THE PERIOPERATIVE NURSING

c. Postoperative Phase
Microsurgical or laser technology Evaluation
Transplantation of mechanical  Appraises the quality of nursing
devices (pacemaker) care during preop and
Reattachment of body parts intraoperative phase.
Use of robots  Determines of the expected
outcomes (A,P,I).
4 domains of perioperative
nursing *OR environment should
S – Safety (aseptic technique be safe for both the
practices) surgical team and the
P – Physiologic responses (reflexes patient.
and consciousness are altered)
B- Behavioral (cognitive function Q – Quality improvement
or logic of pt. is impaired) as an ongoing process
H – Health Care System (hospital U - Understanding
protocols) regulations, standards,
policies, and procedures
that provide guidelines
for acceptable practices.
Perioperative Period A - Accountability for
a. Preoperative Phase – decision to one’s action
have surgery > transport to OR L - Legal rights of
table. patients
b. Intraoperative Phase – OR table > I – Individualized patients
RR/PACU care
c. Postoperative Phase – PACU > T- Technical competence
full recovery Y – Your surgical and
ethical conscience.
Nursing Process into Phases of
Perioperative Nursing Surgical Conscience
a. Preoperative Phase  Awareness inner voice for
Assessment and Planning conscientious practice
 Identify actual or potential Four Major Type of
problems (Physiologic/psychologic) Pathologic Processes
 Determines the Nsg Dx and Requiring Surgical
expected outcome Intervention
 Plans and prioritize the nsg O – Obstruction
intervention. P – Perforation
b. Intraoperative Phase E – Erosion
Implementation T – Tumors
>Carries out plan of care with
skill, efficiency and Anastomosis – cutting of defective
effectiveness. intestine.
 d. Elective – not absolutely
necessary for survival
Classification of Surgical e. Optional – requested by the client.
Procedures f. Day (Ambulatory Surgery) done
1. PURPOSE on out-patient.
a. Diagnostic – Presence
b. Exploratory – Extent SURGICAL RISKS
c. Curative – Treat I. GENERAL RISK FACTORS
c.1 Ablative – removal of O – Obesity
the diseased organ F – Fluid, electrolyte and
c.2 Constructive - Used nutritional problems
for the restoration or A – Age
repair of a function or P- Presence of dse
appearance P – Pharmacotherapy
c.3 Reconstructive – (concurrent or prior)
Repair of a damaged N – Nature of the
organ condition of the pt.
d. Palliative – release of L – Location of the
reduces pain or the symptoms condition
but not really curing., M – Magnitude and
urgency of the surgical
2. DEGREE OF RISK procedure
a. Major Surgery M – Mental attitude of the
H – High Risk person toward surgery
E – Extensive C – Caliber of the
L – Large Amount of Blood professional staff and
Loss healthcare facilities
P – Prolonged
M – May handle or remove SURGICAL SETTINGS
vital organs  Surgical suites
E – Extreme sick of  Ambulatory care settings
complications  Clinics
b. Minor Surgery  Physician offices
L – Less risk  Community setting
O – Obviously not prolonged  Homes
W – With few serious
complications Perioperative Activities
 Assessement
3. URGENCY  Identify actual/ potential prolems
a. Emergency – done immediately  Planing specific are
b. Imperative – done within 24 to 48  Preoperative teaching
hours  Consent – should be signed
c. Planned/Required – weeks or Preoperative Health History
months (ABCDE)
 A. Allergy Cough with sputum production must
B. Bleeding tendencies be assessed for color, consistency,
C. Cortisone or steroid amount, and color
D. Diabetes Mellitus PND – Paroxysmal Nocturnal Dyspnea
E. Emboli R Bronchus – common site of
aspiration
Physiologic Assessment Cricothyroidotomy - also known as
 Age cricothyrotomy, is an important
 Presence of pain emergency procedure that is used to
 Nutritional Status, F &E balance obtain an airway when other, more
 Infection routine methods (eg, laryngeal mask
 Organ function (CP, Renal, GI, airway [LMA] and endotracheal
Liver, Endo, Neuro, Hematologic) intubation) are ineffective or
 Use of medications contraindicated.
 Presence of trauma Tracheostomy - is a medical procedure
— either temporary or permanent —
Preoperative Screening Test that involves creating an opening in the
CBC – determine Hg, Hct and infx neck in order to place a tube into a
Blood Type – in cases of blood person's windpipe. The tube is inserted
transfusion through a cut in the neck below the
S. Electrolyte – evaluate F/E vocal cords. This allows air to enter the
lungs.

I. RESPIRATORY ASSESSMENT III. PHYSICAL ASSESSMENT

a. Demographic  Absence of BS is an indication of
b. Family Hx – genetically inherited Pneumothorax
dse  Crackles BS may maybe an
c. Smoking indication of Pneumonia
d. Drug use – eg. Morphine SO4  Skin and mucus membrane
e. Allergies  Nail – clubbing “ Schamroth’s
f. Travel Sign”
g. Diet Hx  General appearance
h. Occupational Hx  Hering Bruer Reflex – a reflex
triggered to prevent overinflation
II. COMMON S/S: of the lungs
Symptom Analysis 1. ABG
O – Onset pH 7.35 – 7.45
D – Duration PCO2 : 35-45 mmHg
L – Location HCO3: 22-26 mEq/L
F – Frequency 2. Blood Tests
P – Progressing and radiating pattern RBC – Polycythemia-  RBC (120
Q – Quality – ask the pt. to describe days maturity)
A – Aggravating factors WBC – Leukocytopenia
A – Associated manifestations - Leukopenia
T – Tx pt. has already used 3. Sputum Exam
 C&S – Culture and Sensitivity humidifies and warms the air
Test as it is inhaled warms the air
Cytologic Exam- used for Lung as it is inhaled.
CA. o Paranasal Sinuses -
4. Radiographic prominent fxn of the sinuses
CXR – Chest X-ray/Standard X- is to serve as a resonating
ray – to detect areas of chamber in speech.
calcification in the lungs in TB o Pharynx - or throat, is a tube-
patients. like structure that connects
If Opaque dye will be used for X- the nasal and oral cavities to
Ray. the larynx.
PreOp: o Larynx - or voice organ, is a
 Ask for allergy Hx cartilaginous epithelium lined
 Check for BUN-Creatinine structure that connects the
Lab results pharynx and the trachea.
PostOp: - the major fxn is for
 Encourage patient to drink vocalization.
plenty of H20. o Trachea (Windpipe) - serves
 Encourage patient to void as the passage between the
in the toilet larynx and the bronchi.
5. Mantoux/PPD – reactive for TB
test  Lower Respiratory System -
- 24 to 72 hrs. 10mm enables the exchange of gases to
- HIV patient 5mm (+) regulate serum PaO2, PaCO2 and
pH.
o Lungs - Are paired elastic
structures enclosed in the
thoracic cage which is an
airtight chamber with
distensible walls.
o Pleura - Serous membranes
that line the lungs and wall of
the thorax.
RESPIRATORY SYSTEM: Anatomy & o Bronchi and Bronchioles
Physiology Overview o Alveoli - basic gas exchange
unit of the respiratory system
-Comprise of the upper airway and o Alveolar stretch receptors
lower airway structures. respond to inspiration by
sending signals to inhibit
 Upper Respiratory System - inspiratory neurons in the
Filters, moistens and warms air brain stem to prevent lung
during inspiration over distention.
o Nose - serves as a passageway o During expiration stretch
for air to pass to and from the receptors stop sending signals
lungs. It filters impurities and to inspiratory neurons and
 inspiration is ready to start
again.  Management:
o O2 and CO2 are exchanged o Antihistamines
across the alveolar capillary o Corticosteroids nasal sprays
membrane by process of o Desensitizing immunizations
diffusion.
o Neural control of respirations  Nursing Interventions
is located in the medulla. The o Instruct patient with allergic
respiratory center in the rhinitis to avoid or reduce
medulla is stimulated by the exposure to allergens and
concentration of CO2 in the irritants.
bld. o Instructs the patient in
o Chemoreceptors, a secondary correct administration of
feedback system, located in nasal medications
the carotid arteries and aortic o To achieve maximal relief, the
arch respond to hypoxemia. patient is instructed to blow
These chemoreceptors also the nose before applying any
stimulate the medulla. medication into the nasal
cavity.
DISORDERS OF THE UPPER Coryza
RESPIRATORY SYSTEM Immunotherapy
Desensitizing immunization -
RHINITIS - Is a group of disorders introducing attenuated virus or
characterized by inflammation and bacteria gradually to keep the patient
irritation of the mucous immune to certain dse.
membranes of the nose.
 Allergic rhinitis - is further Co2 : 35 - 45 mmHg
classified as seasonal rhinitis O2 : 85-100
(occurs during pollen seasons) or
perennial rhinitis (occurs VIRAL RHINITIS (COMMON COLD)
throughout the year). Commonly  - Most frequent viral infection in
associated with exposure to the general population caused by
airborne particles such as dust, corona virus. It is highly
dander, or plant pollens in people contagious because virus is shed
who are allergic to these for about 2 days before the
substances. symptoms appear and during the
first part of the symptomatic
 Clinical Manifestations: phase.
o Rhinorrhea - excessive nasal
drainage, runny nose.  Clinical Manifestations:
o Nasal congestion o Low-grade fever
o Sneezing o Nasal congestion
o Pruritus of the nose, roof of o Rhinorrhea and nasal
the mouth, throat, eyes, and discharges
ears. o Halitosis, sneezing
o Tearing watery eyes
 o "Scratchy" or sore throat  Cool beverages, warm liquids,
o General malaise, chills and flavored frozen desserts
o Headaches and muscle aches such as Popsicles are often
 Management: shooting
o Symptomatic therapy  Warm saline gargles or throat
o Adequate fluid intake and rest irrigations increase oral fluid
o Prevention of chilling intake
o Warm salt-water gargles to  Ice collar can relieve severe
soothe the sore throat sore throats
o NSAIDs to relieve aches and  CBR during febrile stage
pains  Instruct the patient about
o Antihistamines are used to preventive measures
relieve sneezing, rhinorrhea,
and nasal congestion CHRONIC PHARYNGITIS
o Inhalation of steam or heated, - is a persistent inflammation of the
humidified pharynx. It is common in adults who
o work in dusty surroundings, use their
ACUTE PHARYNGITIS (SORE voice to excess, and suffer from chronic
THROAT) - is a sudden painful cough, of habitually use alcohol and
inflammation of the pharynx, the back tobacco.
portion of the throat that includes the
posterior third of the tongue, soft palate Different 3 Types of Chronic
and sore throat. Pharyngitis
 Commonly referred to as sore A. Hypertrophic - characterized
throat. by general thickening and
 Clinical Manifestations: congestion of the pharyngeal
 Fiery-red pharyngeal mucous membrane.
membrane and tonsils B. Atrophic - late stage of the
 Swollen lymphoid follicles first type )the membrane is
 Enlarged and tender cervical thin, whitish glistening and at
lymph nodes times wrinkled)
 Fever C. Chronic Granular
 Malaise (Clergyman's sore throat)
 Sore throat characterized by numerous
 Pharmacologic Therapy: swollen lymph follicles on the
 Penicillin is the Tx of choice pharyngeal
 Cephalosporin  Clinical Manifestations:
 Macrolides o Constant sense of irritation or
 Gargles with benzocaine may fullness in the throat
relieve symptoms. o Mucus that collects in the
throat
 Nursing Interventions: o Difficulty swallowing
 Liquid or soft diet is provided  Management:
during the acute stage. o Nasal sprays or medications
containing ephedrine sulfate
 or phenylephrine  Nursing Interventions (post-op)
hydrochloride o In the immediate
o Antihistamine decongestant postoperative period, the most
medications comfortable position is prone,
o Acetaminophen with the patient's head turned
 Nursing Management: to the side to allow drainage
o Instruct the patient to avoid from the mouth and pharynx.
contact with others until the o Apply ice collar to the neck
fever subsides to prevent the o Assess for post op bleeding
spread of infection. such as frequent
o Avoidance of alcohol, tobacco, swallowing.
secondhand smoke, and o Instruct the patient to refrain
exposure to cold or to from too much talking and
environmental or occupational coughing
pollutants. o Ice chips may be given to the
patient
TONSILLITIS AND ADENOIDITIS o Alkaline mouthwashes and
 The tonsils are composed of warm saline solutions are
lymphatic tissue and are situated useful in coping with the thick
on each of the oropharynx. mucus and halitosis that may
 The adenoids or pharyngeal tonsils be present after surgery.
consist of lymphatic tissue near o Milk and milk products (ice
the center of the posterior wall of cream and yogurt) may be
the nasopharynx. restricted.
 Acute inflammation/infection that o Provide soft, adequate diet.
is usually caused by GABHS o Instruct the patient to avoid
(group A beta-hemolytic vigorous tooth brushing or
streptococcus) gargling.
o Encourage the use of the cool-
 Clinical Manifestations: mist vaporizer or humidifier in
o Sore throat, fever, snoring and the home
difficulty swallowing o Instruct the patient to avoid
o Enlarged adenoids may cause smoking and heavy lifting for
mouth breathing, earache, 10 days.
draining ears, frequent head
colds, bronchitis, foul-
smelling breath, voice PERITONSILLAR ABCESS (QUINSY)
impairment, and noisy - is the most common major
respiration. suppurative complication of sore
 Management: throat/tonsillitis. This collection of
o Penicillin (first-line antibiotic) purulent exudate between the tonsillar
or cephalosporin. capsule and the surrounding tissues,
o Tonsillectomy if the patient including the soft palate may develop
has had repeated episodes of after an acute tonsillar infection that
tonsillitis despite antibiotic
therapy.
progress to a local cellulitis and LARYNGITIS - an inflammation of the
abscess. larynx, often occurs as a result of voice
abuse or exposure to dust, chemicals,
 Clinical Manifestation smoke and other pollutants.
o Sever sore throat, fever, - most common cause is virus,
trismus (inability to open the bacterial invasion may be secondary.
mouth), and drooling.
o Sever pain, raspy voice  Clinical Manifestations
o Odynophagia (a severe o Hoarseness of voice - initial
sensation of burning, sign
squeezing pain while o Aphonia (complete loss of
swallowing) voice)
o Dysphagia (difficulty o Sever cough
swallowing) o Throat feels worse in the
o Otalgia (pain in the ear), morning and improves when
tender and enlarged cervical the patient is in a warmer
lymph nodes climate.
o Airway obstruction may occu
 Management
Management o Instruct the patient to rest the
o Antimicrobial agents voice and avoid irritants
(Penicillin) (including smoking)
o Corticosteroid therapy o Inhaling cool steam or an
o Needle aspirations are aerosol is provided
performed to decompress the o Administer antibacterial
abscess. therapy as ordered
o Topical corticosteroids may be
 Nursing Interventions given by inhalation
o Assist in performing o Increased oral fld intake
intubation, cricothyroidotomy,
or tracheotomy to treat airway CANCER OF THE LARYNX
obstruction.  Etiology
o Assist in needle aspiration o Most tumors of the larynx are
when indicated squamous cell carcinoma
o Gentle gargling after the o Men > women, age 60-70
procedure with a cool normal o Cigarette smoking and alcohol
saline gargle may relieve consumption are associated
discomfort with laryngeal cance
o Provide cool liquids
o Instruct the patient to refrain  Clinical Manifestations
from or cease smoking o Hoarseness of voice for more
o It is also important to than 2 weeks
reinforce the need for good o Persistent cough and sore
oral hygiene. throat
o Dyspnea
 o Dysphagia o Observe for signs of
o Pain radiating to ear and hemorrhage or infection.
burning sensation in the o Teach about tracheostomy
throat and stoma care
o Weight loss o Assist with period of grieving
o Enlarged cervical lymph nodes
o Unilateral nasal obstruction

 Diagnostic Procedure
o Virtual endoscopy DISORDERS OF THE LOWER
o Optical imaging RESPIRATORY SYSTEM
o CT Scan and MRI
o Direct laryngoscopy  CHRONIC OBSTRUCTIVE
examination PULMONARY DISEASE (COPD)
Refers to a disease characterized by
 Management airflow limitation that is not fully
o Radiation therapy reversible. The airflow limitation is
o Chemotherapy generally progressive and is normally
o Surgery: associated with an inflammatory
response of the lungs due to irritants.
Partial Laryngectomy - A
COPD includes chronic bronchitis
portion of the larynx is and pulmonary emphysema.
removed along with one vocal  Chronic Bronchitis - is a chronic
cord and the tumor. inflammation of the lower respiratory
Complications: Change tract characterized by excessive
in voice quality or mucous secretion, cough, and
hoarseness of voice. dyspnea associated with recurring
Total Laryngectomy - infections of the lower respiratory
Laryngeal structures are tract characterized by three primary
removed, including cartilage, symptoms: chronic cough, sputum
and two or three rings of the production, and dyspnea on
exertion.
trachea.
 Clinical Manifestations:
Complications:
 Blue bloater
permanent loss of voice,  Usually insidious, developing
salivary leak, wound over a period of years.
infection, stomal stenosis  Presence of a productive cough
and dysphagia. lasting at least 3 months a year
for 2 successive years.
 Nursing Interventions  Production of thick, gelatinous
o Arrange for clients with sputum; greater amounts
laryngectomies to meet with produced during superimposed
members of support groups infections
o Establish a method for  Wheezing and dyspnea as
disease progresses.
communication before surgery
o Maintain airway; have suction
 Emphysema - is a complex lung
equipment at bedside. disease characterized by
 destruction of the alveoli, o Dyspnea, decreased exercise
enlargement of distal airspaces, tolerance.
and a breakdown of alveolar o Cough may be minimal,
walls. There is a slowly except with respiratory
progressive deterioration of lung infection.
function form many years before C CS
the development of illness. A Allergens
Two Types of Emphysema:
a. Panlobular Emphysema - L Long
destruction of respiratory Respiration
bronchiole, alveolar duct Infxn
and alveolus.
o All air spaces within the o Sputum expectorational mild.
lobule are essentially o Barrel chest - increased
enlarged, but there is little anteroposterior diameter of
inflammatory disease. chest due to air trapping
o Hyperinflated with diaphragmatic
(hyperexpanded) chest, flattening.
marked dyspnea on  Diagnostic Procedure for COPD
exertion, and weight loss o Spirometry - is used to evaluate
typically occur. airflow obstruction.
o Negative pressure is o ABG levels - decreased PaO2,
required during inspiration pH, and increased CO2.
to move air into an out of o CXR - in late stages,
the lungs. hyperinflation, flattened
o Expiration becomes active diaphragm, increased
and requires muscular
effort. Inflammation, hypertrophy, hypersecretion, loss of
b. Centrilobular elasticity.
(Centroacinar)
Emphysema - pathologic RF:
changes take place mainly
in the center of the
secondary lobule,
preserving the peripheral
portions of the acinus.
o There is derangement of
ventilation-perfusion ratios,
producing chronic
hypoxemia, hypercapnia,
polycythemia, and Chronic Bronchitis
episodes of right-sided heart  Airways
failure.  Chronic Inflammation
o Leads to central cyanosis  Bronchial walls thickening
and respiratory failure, and  Narrowing of the airways
patient also develops Result: hypoxemia (decrease PaO2)
peripheral edema. Respiratory Acidosis
 Clinical Manifestations
o Pink puffer Emphysema
  Alveolar destrxn  Long-acting beta2-adrenergic
 Decreasein are for gas agonists
exchange  Leukotriene modifiers
 Air trapping (loss of elastic (inhibitors)
recoil bullae)
 Increased work of breathing  Nursing Interventions:
(barrel chest)  Assesses the patient’s
respiratory status by
monitoring the severity of
C - Cyanosis, increased CO2, Cardiac symptoms, breath sounds,
Dysrhythmias (decreased O2) peak flow, pulse oximetry,
O - Decreased O2 > Hypoxemia > and VS.
decreased SPO2, Orthopnea,  Administer medications as
P - Prolonged expiration, Pulmonary HTN prescribed and monitor the
(partial SPO2 below 55 mmHg) patient’s responses to those
D - Dyspnea, SOB, decrease in BW medications.
 Administer flds if the patient
is dehydrated emphasize
ASTHMA is a chronic inflammatory adherence to the prescribe
disease of the airways that causes airway therapy, preventive measures,
hyper responsiveness, mucosal edema, and and the need to keep follow-
mucus production is reversible and diffuse up appointments with health
airway inflammation that leads to airway care providers.
narrowing.

 Clinical Manifestation:
 3 most common symptoms:
 Cough
 Dyspnea
 Wheezing
 Chest tightness, diaphoresis,
tachycardia, and a widened
pulse pressure, hypoxemia
and central cyanosis.

 Pharmacologic Therapy
 2 General classes of
medications:
a. Quick relief medications –
for immediate Tx.
a.1. Short-acting beta2-
adrenergic agonists like
Albuterol, (Poventil, Ventolin),
Levalbuterol (Xopenex) and
Pirbuterol (Maxair)
b. Long-acting medications to
achieve and maintain control of
persistent asthma.
 Corticosteroids