Adult Nursing (1) 2024-2025 Past Paper PDF

Faculty of Nursing Kafr El-Sheikh University Adult nursing department Adult nursing (1) 2024-2025 Adult Nursing (1), 2024/2025 1  Table of conte...

Faculty of Nursing Kafr El-Sheikh University Adult nursing department Adult nursing (1) 2024-2025 Adult Nursing (1), 2024/2025 1  Table of contents: 1. Stress, coping & adaptation……………………….………………….3 2. Nursing management of patient with cardiovascular disorders… ……………………………………..………….……………………………...14 3. Perioperative care…………….……………………………...............40 4. Nursing management of patient with gastrointestinal and disorders ….……………………………………………..………………………......…74 5. Nursing management of patient with respiratory disorders…… …………..…………………….…………………………………………….115 6. Pain management………………………………………….................143 7. Fluid and electrolytes imbalances…………………..……………..158 8. Acid- base imbalance ……………………………………………..…194 Adult Nursing (1), 2024/2025 2  Stress, coping & Adaptation  Stress is a state produced by a change in the environment that is perceived as challenging, threatening, or damaging to a person’s dynamic balance or equilibrium.  Eustress: a positive form of stress having a beneficial effect on health, motivation, performance, and emotional well-being  Distress: the negative stress response, a type of stress that results from being overwhelmed by demands, losses, or perceived threats. It has a detrimental effect by generating physical and psychological maladaptation and posing serious health risks for individuals. This generally is the intended meaning of the word stress.  Adaptation: a change or alteration designed to assist in adapting to a new situation or environment.  Maladaptive responses: When responses to stress are ineffective, chronic, recurrent responses or patterns of response that do not promote the goals of adaptation. Types of Stressors: Stressors exist in many forms and categories. They may be described as:  Physical: include cold, heat, and chemical agents  Physiologic: include pain and fatigue  Psychosocial: is fear (e.g., fear of failing an examination, losing a job, and waiting for a diagnostic test result). Sources of Clinical Stress: For patients: Adult Nursing (1), 2024/2025 3   Uncertainty  Fear  Pain  Cost  Lack of knowledge  Risk for harm For nurses  Poor patient outcomes  Risk of making an error  Unfamiliar situations  Excessive workload  Inadequate resources I. Physiologic adaptation: A. Local adaptation syndrome (LAS):  The Local adaptation syndrome is a localized response of the body to stress. It involves only a specific body parts (such as a tissue or organ) instead of the whole body. The stress precipitating the LAS may be traumatic or pathologic.  The two most common responses that influence nursing care are:  Reflex pain response: the reflex pain response is a response of central nervous system to pain. It is rapid and automatic, serving as protective mechanisms to prevent injury.  Inflammatory response: the inflammatory response is a local response to injury or infection. It serves to localize and prevent the spread of infection and promote wound healing. B. General adaptation syndrome (Selye’s Theory of Adaptation):  It describes the body's general response to stress. Adult Nursing (1), 2024/2025 4   It is a physiologic response to stress, is the nonspecific response common to all stressors, regardless of whether they are physiologic, psychological, or social.  It consists of three stages which are alarm reaction, stage of resistance and stage of exhaustion.  Although the alarm stage is short term (minutes to hours), the length of stage of resistance and stage of exhaustion varies greatly, 1. Alarm reaction (fight or flight response):  It is initiated when person perceived a specific stressor and various defense mechanisms are activated.  The alarm reaction is defensive and anti-inflammatory but self-limited”. This primary response is short-lived, lasting from 1 minute to 24 hours.  It is divided into two phases: the shock phase and the countershock phase.  During the shock phase: The autonomic nervous system initiates the fight or flight response to prepare the body to either fight off the  stressor or run away from it. The effect of the sympathetic-adrenalmedullary responses include:  Increased heart rate and blood pressure  Increased blood glucose level  Mental acuity  Dilated pupils  Increased tension of skeletal muscles  Increased ventilation (may be rapid and shallow)  Increased coagulability of blood Adult Nursing (1), 2024/2025 5   During counter shock, the second phase of the alarm reaction, there is a reversal of body change. 2. Stage of resistance:  Adaptation to the noxious stressor occurs, the body attempts to cope with the stressor and to limit the stressor to the smallest area of the body that can deal with it  Cortisol activity is still increased. 3. Stage of exhaustion:  If exposure to the stressor is prolonged, the third stage, exhaustion, occurs.  This stage is the result of prolonged or chronic stress  The adaptation that the body made during the second stage cannot be maintained.  At the end of this stage, the body may either rest and return to normal, or death may be the ultimate consequence. The end of this stage depends largely on the adaptive energy resources of the individual, the severity of the stressor, and the external adaptive resources that are provided. II. Psychological adaptive responses: includes: the mind-body interaction, anxiety, coping/defense mechanisms. A. The mind-body- interaction:  It is thought that humans react to threats of danger as if they were physiologic threats. Each person reacts in her or his own way.  With prolonged stress some people may develop chronic diarrhea while others may develop nausea or heart palpitation; such illnesses are real and are called psychosomatic disorders Adult Nursing (1), 2024/2025 6  B. Anxiety:  A common reaction to stress is anxiety.  It is a feeling of apprehension caused by anticipating a danger.  It is altering signal that warns of im  pending danger and enables the person to take measures to deal with threat.  Anxiety is often present before new experiences, which may be perceived as a threat to one's identity and self- esteem. The four level of anxiety are: mild, moderate, sever and panic  Mild level anxiety: is manifested by increased questioning, mild restlessness, feelings of increased arousal and alertness, uses learning to adapt. Can have a positive effect. Anxiety beyond that level is generally negative and has unpleasant effects.  Moderate anxiety: is manifested by quavering voice, tremors, increased muscle tension, complaints of “butterflies in the stomach” and slight increase in respiration and pulse. Learning slightly impaired.  Sever anxiety: is manifested by Increased motor activity, inability to relax, Fearful facial expression, Communication difficult to understand, Inability to focus, Learning severely impaired, Tachycardia, hyperventilation Headache, dizziness nausea  Panic: Communication may not be understandable, agitation, Trembling, poor motor coordination, Perception distorted, Unable to learn or function Dyspnea, palpitations chest pain, Paresthesia, sweating. C. Coping: is the person's cognitive and behavioral effects to manage specific external or internal stressors that seem to exceed available resources. Adult Nursing (1), 2024/2025 7  The effectiveness of an individual's coping is influenced by a number of factors, including  The number, duration, and intensity of the stressors.  Past experiences of the individual.  Support systems available to the individual.  Personal qualities of the person.  Many coping behaviors are learned, based on one's family, past experience and sociocultural influences and expectations.  Coping can be either positive or negative. Positive coping includes activities such as exercise and use of social support. Negative coping includes substance abuse and denial. Typical coping behaviors include the following:  Crying, laughing, sleeping, cursing  Physical activity, exercise  Smoking, drinking  Lack of eye contact, withdrawal  Limiting relationships to those with similar values and interests. Effective coping results in adaptation; Ineffective coping results in maladaptation. D. Defense mechanisms: These mechanisms protect one's self-esteem and are useful in mild to moderate anxiety. When extreme, however, they distort reality and create problems with relationships. Examples of defense mechanisms:  Compensation: a person attempts to overcome a perceived weakness by emphasizing a more desirable trait or overachieving in a more comfortable area. Adult Nursing (1), 2024/2025 8   Denial: a person refuses to acknowledge the presence of a condition that is disturbing.  Displacement: a person transfers an emotional reaction from one object or person to another person or object.  Rationalization: a person tries to give a logical or socially acceptable explanation for questionable behavior.  Repression: a person voluntary excludes an anxiety producing event from conscious awareness. Effects of stress: A. Effects of stress on basic human needs: Physiologic:  Change in appetite, activity or sleep  Change in elimination patterns  Increased pulse, respirations, blood pressure. safety and security:  Feels threatened or nervous  Use ineffective coping mechanisms  Is attentive Love and belonging:  Is withdrawn an isolated  Blames others for own faults  Demonstrates aggressive behaviors  Becoming overly dependent on others Self esteem  Becomes a workaholic  Exhibits attention-seeking behaviors Adult Nursing (1), 2024/2025 9  Self-actualization  Refuse to accept reality  Centers on own problems  Demonstrates lack of control Long term stress:  Long term stress is a serious threat to physical and emotional health. As the duration, intensity or number of stressors increases, a person ability to adopt is lessened.  Long term stress affects physical status, increasing the risk for disease or injury. Examples of physical illnesses associated with stress  Autoimmune disorders: e.g., grave’s disease, rheumatoid arthritis  Cardiovascular disorders: e.g., coronary artery disease, hypertension  Respiratory disorders: e.g., asthma  Gastrointestinal disorders: e.g., esophageal reflux, ulcerative colitis Family stress:  The stress that affects an ill person affects the person's family members or significant other. Stressors of the family include:  Changes in family structure and role,  Anger and feeling of hopelessness and guilt,  Loss of control over normal routines  Concerns for financial stability. Nursing management for Stress: Is directed toward reducing and controlling stress and improving coping. I. Teach clients about:  The importance of adequate exercise, a balanced diet, and rest and sleep to energize the body and enhance coping abilities. Adult Nursing (1), 2024/2025 10   Support groups: exist especially for people in similar stressful situations e.g. people with ostomies; chronic illnesses and disabilities…..etc. Being a member of a group with similar problems or goals has a releasing effect on a person that promotes freedom of expression and exchange of ideas.  Stress management techniques: 1. Relaxation techniques:  Are useful in many situations such as pain, anxiety, sleeplessness, illness and anger.  Relaxation promotes a body reaction opposite to fight or flight response: respiratory, pulse, blood pressure, metabolic rates and energy use are all decreased.  It is especially helpful because it allows people to control their feelings and behaviors.  Two helpful relaxation activities to be practiced 3-4 time at each session, are deep breathing and progressive muscle relaxation. A. Deep breathing exercises (abdominal or diaphragmatic breathing)  Sit comfortably and place one hand on your chest and the other hand on your stomach. Inhale slowly and deeply. Letting your abdomen expand as much as possible. Hold your breath for a few seconds.  Exhale slowly through your mouth, blowing through Pursed-lip when your abdomen feels empty, begin again with a deep inhalation. B. Progressive Muscle Relaxation:  The person tenses the muscles in the entire body (one muscle group at a time), holds, senses the tension, and then relaxes. Adult Nursing (1), 2024/2025 11   As each muscle group is tensed, the person keeps the rest of the body relaxed.  Each time the focus is on feeling the tension and relaxation. When the exercise is completed, the entire body should be relaxed. 2. Anticipatory guidance:  It focuses on psychological preparing a patient for unfamiliar or painful event (Providing sensory and procedural information).  Nurses use this technique to teach the patient about procedures and surgical experiences.  When patient knows what to expect, their anxiety is reduced and their coping mechanisms are more effective. 3. Guided Imagery:  In guided imagery a person creates a mental image concentrate on the image and becomes less responsive to other stimuli (including pain).  The nurse sits by the patient and reads a description of a scene or an experience that the patient has described as happy, pleasant or peaceful.  The patient is then guided through the image. 4. Meditation: it has four components:  Quiet environment,  A passive attitude,  A comfortable position  Focus. II. Help clients to:  Determine situations that precipitate anxiety and identify signs of anxiety. Adult Nursing (1), 2024/2025 12   Verbalize feelings, perceptions, and fears as appropriate. Some cultures discourage the expression of feelings.  Identify personal strengths.  Recognize usual coping patterns and differentiate positive from negative coping mechanisms.  Identify available support systems. III. Use the following communication skills with patient  Communicate in short, clear sentences,  Listen attentively; try to understand the client's perspective on the situation.  Provide an atmosphere of trust; convey a sense of caring and empathy.  Provide factual information concerning diagnosis, treatment, and prognosis as needed.  Encourage an attitude of realistic hope as a way of dealing with feelings of helplessness.  Determine if it is appropriate to encourage clients' participation in the plan of care; give them choices about some aspects of care but do not overwhelm them with choices.  Acknowledge the patient’s spiritual/cultural background and encourage the use of spiritual resources if desired.  Assist the patient and family to identify appropriate short and long-term goals.  Control the environment to minimize additional stressors such as reducing noise, limiting the number of persons in the room, and providing care by the same nurse as much as possible. Adult Nursing (1), 2024/2025 13  Nursing Management of Patients with cardiovascular disorders Coronary artery disease (CAD)  Is the most prevalent type of cardiovascular disease in adults. It is sometimes called coronary heart disease or ischemic heart disease. Coronary artery disease is a narrowing or blockage of the arteries that provide oxygen and nutrients to the heart. It is caused by atherosclerosis Atherosclerosis: It is an abnormal accumulation of lipid, or fatty substances, and fibrous tissue in the lining of arterial blood vessel walls. These accumulations are referred to as atheromas or plaques which block and narrow the coronary vessels in a way that reduces blood flow to the myocardium. Atherosclerosis involves a repetitious inflammatory response to injury of the artery wall and subsequent alteration in the structural and biochemical properties of the arterial walls.  Although heart disease is most often caused by atherosclerosis of the coronary arteries, other phenomena may also decrease blood flow to the heart. Examples include:  Vasospasm (sudden constriction or narrowing) of a coronary artery,  Myocardial trauma  Congenital anomalies,  Decreased oxygen supply (eg, from acute blood loss, anemia, or low blood pressure), and increased oxygen demand (eg, from rapid heart rate, thyrotoxicosis, or use of cocaine). Risk Factors for Coronary Artery Disease: A.Non-modifiable Risk Factors Adult Nursing (1), 2024/2025 14   Family history of coronary artery disease (CAD): first-degree relative with cardiovascular disease at 55 years of age or younger for men and at 65 years of age or younger for women.  Increasing age: more than 45 years for men; more than 55 years for women.  Gender: men develop CAD at an earlier age than women.  Race: higher incidence of heart disease in African Americans than in Caucasians) B.Modifiable Risk Factors:  Hyperlipidemia  Normal lipid profile (total cholesterol, LDL, HDL, and triglyceride)  Low-density lipoprotein (LDL) cholesterol less than 100 mg/dL (less than 70 mg/dL for very high-risk patients)  Total cholesterol less than 200 mg/dL  High-density lipoprotein (HDL) cholesterol greater than 60 mg/dL  Triglyceride less than 150 mg/dL  Cigarette smoking, Hypertension, Diabetes mellitus, Metabolic syndrome, Obesity, Physical inactivity Angina pectoris  Angina pectoris is a clinical syndrome usually characterized by episodes or of pain or pressure in the anterior chest. The cause is insufficient coronary blood flow, resulting in a decreased oxygen supply when there is increased myocardial demand for oxygen in response to physical exertion or emotional stress. factors are associated with typical anginal pain:  Physical exertion, which can precipitate an attack by increasing myocardial oxygen demand. Adult Nursing (1), 2024/2025 15   Exposure to cold, which can cause vasoconstriction and elevated blood pressure, with increased oxygen demand.  Eating a heavy meal: which increases the blood flow for digestion, thereby reducing the blood supply available to the heart muscle.  Stress or any emotion-provoking situation: causing the release of catecholamines, this increases blood pressure, heart rate, and myocardial workload. Clinical Manifestations:  Uncomfortable pressure, squeezing, or fullness in substernal chest area  Can radiate across chest to the medial aspect of one or both arms and hands, jaw, shoulders, upper back, or epigastrium.  Radiation to arms and hands, described as numbness, tingling, or aching  Pain duration: 5–15 min  Anxiety may occur with angina.  Stable angina: predictable and consistent pain that occurs on exertion and is relieved by rest and/or nitroglycerin.  Unstable angina: It may occur at rest. symptoms increase in frequency and severity; may not be relieved with rest or nitroglycerin  The patient with diabetes mellitus may not have severe pain with angina because diabetic neuropathy can blunt nociceptor transmission, dulling the perception of pain. Medical Management: The objectives of the medical management of angina are to decrease the oxygen demand of the myocardium and to increase the oxygen supply. A. Oxygen Administration: Oxygen therapy is usually initiated at the onset of chest pain in an attempt to increase the amount of oxygen delivered Adult Nursing (1), 2024/2025 16  to the myocardium and to decrease pain. Administers oxygen therapy if the patient’s respiratory rate is increased or if the oxygen saturation level is decreased. B. Pharmacologic Therapy: 1. Nitrates e.g., Nitroglycerin:  Short-term and long-term reduction of myocardial oxygen consumption through selective vasodilation.  Nitroglycerin may be given by several routes: sublingual tablet or spray, oral capsule, topical agent, and intravenous (IV) administration.  Sublingual nitroglycerin is generally placed under the tongue which alleviates the pain of ischemia within 3 minutes. 2. Beta-Adrenergic Blocking Agents (beta-blockers):  Reduction of myocardial oxygen consumption by blocking beta- adrenergic stimulation of the heart.  This helps control chest pain and delays the onset of ischemia during work or exercise. Beta-blockers reduce the incidence of recurrent angina, infarction, and cardiac mortality.  Side effects include: depression, fatigue, masking of symptoms of hypoglycemia. Patients taking beta-blockers are cautioned not to stop taking them abruptly. Beta-blocker therapy should be decreased gradually over several days before being discontinued. If a beta-blocker is given intravenously for an acute cardiac event, the ECG, blood pressure, and heart rate are monitored closely after the medication has been administered. 3. Calcium Ion Antagonists (calcium channel blockers):  Calcium channel blockers increase myocardial oxygen supply by dilating the smooth muscle wall of the coronary arterioles. Adult Nursing (1), 2024/2025 17   Indicated in patients not responsive to beta-blockers; used as primary treatment for vasospasm. 4. Antiplatelet Medications e.g., Aspirin:  Prevent platelet aggregation and subsequent thrombosis, which impedes blood flow.  Because aspirin may cause gastrointestinal upset and bleeding, the use of H2-blockers or proton pump inhibitors should be considered to allow continued aspirin therapy. 5. Anticoagulants such as Heparin:  Heparin prevents the formation of new blood clots.  Treating patients with unstable angina with heparin reduces the occurrence of MI  It is commonly be given subcutaneous injection  It increases the risk of bleeding; the patient is monitored for signs and symptoms of external and internal bleeding, such as low blood pressure, increased heart rate, and decreased serum hemoglobin and hematocrit.  The patient receiving heparin is placed on bleeding precautions. Potential complications:  Myocardial Infarction  Dysrhythmias and cardiac arrest  Heart failure  Cardiogenic shock Nursing Interventions: 1. When a patient experiences chest pain, the patient is directed to stop all activities and sit or rest in bed in a semi-Fowler’s position to reduce the oxygen requirements of the ischemic myocardium. Adult Nursing (1), 2024/2025 18  2. Nitroglycerin is administered sublingually, and the patient’s response is assessed (relief of chest pain and effect on blood pressure and heart rate). If the chest pain is unchanged or is lessened but still present, nitroglycerin administration is repeated up to three doses. 3. Assesses the patient’s angina, asking questions to determine whether the angina is the same as the patient typically experiences. 4. If the pain is significant and continues after these interventions, the patient is further evaluated for acute MI 5. Measuring vital signs and observing for signs of respiratory distress. 6. Administer oxygen therapy if the patient’s respiratory rate is increased or if the oxygen saturation level is decreased. 7. Providing information about the illness, its treatment, and methods of preventing its progression are important nursing interventions.  Take medications, especially aspirin and beta-blockers, as prescribed.  Carry nitroglycerin at all times; state when and how to use it; identify its side effects.  Identify the level of activity that causes the patient’s pain or prodromal symptoms, and plans the patient’s activities accordingly.  Participate in a regular daily program of activities that do not produce chest discomfort, shortness of breath, or undue fatigue.  Follow the prescribed exercise regimen. Alternate activity with periods of rest.  Stop smoking and other forms of tobacco, (because smoking increases the heart rate, blood pressure, and blood carbon monoxide levels).  Follow a diet low in saturated fat, high in fiber, and if indicated, lower in calories. Adult Nursing (1), 2024/2025 19   Achieve and maintain normal blood pressure. Avoid using medications or any over-the-counter substances (e.g., diet pills, nasal decongestants) that can increase the heart rate and blood pressure without first discussing with a health care provider.  Achieve and maintain normal blood glucose levels.  Addressing the spiritual needs of the patient and family may also assist in allaying anxieties and fears.  Recognize that temperature extremes (particularly cold) may induce anginal pain; therefore, avoid exercise in temperature extremes.  Use appropriate resources for support during emotionally stressful times (eg, counselor, nurse, and physician).  Use various stress reduction methods. Myocardial infarction (MI)  Refers to the dynamic process in which one or more regions of the heart experience sever prolonged decrease in oxygen supply because of insufficient coronary blood flow, subsequently necrosis or death to myocardial tissue occurs. Clinical Manifestations:  chest pain as angina pectoris  Pain or discomfort ranges from mild to severe  Associated with shortness of breath, diaphoresis, palpitations, fatigue, and nausea or vomiting.  Duration of pain: >15 min  Emotional upset or unusual physical exertion occurring within 24 hr of symptom onset, can occur at rest or while asleep. Adult Nursing (1), 2024/2025 20   Chest pain or discomfort not relieved by rest or nitroglycerin. In many cases, the signs and symptoms of MI cannot be distinguished from those of unstable angina. Potential Complications of MI:  Acute pulmonary edema  Heart failure  Cardiogenic shock  Dysrhythmias and cardiac arrest  Pericardial effusion and cardiac tamponade 1. Medical Management:  The goals of medical management are to minimize myocardial damage, preserve myocardial function, and prevent complications. A. Pharmacologic Therapy: 1. Nitroglycerin 2. Aspirin 3. Analgesics: The analgesic of choice for acute MI is morphine administered in IV boluses to reduce pain and anxiety. It also reduces preload and afterload, which decreases the workload of the heart and relaxes bronchioles to enhance oxygenation. The cardiovascular response to morphine is monitored are fully, particularly the blood pressure, which can decrease, and the respiratory rate, which can be depressed. 4. Angiotensin-Converting Enzyme Inhibitors (ACE) inhibitors:  Prevent the conversion of angiotensin I to angiotensin II.  In the absence of angiotensin II, the blood pressure decreases and the kidneys excrete sodium and fluid (diuresis), decreasing the oxygen demand of the heart. Adult Nursing (1), 2024/2025 21   Use of ACE inhibitors in patients after MI decreases mortality rates and prevents remodeling of myocardial cells that is associated with the onset of heart failure.  It is important to ensure that a patient is not hypotensive, hyponatremic, hypovolemic, or hyperkalemic before administering ACE inhibitors. Blood pressure, urine output, and serum sodium, potassium, and creatinine levels need to be monitored closely. 5. Thrombolytics:  The purpose of thrombolytics is to dissolve, allowing blood to flow through the coronary artery again (reperfusion), minimizing the size of the infarction and preserving ventricular function.  The duration of oxygen deprivation is directly related to the number of myocardial cells that die. To be effective, thrombolytic must be administered as early as possible after the onset of symptoms that indicate an acute MI, generally within 3 to 6 hours. The selected thrombolytic agent should be initiated within 30 minutes of presentation to the hospital. Are administered by IV route. Absolute Contraindications of Thrombolytic Therapy:  Active bleeding  Known bleeding disorder  History of hemorrhagic stroke  History of intracranial vessel malformation  Recent major surgery or trauma  Uncontrolled hypertension  Pregnancy Adult Nursing (1), 2024/2025 22  All patients who receive thrombolytic therapy are placed on bleeding precautions to minimize the risk for bleeding.  Minimize the number of times the patient’s skin is punctured  Draw blood for laboratory tests when starting the IV line  Start IV lines before thrombolytic therapy; designate one line to use for blood draws  Avoid intramuscular injections  Avoid continual use of noninvasive blood pressure cuff  Monitor for acute dysrhythmias and hypotension  Check for signs and symptoms of bleeding: decrease in hematocrit and hemoglobin values, decrease in blood pressure, increase in heart rate, oozing or bulging at invasive procedure sites, back pain, muscle weakness, changes in level of consciousness, complaints of headache.  Treat major bleeding by discontinuing thrombolytic therapy and any anticoagulants; apply direct pressure and notify the physician immediately.  Treat minor bleeding by applying direct pressure if accessible and appropriate; continue to monitor. B. Oxygen Administration C. Invasive coronary artery procedures:  Cardiac catheterization: is an invasive diagnostic procedure in which radiopaque arterial and venous catheters are introduced into selected blood vessels of the right and left sides of the heart. Catheter advancement is guided by fluoroscopy.  During cardiac catheterization, the patient has one or more IV lines in place for the administration of sedatives, fluids, heparin, and other medications. BP and ECG monitoring is necessary to observe for Adult Nursing (1), 2024/2025 23  hemodynamic instability or dysrhythmias. The myocardium can become ischemic and trigger dysrhythmias as catheters are positioned in the coronary arteries or during injection of contrast agents.  Resuscitation equipment must be readily available, and staff must be prepared to provide advanced cardiac life support measures as necessary.  Radiopaque contrast agents are used to visualize the coronary arteries. Some contrast agents contain iodine, and the patient is assessed before the procedure for previous reactions to contrast agents or allergies to iodine-containing substances (e.g., seafood). If the patient has a suspected or known allergy to the substance, antihistamines or methylprednisolone (Solu-Medrol) may be administered before the procedure.  the following blood tests are performed to identify abnormalities that may complicate recovery: blood urea nitrogen (BUN) and creatinine levels, international normalized ratio (INR) and prothrombin time (PT), activated thromboplastin time (aPTT), hematocrit and hemoglobin values, platelet count, and electrolyte levels Nursing responsibilities before cardiac catheterization include the following:  The patient is instructed to fast, usually for 8 to 12 hours, before the procedure. If catheterization is to be performed as an outpatient procedure, a friend, family member, or other responsible person must transport the patient home.  The patient is informed of the expected duration of the procedure and advised that it will involve lying on a hard table for less than 2 hours. Adult Nursing (1), 2024/2025 24   The patient is reassured that IV medications are given to maintain comfort.  The patient is informed about sensations that will be experienced during the catheterization. Knowing what to expect can help the patient cope with the experience. The nurse explains that an occasional pounding sensation (palpitation) may be felt in the chest because of extra heartbeats that almost always occur, particularly when the catheter tip touches the endocardium. The patient may be asked to cough and to breathe deeply, especially after the injection of contrast agent. Coughing may help disrupt a dysrhythmia and clear the contrast agent from the arteries. Breathing deeply and holding the breath help lower the diaphragm for better visualization of heart structures. The injection of a contrast agent into either side of the heart may produce a flushed feeling throughout the body and a sensation similar to the need to void, which subsides in 1 minute or less.  The patient is encouraged to express fears and anxieties. The nurse provides teaching and reassurance to reduce apprehension. Nursing responsibilities after cardiac catheterization may include the following:  The catheter access site is observed for bleeding or hematoma formation. Peripheral pulses are assessed in the affected extremity (dorsalis pedis and posterior tibial pulses in the lower extremity, radial pulse in the upper extremity) every 15 minutes for 1 hour, and then every 1 to 2 hours until the pulses are stable.  Temperature, color, and capillary refill of the affected extremity are frequently evaluated. The patient is assessed for affected extremity pain, Adult Nursing (1), 2024/2025 25  numbness, or tingling sensations that may indicate arterial insufficiency. Any changes are reported promptly.  Dysrhythmias are carefully screened by observing the cardiac monitor or by assessing the apical and peripheral pulses for changes in rate and rhythm. A vasovagal reaction, consisting of: bradycardia, hypotension, and nausea, can be precipitated by a distended bladder or by discomfort from manual pressure that is applied during removal of an arterial or venous catheter. The vasovagal response is reversed by promptly elevating the lower extremities above the level of the heart, infusing a bolus of IV fluid, and administering IV atropine to treat the bradycardia.  Bed rest is maintained for 2 to 6 hours after the procedure. If manual or mechanical pressure is used, the patient must remain on bed rest for up to 6 hours with the affected leg straight and the head of the bed elevated no greater than 30 degrees. For comfort, the patient may be turned from side to side with the affected extremity straight. The patient may be permitted to ambulate within 2 hours.  Analgesic medication is administered as prescribed for discomfort.  The patient is instructed to report chest pain and bleeding or sudden discomfort from the catheter insertion sites promptly.  The patient is monitored for contrast agent–induced nephropathy by observing for elevations in serum creatinine levels.  Oral and IV hydration is used to increase urinary output and flush the contrast agent from the urinary tract; accurate intake and output are recorded.  Patient safety is ensured by instructing the patient to ask for help when getting out of bed the first time after the procedure. The patient is Adult Nursing (1), 2024/2025 26  monitored for bleeding from the catheter access site and for orthostatic hypotension, indicated by complaints of dizziness or lightheadedness 2. Percutaneous Coronary Interventions (PCI): Invasive interventional procedures to treat CAD include: PTCA, intracoronary stent implantation and atherectomy. All of these procedures are classified as PCIs. The procedure is used to open the occluded coronary artery and promote reperfusion to the area that has been deprived of oxygen. A. Percutaneous transluminal coronary angioplasty (PTCA): a type of percutaneous coronary intervention in which a balloon is inflated within a coronary artery to break an atheroma and open the vessel lumen, improving coronary artery blood flow. Catheters are inserted through the femoral artery, up through the aorta, and into the coronary arteries. Angiography is performed using injected radiopaque contrast agents (commonly called dye) to identify the location and extent of the blockage. B. Coronary Artery Stent: a woven mesh that provides structural support to a coronary vessel, preventing its closure. After PTCA, the area that has been treated may close off partially or completely, a process called restenosis. A coronary artery stent may be placed to overcome these risks. C. Atherectomy: is an invasive interventional procedure that involves the removal of the atheroma, or plaque, from a coronary artery by cutting or grinding. It may be used in conjunction with PTCA. 3. Coronary Artery Revascularization:  Coronary artery bypass graft (CABG): is a surgical procedure in which a blood vessel from another part of the body is grafted onto the occluded Adult Nursing (1), 2024/2025 27  coronary artery below the occlusion in such a way that blood flow bypasses the blockages  CABG procedures are performed with the patient under general anesthesia. A. The traditional CABG procedure: the surgeon performs a median sternotomy and connects the patient to the cardiopulmonary bypass (CPB) machine (The procedure mechanically circulates and oxygenates blood for the body while bypassing the heart and lungs). CPB maintains perfusion to body organs and tissues and allows the surgeon to complete the anastomoses in a motionless, bloodless surgical field).  Next, a blood vessel from another part of the patient’s body (A vessel commonly used for CABG is the greater saphenous vein, followed by the lesser saphenous vein) is grafted distal to the coronary artery lesion, bypassing the obstruction.  CPB is then discontinued, chest tubes and epicardial pacing wires are placed and patient admitted to ICU. B. Alternative Coronary Artery Bypass Graft Techniques: A number of alternative CABG techniques have been developed that may have fewer complications for some groups of patients.  Off-pump CAB (OPCAB) involves a standard median sternotomy incision, but the surgery is performed without CPB. A beta-adrenergic blocker may be used to slow the heart rate. The surgeon also uses a myocardial stabilization device to hold the site still for the anastomosis of the bypass graft into the coronary artery while the heart continues to beat. Adult Nursing (1), 2024/2025 28   Minimally invasive surgical techniques: that eliminate median sternotomy have also been developed. These endoscopic techniques use smaller incisions and a robotic system to place bypass grafts.  Robot-assisted heart surgery : In this type of minimally invasive heart surgery, robotic arms are used to do the surgery. The surgeon controls the arms from a nearby computer station. The surgeon looks at a magnified 3D view of the heart on a video monitor. When the surgeon's arms and wrists move, the robotic arms move the same way to do the surgery. Surgical tools are attached to the robotic arms. A surgical team at the operating table changes those tools as needed. Advantages of minimally invasive heart surgery? Compared to open-heart surgery, minimally invasive heart surgery may offer benefits such as:  Faster recovery.  Less blood loss.  Less visible scars.  Lower risk of bleeding or infection.  Reduced pain.  Shorter hospital stays. Complications of Coronary Artery Bypass Graft:  Cardiac Complications: Decreased Cardiac Output Hypovolemia (most common cause of decreased cardiac output after cardiac surgery), Persistent bleeding, Cardiac tamponade, Fluid overload, Hypothermia, Hypertension, Dysrhythmias, Cardiac failure and Myocardial infarction (MI) (may occur intraoperatively or postoperatively) Adult Nursing (1), 2024/2025 29   Pulmonary Complications: e.g. Impaired gas exchange  Neurologic Complications: e.g. Neurologic changes; stroke  Renal Failure and Electrolyte Imbalance  Other Complications: e.g. Hepatic failure and Infection Nursing Interventions: 1. Obtain 12-lead electrocardiogram (ECG) to be read within10 minutes. 2. Obtain laboratory blood specimens of cardiac enzymes and biomarkers or other diagnostics to clarify the diagnosis. 3. Bed rest in bed for a minimum of 12 to 24 hours (reduce myocardial oxygen consumption) with the backrest elevated helps decrease chest discomfort and dyspnea 4. Supplemental oxygen 5. Administer routine medical interventions 6. Vital signs are assessed frequently. It is important to check skin temperature and peripheral pulses frequently to monitor tissue perfusion. Pulse oximetry guides the use of oxygen therapy. 7. Monitor fluid volume status to prevent overloading the heart and lungs 8. Encourage the patient to breathe deeply and change position frequently to help keep fluid from pooling in the bases of the lungs. 9. Alleviating anxiety and decreasing fear are important nursing functions that reduce the sympathetic stress response. Decreased sympathetic stimulation decreases the workload of the heart, which may relieve pain and other signs and symptoms of ischemia. interventions that can be used to reduce anxiety include:  The development of a trusting and caring relationship with the patient is critical in reducing anxiety.  Providing information to the patient and family. Adult Nursing (1), 2024/2025 30   Ensuring a quiet environment, preventing interruptions that disturb sleep  Teaching relaxation techniques, using humor, and providing spiritual support consistent with the patient’s beliefs. 10. Instruct the patient and family to:  Avoid any activity that produces chest pain, extreme dyspnea, or undue fatigue  Avoid extremes of heat and cold and walking against the wind  Lose weight, if indicated  Stop smoking  Develop heart-healthy eating patterns and avoid large meals  Adhere to medical regimen, especially in taking medications  Follow recommendations that ensure blood pressure and blood glucose are in control  Walk daily, increasing distance and time as prescribed  Avoid physical exercise immediately after a meal  Alternate activity with rest periods (some fatigue is normal and expected during convalescence)  Contact the physician if any of the following occur: shortness of breath, fainting, slow or rapid heartbeat, swelling of feet and ankle. Chronic Heart failure Heart failure (HF): a clinical syndrome resulting from structural or functioning cardiac disorders that impair the ability of left ventricle to fill or eject blood. Left sided heart failure: inability of the left ventricle to fill or eject sufficient blood into systemic circulation. Adult Nursing (1), 2024/2025 31  Congestive heart failure: a fluid overload condition(congestion) associated with heart failure. Etiology: Myocardial dysfunction is most often caused by:  Coronary artery disease (primary cause)  Hypertension  Cardiomyopathy  Valvular disorders  Cardiac dysrhythmias may cause HF or may be a result of HF; either way  Patients with diabetes mellitus are also at high risk for HF.  Several systemic conditions, including progressive renal failure and uncontrolled hypertension, acute illness such as pneumonia with fever and hypoxia increase the metabolic rate and may precipitate HF.  Other factors, such as acidosis (respiratory or metabolic), electrolyte abnormalities, and antiarrhythmic medications, can worsen myocardial function. Clinical Manifestations: A. Left-Sided Heart Failure: Pulmonary congestion occurs when the left ventricle cannot effectively pump blood out of the ventricle into the aorta and the systemic circulation.  Exertional Dyspnea, cough, pulmonary crackles, wheeze and low oxygen saturation levels.  An extra heart sound, the S3, or “ventricular gallop,” may be detected on auscultation.  The patient may report orthopnea (difficulty breathing when lying flat). Some patients have sudden attacks of dyspnea at night, a condition known as paroxysmal nocturnal dyspnea Adult Nursing (1), 2024/2025 32   The cough associated with left ventricular failure is initially dry and nonproductive. The cough may become moist over time. Large quantities of frothy sputum, which is sometimes pink (blood-tinged)  Reducing urine output (oliguria).  Decreased gastrointestinal perfusion causes altered digestion.  Decreased brain perfusion causes dizziness, lightheadedness, confusion, restlessness, and anxiety due to decreased oxygenation and blood flow.  The skin appears pale and feels cool and clammy.  Increase the HR (tachycardia), often causing the patient to complain of palpitations. The pulses become weak and thready.  The patient becomes easily fatigued and has decreased activity tolerance. B. Right-Sided Heart Failure: This occurs because the right side of the heart cannot eject blood and cannot accommodate all the blood that normally returns to it from the venous circulation. May be secondary to chronic pulmonary problem.  Edema of the lower extremities (dependent edema),  Hepatomegaly (enlargement of the liver),  Ascites (accumulation of fluid in the peritoneal cavity),  Anorexia (loss of appetite) and nausea or abdominal pain, and fatigue.  Weight gain and distended jugular vein due to retention of fluid.  Respiratory distress Medical Management:  The overall goals of management of HF are to relieve patient symptoms, to improve functional status and quality of life, and to extend survival.  Medical management is based on the type, severity, and cause of HF. Adult Nursing (1), 2024/2025 33  A.Pharmacologic Therapy: 1. Angiotensin-Converting Enzyme (ACE) Inhibitors: ACE inhibitors play an important role in the management of systolic HF  promote vasodilation and diuresis  Vasodilation reduces resistance to left ventricular ejection of blood, diminishing the heart’s workload and improving ventricular emptying.  ACE inhibitors decrease of aldosterone (a hormone that causes the kidneys to retain sodium and water) which stimulate the kidneys to excrete sodium and fluid (while retaining potassium)  Available as oral and IV medications, 2. Angiotensin Receptor Blockers (ARBs):  Decreased blood pressure, decreased systemic vascular resistance, and improved cardiac output. It relieves signs and symptoms of HF, prevents progression of HF.  ARBs block the effects of angiotensin II at the angiotensin II receptor.  ARBs also have similar side effects  are prescribed as an alternative to ACE inhibitors, especially when patients cannot tolerate 3. Beta-adrenergic Blocking Agents (beta-blockers) 4. Diuretics: Decreases fluid volume overload and signs and symptoms of HF. 5. Digitalis: Digoxin increases the force of myocardial contraction and slows conduction through the atrioventricular node. 6. Calcium Channel Blockers 7. Other Medications for Heart Failure:  Anticoagulants may be prescribed, especially if the patient has a history of atrial fibrillation or a thromboembolic event. Adult Nursing (1), 2024/2025 34   Medications that manage hyperlipidemia B. Nutritional Therapy:  A low-sodium (2 to 3 g/day) diet and avoidance of drinking excessive amounts of fluid are usually recommended.  Dietary restriction of sodium reduces fluid retention and the symptoms of peripheral and pulmonary congestion. C.Supplemental Oxygen:  Oxygen therapy may become necessary as HF progresses.  The need is based on the degree of pulmonary congestion and resulting hypoxia. Some patients require supplemental oxygen only during periods of activity. Potential Complications of heart failure:  Hypotension, poor perfusion, and cardiogenic shock  Dysrhythmias  Thromboembolism  Pericardial effusion and cardiac tamponade Nursing intervention: 1. Administering and Monitoring Pharmacologic Therapy: A.Angiotensin-Converting Enzyme Inhibitors: Observe for hypotension, hypovolemia, increased serum K, cough & worsening renal function, especially if they are also receiving diuretics. B.Angiotensin Receptor Blockers (ARBs): Observe for symptomatic hypotension, increased serum K, and worsening renal function. C.Beta-adrenergic Blocking Agents (beta-blockers): Observe for decreased heart rate, symptomatic hypotension, and fatigue. D.Calcium Channel Blockers: Observe for symptomatic hypotension, drowsiness, or dizziness Adult Nursing (1), 2024/2025 35  E. Diuretics:  Observe for electrolyte abnormalities (hypokalemia with thiazide and loop Diuretics, hyperkalemia with potassium-sparing diuretics, hyponatremia with prolonged diuretic therapy may produce).  Renal dysfunction (increased serum blood urea nitrogen and creatinine),  Monitor daily intake, and output.  Assess lung sounds, jugular vein distention, daily weight, and assess peripheral, abdominal, or sacral edema to identify response to therapy. Edema usually affects the feet and ankles and worsens when the patient stands or sits for a long period and improves with leg elevation.  Assess for signs of volume depletion, such as postural hypotension, dizziness, and balance problems.  Monitor for elevated serum uric acid levels and the development of gout. F. Digitalis:  Assess the patient’s clinical response to digoxin therapy by: Evaluating relief of symptoms such as dyspnea, orthopnea, crackles, hepatomegaly, and peripheral edema.  Monitor the patient for factors that increase the risk of digitals toxicity:  Decreased potassium level (hypokalemia), which may be caused by diuretics. Hypokalemia increases the action of digoxin and predisposes patients to digoxin toxicity and dysrhythmias.  Use of medications that enhance the effects of digoxin, including oral antibiotics and cardiac drugs that can further decrease heart rate.  Impaired renal function, particularly in patients age 65 and older. Because digoxin is eliminated by the kidneys, renal function (serum Adult Nursing (1), 2024/2025 36  creatinine) is monitored and doses of digoxin are adjusted accordingly.  Before administering digoxin: it is standard nursing practice to assess apical heart rate.  Monitor for gastrointestinal side effects: anorexia, nausea, vomiting, abdominal pain, and distention.  Monitor for neurologic side effects: headache, malaise, nightmares, forgetfulness, social withdrawal, depression, agitation, confusion, hallucinations, decreased visual acuity, yellow or green halo around objects (especially lights), or “snowy” vision. 2. A low-sodium (2 to 3 g/day) diet and avoidance of drinking excessive amounts of fluid are usually recommended. 3. Supplemental Oxygen 4. Bed rest with elevated head of the bed 5. Promoting Activity Tolerance: a total of 30 minutes of physical activity every day should be encouraged. 6. Assesses for skin breakdown and institutes preventive measures. 7. Frequent changes of position, positioning to avoid pressure, and leg exercises may help prevent pressure ulcers. 8. Along with reassurance, the nurse can begin teaching the patient ways to control anxiety and avoid anxiety provoking situations. 9. The patient is assessed for factors that contribute to a sense of powerlessness. Listen actively to patients encourages them to express their concerns and ask questions. Other strategies include providing the patient with decision-making opportunities, such as when activities are to occur or encouraging food and fluid choices consistent with the dietary restrictions. Adult Nursing (1), 2024/2025 37  10. Provide patient education and involves the patient in the therapeutic regimen to promote understanding and adherence to the plan. Make sure that the patient or caregiver will be able to:  Identify heart failure as a chronic disease that can be managed with medications and specific self-management behaviors.  Take or administer medications daily, exactly as prescribed. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen should be avoided because they decrease renal perfusion, especially in the elderly.  Monitor effects of medication such as changes in breathing and edema.  Know signs and symptoms of orthostatic hypotension and how to prevent it.  Weigh self-daily at the same time with same clothes.  Restrict sodium intake: adapt diet by examining nutrition labels to check Sodium content per serving; avoid canned or processed foods; eat fresh foods; consult the written diet plan and the list of permitted and restricted foods & use of flavorings, such as lemon juice, vinegar, and herbs, may be used to improve the taste of the food and facilitate acceptance of the diet.  Small, frequent meals decrease the amount of energy.  Participate in a daily exercise program: Increase walking and other activities gradually, provided they do not cause unusual fatigue or dyspnea, Conserve energy by balancing activity with rest periods & avoid activity in extremes of heat and cold, which increase the work of the heart. Adult Nursing (1), 2024/2025 38   Develop methods to manage and prevent stress: e.g. avoid tobacco, avoid alcohol and engage in diversional activities, meditation, guided imagery, or music therapy.  Keep regular appointments with physician or clinic and report immediately to the physician or clinic any of the following:  Gain in weight of 0.9–1.4 kg in 1 day, or 2.3 kg in 1 week.  Loss of appetite.  Unusual shortness of breath with activity.  Swelling of ankles, feet, or abdomen.  Persistent cough.  Development of restless sleep; increase in number of pillows needed to sleep. Adult Nursing (1), 2024/2025 39  Perioperative nursing care After completing this lecture, the student will be able to: 1. Describe the phases of the perioperative period. 2. Discuss various types of surgery according to the purpose, degree of urgency, and degree of risk. 3. Identify essential aspects of preoperative assessment. 4. Give examples of pertinent nursing diagnoses for surgical clients. 5. Identify nursing responsibilities in planning perioperative nursing care. 6. Describe essential preoperative teaching, including pain assessment and management, moving, leg exercises, and deep-breathing and coughing exercises. 7. Describe essential aspects of preparing a client for surgery. 8. Compare various types of anaesthesia. 9. Identify essential nursing assessments and interventions during the immediate post anaesthetic phase. 10. Demonstrate ongoing nursing assessments and interventions for the postoperative client. 11. Identify potential postoperative complications and describe nursing interventions to prevent them. Outlines 1. Phases of the perioperative period. 2. Classification of surgery according to the urgency, purpose, and degree of risk. 3. Pre-operative nursing assessment  Review medical history (present & past medical history)  Physical assessment Adult Nursing (1), 2024/2025 40   Informed Consent 4. Preoperative teaching 5. Preparing the person, the day before surgery 6. Intraoperative phase 7. Responsibilities of scrub nurse: 8. Responsibilities of circulating nurse: 9. Responsibilities of anesthetic nurse 10. Types of anesthesia 11. Prevention of Intraoperative Complications. 12. Immediate postoperative period nursing care (post-anesthesia) 13. Nursing management in the post anesthesia care unit (PICU). 14. Intermediate (hospital stay) phase 15. Post-Operative Complications and nursing intervention. 16. Types of wound healing. 17. Nursing management for patient with wound. 18. Client and family teaching. Introduction Surgery is a unique experience of a planned physical alteration encompassing three phases: preoperative, intraoperative, and postoperative. These three phases are together referred to as the perioperative period. Perioperative nursing is the delivery of nursing care through the framework of the nursing process. Perioperative is a term used to describe the entire span of surgery, including before and after the actual operation. Adult Nursing (1), 2024/2025 41  Post Operative Phases: The three phases of perioperative care are: Preoperative Phase: The time from when decision for surgical intervention is made to when the patient is transferred to the operating room. Intraoperative Phase: Period of time from when the patient is transferred to the operating room to when he or she is admitted to the post-anesthesia care unit (PICU). Postoperative Phase: Period of time that begins with the admission of the patient to the post-anesthesia care unit and ends after follow- up evaluation in the clinical setting or home. 1. Classification of surgical procedure: 1. According to urgency: a. Emergency surgery: Performed immediately to preserve life or function (e.g., controlling of bleeding, or traumatic amputation). b. Urgent surgery: When surgery is necessary within 24 hours of diagnosis to reduce the risk of complications that can occur with a delay (e.g., internal fixation of a fracture). c. Elective surgery: When the surgical intervention is the preferred treatment for a condition that is not imminently life threatening, or to improve the clients life (e,g. hernia). d. Required: The condition requires surgery within a few weeks e.g. (eye cataract). e. Optional: Requested by the person (Mammoplasty). Adult Nursing (1), 2024/2025 42  2. According to purpose of surgery: a. Diagnostic and explorative surgery: Performed to validate a diagnosis e.g., biopsy of a mass in a breast. b. Curative (e.g., excision of a tumor or an inflamed appendix or removal of a gallbladder (cholecystectomy). c. Palliative surgery: Performed to reduce symptoms of a disease without curing e.g., resection of nerve roots to relieve pain. d. Reconstructive or cosmetic surgery: (eg, mammoplasty or a cleft palate repair.). e. Transplant surgery: Performed to replaces malfunctioning structures e.g., kidney transplant. 3. According to degree of Risk a. Minor: performed in in settings such as physician office, an outpatient surgery setting, low risk and few complications e.g. (breast biopsy). b. Major: may require hospitalization and specialized care, has a higher degree of risk, involves major body organs or life-threatening situations. Pre-operative nursing assessment 1. Review medical history (present & past medical history) a. History of allergies b. Medications (list all current medications) c. Previous surgery and anesthesia: previous surgeries are important to the intraoperative and postoperative phases d. Ex: previous heart or lung surgery may necessitate adaptations to anesthesia and in positioning during surgery. Previous surgical complications: DVT, hyperthermia, latex sensitivity, and pneumonia may put the patient at risk Adult Nursing (1), 2024/2025 43  e. Review completion of preoperative diagnostic testing. (Blood group, cross-match, hepatitis C&B…….). f. Review diagnostic studies as (Chest x-ray, Electrocardiogram ECG). g. Smoking habit. h. Determining the teaching and psychosocial needs of the patient and family. 2. Physical assessment  Cardiovascular system assessment. - Assess heart rate (rate, rhythm ………...). - Edema or jugular vein distention is documented.  Respiratory system assessment: - Assess respiratory rate and pattern. - Oxygen saturation is obtained and smoking habit.  Gastrointestinal system assessment - The abdomen is inspected for distention. - Bowel sounds are auscultated.  Neurological system assessment. - Patient Able to comprehend and level of cognitive impairment.  Musculoskeletal system assessment - Deformities may interfere with intraoperative and postoperative positioning. - The patient’s joint range of motion, muscular strength, gait, and mobility are observed.  Nutritional status assessment  Malnutrition and obesity increase surgical risk.  Psychological assessment: Adult Nursing (1), 2024/2025 44   The most common preoperative psychological problems are anxiety and knowledge deficit. Informed Consent  Voluntary and informed written consent from the patient is necessary before surgery can be done.  Such written permission protects the patient against illegal surgery and protects surgeon against claims of an unauthorized operation.  Nature and intention of the surgery.  Name and qualifications of the person performing the surgery.  Risks, including tissue damage, disfigurement, or even death.  Chances of success.  Possible alternative measures.  The right of the client to refuse consent or later withdraw consent. Preoperative teaching:  Surgical events and sensation: educate about what they will be seeing. they are the most important person  Pain management: Teach patients how to report their pain level using a pain rating scale.  Pain relief methods are described, such as analgesic injections, an epidural catheter, deep breathing, music and guided imagery.  Physical activity: most common causes of postoperative complications are alterations in cardiovascular and respiratory function. Activity reduces risk for DVT, pneumonia, atelectasis, thrombophlebitis. (Deep breathing, coughing, incentive spirometry, leg exercises, turning in bed). Adult Nursing (1), 2024/2025 45  a. Deep breathing exercise: During surgery the cough reflex is suppressed, mucus accumulates, in the tracheobronchial passageways, and lungs do not ventilate fully.  Respirations are often less effective as a result of the anesthesia, pain medication, and pain from incision.  Patient with thoracic or high abdominal incisions are prone to shallow breathing.  Deep breathing helps hyperventilate the alveoli and prevent them from collapsing. Improve lung expansion and volume, help expel anesthetic gases and mucus, and facilitate oxygenation of tissues. b. Coughing exercise: helps remove retained mucus. Teach patient how to splint the incision. c. Incentive spirometry: helps increase lung volume and inflation of alveoli and facilitate venous return. d. Leg exercise: to avoid circulatory stasis in the legs, thrombi, DVT and increase venous return. e. Turning in bed: improves venous return, respiratory function. Decrease ulcer formation. Should change position every 2 hours when awake. Preparing the person, the day before surgery 1. Skin preparation  The goal of preoperative skin preparation is to decrease number of bacteria on skin.  It is ideal for the patient to bathe or shower using bacteriostatic soap on the day of surgery. Adult Nursing (1), 2024/2025 46   Hair shaving should be performed as close to the operative time as possible, electric clippers are used for safe hair removal immediately before the operation. 2. GIT preparation  The patient should be fasting from 10 to 12 hours preoperatively.  Enemas are not commonly prescribed preoperatively unless the patient is undergoing abdominal or pelvic surgery. 3. The patient is dressed in hospital gown. 4. Remove hairpins. 5. Instruct patient to remove dentures or partial plates, contact lenses, or glasses. 6. Remove jewelry, makeup and nail polish. 7. Check the identification band. 8. Administer preoperative medication as ordered  Sedative and tranquilizers such as lorazepam (Ativan) IV 15-20 minutes prior to surgery or by IM 2 hours prior the procedure (to reduce anxiety and ease anesthetic induction).  Narcotic analgesics such as morphine (to provide client sedation and reduce the required amount of anesthetic).  Anticholinergics such as atropine (to reduce oral and pulmonary secretions and prevents laryngospasm).  Prophylactics antibiotics: is given when bacterial contamination is expected. Admitting the patient to surgery (Final checklist) The preoperative checklist is the last procedure before taking the patient to the operating room. Most facilities have a standard form for this check. Adult Nursing (1), 2024/2025 47   Verification and identification.  Review of patient’s record.  Consent form.  Patient’s preparedness.  NPO status  Proper attire (hospital gown)  Skin preparation  IV started with correct gauge needle  Dentures removed if present  Jewelry, contact lenses, glasses removed and secured in locked area. Diagnosing NANDA nursing diagnoses that may be appropriate for the preoperative client include the following: 1. Deficient Knowledge related to  A lack of education about the perioperative process  A lack of exposure to the specific perioperative experience. 2. Anxiety related to  Effects of surgery on ability to function in usual roles  Outcome of exploratory surgery for malignancy  Risk of death  Loss of control during anesthesia or waking up during anesthesia  Perceived inadequate postoperative analgesia  Change in health status and/or body image. 3. Grieving related to  Perceived loss of body part associated with planned surgery. Adult Nursing (1), 2024/2025 48  4. Ineffective Coping related to  lack of clear outcomes of surgery  Unresolved past negative experience with surgery. Intraoperative phase Surgical Team 1. Surgeon, surgical assistant. 2. Anesthesiologist. 3. Circulating Nurse. 4. Scrub Nurse. Role of nurse in operating room Operating room responsibilities are divided between the scrub nurse and the circulating nurse. Responsibilities of scrub nurse:  Perform surgical hand scrub.  Dons sterile gown and gloves aseptically.  Arrange sterile supplies and instruments in manner prescribed for procedure.  Check instruments for proper functioning.  Count sponges, needles, and instruments with circulating nurse.  Assist with surgical draping of client.  Maintain sterile field.  Hands surgeon instruments, sponges, and necessary supplies during procedure".  Identifies and handles surgical specimens correctly. Adult Nursing (1), 2024/2025 49  Responsibilities of circulating nurse  Prepares operating room with necessary equipment and supplies and ensures that equipment is functional.  Open sterile supplies for scrub nurse.  Confirm client's allergies.  Monitors intake and output (I&O) and blood loss.  Check medical record for completeness.  Count all gauze sponges, sharps, and instruments with the scrub nurse before incision closure, to prevent foreign bodies from being left inside the client.  Observes sterile field closely for any breaks in aseptic technique and reports.  Handles and initiates transport of specimens. Responsibilities of anesthetic nurse  Prepares safe environment for induction of anesthesia.  Checks suction apparatus, O2 and gas supply, and gas cylinder machine to be well prepared for use.  Checks and records all drugs required by the anesthesiologist. Anesthesia It is an artificially induced state of partial or total loss of sensation, occurring with or without consciousness. Types of Anesthesia 1. General 2. Regional 3. local 1. General anesthesia:  Blocks awareness centers in the brain.  Produces unconsciousness, body relaxation, and loss of sensation. Adult Nursing (1), 2024/2025 50   Protective reflexes such as cough and gag reflexes are lost  Is administered by inhalation or I.V. infusion. Four stages are used to describe the induction of general anesthesia:  Stage (1) Beginning anesthesia: This short period is crucial for producing unconsciousness. The client experiences dizziness, detachment, a temporary heightened sense of awareness to noises and movements, and a sensation of ‘‘heavy’’ extremities and being unable to move them. Inhaled or IV anesthetics are used to produce this phase.  When the client becomes unconscious, his or her airway is secured with an endotracheal tube.  Stage (2) Excitement: During this stage the client may struggle, shout, talk, sing, laugh, or cry. He or she may make uncontrolled movements, so team members must protect the client from falling or other injury. Quick and smooth administration of anesthesia can prevent this phase.  Stage (3) Surgical anesthesia: In this stage the client remains unconscious through continuous administration of the anesthetic agent. This level of anesthesia maybe maintained for hours with a range of light to deep anesthesia.  Stage (4) Medullary depression: This stage occurs when the client receives too much anesthesia. The client will have shallow respirations, weak pulse, and widely dilated pupils unresponsive to light. Without prompt intervention, death can occur. Adult Nursing (1), 2024/2025 51  2. Regional anesthesia:  Regional anesthesia uses local anesthetics to block the conduction of nerve impulses in a specific region.  Doesn’t produce unconsciousness.  Is administered by spinal or epidural.  Advantages of regional anesthesia include less risk for respiratory, cardiac, or gastrointestinal complications. Type of regional anesthesia Type of regional anesthesia Uses and Effects Spinal anesthesia It requires a lumbar puncture into the subarachnoid space of the lumbar area (usually L4 or L5), which contains cerebrospinal fluid Anesthetizes spinal nerves as they exit the spinal cord Used for surgery involving the abdomen, perineum, and lower extremities Epidural block is an injection of an anesthetic agent into the epidural space, the area inside the spinal column but outside the dura mater. Although similar to spinal anesthesia, headache that frequently follows usually not present. Peripheral nerve block The anesthetic is injected near a specific (Local Conduction Blocks) nerve or bundle of nerves to block sensations of pain from a specific area of the body. examples are brachial plexus block, ulnar nerve block, and sciatic nerve block Adult Nursing (1), 2024/2025 52  Fig. (1) Epidural and spinal anesthesia 3. Local anesthesia: - Blocks transmission of nerve impulses at the site of action, analgesia over limited tissue area and doesn’t produce unconsciousness. - Injection of an anesthetic agent such as (lidocaine) to a specific area of the body Prevention of Intraoperative Complications: Nurses who work in the OR assess the client continuously and protect the client from potential complications, including: Infection Fluid volume excess or deficit: Injury related to positioning: Hypothermia: Adult Nursing (1), 2024/2025 53  Malignant hyperthermia: Infection: Strict aseptic technique is absolutely necessary before and during surgery. If a nurse notes a break in technique, he or she immediately notifies the surgeon and OR personnel. Clients are also at risk for the retention of foreign objects in the wound. The scrub nurse and circulating nurse count surgical instruments, gauze sponges, and sharps to prevent this problem. The circulating nurse records the counts on the intraoperative record. Fluid volume excess or deficit: The anesthesiologist usually adds fluids to the IV lines, but the circulating nurse also may perform this function. The circulating nurse is responsible for recording and keeping a running total of IV fluids administered. If the client has an indwelling catheter, the nurse measures urine output during surgery. Injury related to positioning: The OR staff positions the client on the OR table according to the type of surgery. Careful positioning and monitoring help to prevent interruption of blood supply secondary to prolonged pressure, nerve injury related to prolonged pressure, postoperative hypotension, dependent edema, and joint injury related to poor body alignment. Hypothermia: During the procedure, the client may be at risk for hypothermia. Adult Nursing (1), 2024/2025 54  Causes of the low temperature in the OR; 1. Administration of cold IV fluids. 2. Inhalation of cool gases. 3. Exposure of body surfaces for the surgi