Diagnostic Findings
parts of the body. Is a multi-system • History: Ask the following
inflammatory disease that affects any body o Systemic symptoms include
system but primarily the musculo-skeletal, fatigue, malaise, weight loss,
cutaneous, renal, nervous, and anorexia, and fever.
cardiovascular systems o Musculoskeletal and cutaneous
symptoms, including joint and
muscle pain, puffiness of hands and
feet, joint swelling and tenderness,
hand deformities, and skin lesions
such as the characteristic "butterfly
Pathophysiology rash" (fixed reddish and flat rash
that extends over both cheeks and
• The body loses its ability to discriminate
the bridge of the nose). Other
between antigens and its own cells and
symptoms may include
tissues. It produces antibodies against itself,
maculopapular rash (small, colored
called autoantibodies, and these antibodies
area with raised red pimples),
react with the antigens and result in the
sensitivity to the sun, photophobia,
development of immune complexes.
vascular skin lesions, leg ulcers,
• Immune complexes proliferate in the tissues
oral ulcers, and hair loss.
of the client with SLE and result in
o Genitourinary tract (menstrual
inflammation, tissue damage, and pain.
abnormalities, amenorrhea,
Etiology
spontaneous abortion) or central
• Not known, however a familial association
nervous system (visual problems,
has been noted that suggests a genetic
memory loss, mild confusion,
predisposition. Patients with SLE have at
BSN-3C0
headache, seizures, psychoses, loss needs to have at least four of the criteria
of balance, depression). (including one clinical and one
o Hematologic system (venous or immunological) using the mnemonic SOAP
arterial clotting, bleeding BRAIN MD:
tendencies),
o Cardiopulmonary system (chest
pain, shortness of breath, lung
congestion),
o Gastrointestinal system (nausea,
vomiting, difficulty swallowing,
diarrhea, and bloody stools).
o Immune system dysfunction or
recent viral infections,hormonal
abnormality or ultraviolet radiation.
o Medications taken implicated as
initiating lupus-like symptoms.
• Physical Examination: Check for the Medical Management
following • Involves regular monitoring to assess
o lesions and necrosis on the disease activity and therapeutic effectiveness
fingertips, toes, and elbows • General supportive therapy includes
o hair loss. adequate sleep and avoidance of fatigue
o signs of arthritis, because mild disease exacerbations may
lymphadenopathy, and peripheral subside after several days of bed rest.
neuropathy. • A physical therapy program is important to
o joint discomfort. maintain mobility and range of motion
o pleural or pericardial friction rub. without allowing the patient to get overtired.
o splenomegaly, or hepatomegaly. If the kidneys are involved, renal dialysis or
o hematuria, proteinuria, and casts. transplantation may be required.
o fever, pallor, and signs of bleeding, Pharmacological Management
including petechiae and bruising. • Hydroxychloroquine (Plaquenil) - Reduces
o increased blood pressure rash, photosensitivity, arthralgias, arthritis,
• Psychosocial alopecia, and malaise
o problems maintaining professional • Corticosteroids- Control SLE in most severe
and family roles and may or life-threatening cases
experience loss over a deteriorating (glomerulonephritis, debilitation from
health status or loss of childbearing symptoms)
potential • Disease-modifying antirheumatic drugs
Diagnostics Tests (DMARDs) - Suppress immune system and
• Complete blood count, erythrocyte reduce consequences of disease
sedimentation rate, antinuclear antibody, • NSAIDs - Treat the joint pain and swelling;
urinalysis, anti-DNA antibody, complement should be avoided in patients with active
levels, anti–double-stranded DNA antibody nephritis
assay, blood urea nitrogen, creatinine, • Monoclonal antibody (rituximab [Rituxan]).
creatinine clearance, creatine kinase assay, • Topical steroids are often used to treat skin
liver function tests. rashes.
• To make the diagnosis of lupus, the • Anticonvulsants for seizures
American College of Rheumatology
developed the following list. The patient
BSN-3C0
Nursing Management an absence of rashes and

• Nursing Assessment skin lesions.
o Physical changes: Vital signs, ▪ implement a pain
particularly blood pressure and management plan that
temperature; daily weight, intake includes pharmacological
and output; signs of bleeding or and nonpharmacological
tarry stools, petechiae, bruising, measures.
pallor ▪ participate in self-care
o Physical changes: Location site and activities.
description of any skin lesions or ▪ Verbalize reduction in
rashes and overall condition of the fatigue level, as evidenced
skin by reports if increased
o Physical changes: Presence of any energy and ability to
seizure activity, visual perform desired activities.
disturbances, headaches, ▪ demonstrate the use of
personality changes, or memory energy-conservation
deficits principles.
o Tolerance to activity, level of pain ▪ verbalize understanding of
and fatigue, patient's ability to disease process and its
perform activities of daily living treatment
and range of motion of extremities; • Nursing Interventions
note the extent of joint involvement o Assess and monitor skin for rash:
and the presence of tingling, The hallmark sign of SLE is a
numbness, or weakness malar butterfly rash across the
• Nursing Diagnosis cheeks and bridge of the nose; rash
o Impaired Skin Integrity related to may develop on the face, neck,
Exacerbation of disease chest or extremities
process/High-dose corticosteroid o Assess mucous membranes;
use/Inflammation/Use of encourage oral hygiene; rinse
immunosuppressant mouth with half-strength peroxide
drugs/Vasoconstriction three times per day. Oral lesions
o Acute pain related to inflammation and ulcers are common symptoms;
associated with increased disease peroxide helps to keep oral lesions
activity clean and promote healing
o Fatigue related to o Assess and manage pain:
Anemia/Depression/Disease Inflammation and SLE related
condition arthritis can cause significant pain
o Deficient knowledge related to and stiffness of joints; Medication
Complexity of treatment/Emotional may be necessary, but encourage
state affecting other alternatives as well.
learning/Misinterpretation of o Encourage deep breathing exercises
information/New condition or to promote adequate gas exchange
treatment and prevent lung diseases
• Planning (Splinting/Incentive
o The patient will spirometer/Relaxation) :Patients
▪ maintain optimal skin may report chest pain with deep
integrity, as evidenced by breathing. Encourage breathing
exercises to open airways, reduce
pain and relieve anxiety. Incentive
BSN-3C0
spirometers and splinting with

pillows may be beneficial.
o Cluster care and schedule activity:
Fatigue is a common complaint for
patients with lupus. Encourage
activity as tolerated but discourage
patients from overexertion. Cluster
care to reduce fatigue and conserve
energy.
o Monitor lab / diagnostic tests: Lab
tests can help determine the extent,
if any, of organ failure or
dysfunction and therefore
determine progression of disease
and response to treatments.
o Administer medications
appropriately: Medications are
often given to suppress immune
system, treat existing inflammation
and manage symptoms such as
pain. Monitor for GI discomfort or
irritation when giving medications;
prevent constipation if opioids are
given.
o Nutrition and lifestyle education:
Maintaining a healthy lifestyle and
staying active can help improve
immunity and reduce the number
and frequency of flares. Sun
exposure often triggers rash and
flare, try to avoid; Rest helps
promote healing and reduces
inflammation.
• Expected Outcomes
o Patient verbalized relief of pain and
discomfort
o Patient verbalized relief of fatigue
o Patient skin integrity is maintained
o Patient complied with the
prescribed medications
o Patient increased knowledge
regarding the disease
o Patient shows no signs of
complications

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Care of Clients with Problems in the Oxygenation, Fluid & Electrolyte, Infectious, Inflammatory, Immunologic Response

Cruz, Larraine Jhasmine D.

Module 1 compulsion to take the drug

● Hyperalgesia ○ chemical substances that increase

○ nerve fiber that usually does not

Neurophysiological Transmission of Pain

● Substance P areas controlling blood pressure, heart

● The pain gate in the spinal cord can be shut

- Patient is asked to mark on the

Factors that Influence Pain Response:

● Gender ● Anxiety r/t past experiences of poor pain

their pain o platelet aggregation and

▪varying effects in ● EMLA (eutectic mixture of local

▪ Act directly on opiate all injection parts connected to the

● Antiseizure medications (phenytoin painful sensations can

● Relaxation Techniques electrical pulses to the

III. Neurologic and Neurosurgical Interventions

■ A high risk patient is at ● EXPLORATORY

PREOPERATIVE PHASE ● Upper respiratory infection

● Nutritional Status ○ General anesthesia is usually

and difficult ○ Response is determined by culture,

■ for cancer patients ○ Visual Impairment/Blindness

SURGEON AND ■ Permission for a lifesaving

renders the patient ■ Muscle pumping exercises

●Repeat 5 X and ○ Anxiolytic agents (e.g. alprazolam

Preparing the patient on the day of the surgery

● Assist in transferring the patient from bed to

Ante Before or forward

Anti Against or opposite

Hyper Above or over or

Retro Behind or posterior to

Operating room Colon Colon

Ectomy Removal or surgical

Ostomy Creation of an artificial/

Otomy Cutting into an organ/

Pexy Fix/ suture in place

Plasty Restoration of a lost

● Position - Anesthesiologist ●The person who

receptacles, under the ● Cultures are obtained under sterile

● Cross infection - Infection contracted by a and should be changed

-All articles must be

●Cold sterilization department and hospital

● C-arm machine is a piece of medical ● Gowning

○ Stages of general anesthesia

Analgesia Loss of Drowsy, Close

● Simple local infiltration

○ For alcoholics extremities from dangling over the

● Rectoperineal and vaginal area Phase I

● Monitor & maintain client’s temperature; ● Provide wound care

○ Report tachycardia, tachypnea,

○ Reinforce deep breathing,

○ ABG- respiratory alkalosis

● A strategy to prevent dehiscence is to place Deep vein thrombosis

● heals as edges are approximated by close ● Physiologic mechanisms to

Classification of stress Adaptation

or behavior so that a person is better suited Models of Stress

o The response is a physiological one Pathophysiology of stress and disease

• Local Adaptation Syndrome (LAS)

damage. The response social support or help, knowledge,

Psychological adaptation to anxiety

▪ Ways people describe,

o Physical • the client is