Exam 112 lec( wala respi).pdf

Five Types of Surgery 1. Diagnostic Surgery ○ Purpose: To determine the nature or extent of a disease. ○ Examples: Biopsies (removing tissue for analysis), exploratory laparotomy (opening the abdomen to examine internal organs). ○ Key Point: Helps in diagnosin...

Five Types of Surgery 1. Diagnostic Surgery ○ Purpose: To determine the nature or extent of a disease. ○ Examples: Biopsies (removing tissue for analysis), exploratory laparotomy (opening the abdomen to examine internal organs). ○ Key Point: Helps in diagnosing conditions, leading to appropriate treatment decisions. 2. Palliative Surgery ○ Purpose: To relieve symptoms of a disease without curing it. ○ Examples: Debulking a tumor to alleviate pressure, creating a stoma for bowel obstruction. ○ Key Point: Focuses on improving quality of life rather than curing the underlying disease. 3. Preventive Surgery ○ Purpose: To prevent diseases or complications before they occur. ○ Examples: Mastectomy in high-risk patients (BRCA mutation carriers), removal of polyps to prevent colorectal cancer. ○ Key Point: Aims to reduce the risk of developing a condition. 4. Procurement Surgery ○ Purpose: To obtain organs or tissues for transplantation. ○ Examples: Organ harvesting from a deceased donor. ○ Key Point: Vital for transplant medicine, enabling life-saving procedures for recipients. 5. Curative Surgery ○ Purpose: To eliminate a disease or condition entirely. ○ Examples: Tumor removal, appendectomy for appendicitis. ○ Key Point: Aimed at curing the underlying health issue. Three Types of Surgical Approaches 1. Ablative Surgery ○ Definition: Involves removing tissue or an organ to treat a disease. ○ Examples: Amputation of a limb, resection of a tumor. ○ Key Point: Directly targets and removes diseased tissue. 2. Reconstructive Surgery ○ Definition: Aims to restore the form and function of a body part. ○ Examples: Breast reconstruction post-mastectomy, skin grafting for burn treatment. ○ Key Point: Focuses on restoring appearance and function after trauma, disease, or surgery. 3. Constructive Surgery ○ Definition: Involves creating new anatomical structures to improve function.  ○ Examples: Creating a new ear (otoplasty), reconstructing facial features after injury. ○ Key Point: Aims to create or restore structure that is absent or defective. Categories of Surgery by Urgency 1. Emergent Surgery ○ Definition: Requires immediate intervention to prevent death or serious harm. ○ Examples: Trauma surgery (e.g., for internal bleeding), surgery for acute appendicitis. ○ Key Point: Performed without delay; the patient’s life is at risk. 2. Urgent Surgery ○ Definition: Necessary within a short time frame to avoid complications or deterioration. ○ Examples: Surgery for a fractured bone or an obstructed bowel. ○ Key Point: Scheduled promptly, usually within 24 hours. 3. Required Surgery ○ Definition: Needed but can be scheduled in a few days to weeks. ○ Examples: Gallbladder removal for symptomatic gallstones. ○ Key Point: Important to address issues but not immediately life-threatening. 4. Elective Surgery ○ Definition: Planned surgery that is not urgent and can be scheduled at the patient’s convenience. ○ Examples: Hysterectomy for non-cancerous conditions, hernia repair. ○ Key Point: Improves quality of life, but delays won't result in immediate harm. 5. Optional Surgery ○ Definition: Not necessary for health but chosen for cosmetic or personal reasons. ○ Examples: Rhinoplasty: Nose reshaping. Otoplasty: Ear correction. Rhytidoplasty: Facelift. Blepharoplasty: Eyelid surgery. Mentoplasty: Chin surgery. Soft Tissue Augmentation: Fillers or implants. Hair Transplant: Restoring hair loss. ○ Key Point: Enhances appearance and self-esteem but is purely elective. Categories of Surgery by Degree of Risk 1. Major Surgery  ○ Definition: Involves significant risk to the patient, often requiring extensive tissue manipulation or prolonged anesthesia. ○ Examples: Heart bypass surgery, major abdominal surgeries (like colectomy), or joint replacements. ○ Key Point: Higher potential for complications and longer recovery times. 2. Minor Surgery ○ Definition: Generally lower risk, often outpatient procedures with minimal tissue manipulation and shorter recovery. ○ Examples: Skin lesion removal, minor hernia repair, or cataract surgery. ○ Key Point: Typically involves local anesthesia and has fewer complications. Common Preoperative Diagnostic Tests 1. Urinalysis ○ Purpose: Assesses kidney function and checks for urinary tract infections or other abnormalities. 2. Chest X-ray ○ Purpose: Evaluates lung health and checks for any underlying respiratory issues or cardiac enlargement. 3. Blood Studies ○ Components: RBC (Red Blood Cells): Evaluates anemia and oxygen-carrying capacity. Hb (Hemoglobin): Measures oxygen transport ability. Hct (Hematocrit): Assesses blood volume in relation to total blood. WBC (White Blood Cells): Indicates immune status and possible infection. WBC Differential: Provides detailed information on specific white blood cell types. 4. Electrolytes ○ Purpose: Measures levels of sodium, potassium, chloride, and bicarbonate to assess metabolic status. 5. ABGs and Oximetry ○ Purpose: Evaluates oxygenation, carbon dioxide levels, and acid-base balance in the blood. 6. PT, PTT, INR, Platelet Count ○ Purpose: Assesses coagulation status to identify bleeding risks. 7. Blood Glucose ○ Purpose: Screens for diabetes and evaluates glucose control. 8. Creatinine ○ Purpose: Measures kidney function and helps assess renal status. 9. BUN (Blood Urea Nitrogen)  ○ Purpose: Evaluates kidney function and hydration status. 10. Serum Albumin ○ Purpose: Assesses nutritional status and liver function. 11. ECG (Electrocardiogram) ○ Purpose: Evaluates heart rhythm and identifies any cardiac abnormalities. 12. Pulmonary Function Studies ○ Purpose: Assesses lung function and capacity, particularly important for patients with respiratory issues. 13. Liver Function Tests ○ Purpose: Evaluates liver health and function. 14. Type and Crossmatch ○ Purpose: Ensures compatibility for blood transfusions. 15. HCG (Human Chorionic Gonadotropin) ○ Purpose: Tests for pregnancy status, especially in women of childbearing age. Preoperative Preoperative Consent 1. General Consent vs. Informed Consent: ○ General Consent: This is typically a broad consent that allows healthcare providers to deliver a range of treatments. It may be obtained at the time of admission and is often not specific to a particular procedure. ○ Informed Consent: This is a more detailed and specific process that requires the healthcare provider to explain the procedure, risks, benefits, and alternatives. The patient must understand this information and voluntarily agree to the procedure. Nursing Responsibilities 1. Pre-admissions: ○ Gather medical history, current medications, allergies, and previous surgeries. ○ Educate the patient on what to expect during the surgical process, including any necessary preoperative instructions. ○ Assess psychosocial factors, ensuring support systems are in place. 2. Admission to the Surgical Unit: ○ Verify the patient's identity and surgical site using a two-person identification process. ○ Complete a thorough nursing assessment, including vital signs, lab results, and physical status. 3. In-Hold Area: ○ Monitor the patient’s anxiety levels and provide emotional support. ○ Administer preoperative medications as prescribed (e.g., anxiolytics). 4. Psychological Assessment and Care:  ○ Evaluate the patient's mental readiness for surgery. Assess coping mechanisms, fears, and support systems. ○ Provide reassurance, answer questions, and clarify misconceptions about the surgical process. General Physical Preparation 1. Before Surgery: ○ Ensure preoperative instructions are followed (e.g., fasting, medication adjustments). ○ Perform necessary laboratory tests and imaging studies. ○ Administer prophylactic antibiotics if indicated. Teaching Preoperative Exercise Educate patients on preoperative exercises, such as deep breathing and leg exercises, to enhance respiratory function and circulation post-surgery. Encourage mobility to reduce the risk of postoperative complications like pneumonia and deep vein thrombosis (DVT). Preparing the Patient the Evening Before Surgery 1. Dietary Restrictions: ○ Confirm that the patient has followed fasting guidelines, typically involving no solid food after midnight and limited clear liquids up to a few hours before surgery. 2. Medication Management: ○ Review and adjust medications as necessary, including holding anticoagulants or other drugs as directed. 3. Emotional Preparation: ○ Encourage relaxation techniques (e.g., guided imagery, deep breathing) to reduce anxiety. 4. Instructions Review: ○ Go over the surgical plan, including what to expect postoperatively. Ensure the patient understands the importance of adhering to instructions. Preparing the Patient on the Day of Surgery 1. Early Morning Care: ○ Perform a final assessment, including vital signs. ○ Administer prescribed preoperative medications. ○ Ensure the patient has emptied their bladder before the procedure. 2. Grooming and Hygiene:  ○Assist the patient with personal hygiene and ensure that any necessary skin preparations (e.g., antiseptic wash) are completed. 3. Dressing: ○ Change into a hospital gown and remove any personal items (jewelry, dentures) to prevent loss or interference during surgery. 4. Emotional Support: ○ Reassure the patient, remind them of the supportive staff, and encourage any last-minute questions. Intraoperative Types of Anesthesia 1. General Anesthesia General anesthesia induces a state of unconsciousness and unresponsiveness, typically achieved through intravenous and inhalational agents. It is characterized by four distinct stages: Induction: This initial stage involves the administration of anesthetic agents, leading the patient from an awake state to unconsciousness. It can be achieved via IV drugs like propofol or inhalation agents. Excitement: During this phase, the patient may exhibit involuntary movements, heightened reflexes, and increased heart rate. This is often a brief stage as the goal is to progress quickly to surgical anesthesia. Surgical Anesthesia: At this stage, the patient is completely unconscious and lacks sensation, making it safe to perform surgery. The anesthetist monitors vital signs closely and maintains the desired depth of anesthesia. Danger: This is the final stage, characterized by a risk of respiratory and cardiovascular collapse. Proper monitoring and management are essential to avoid reaching this stage during surgery. Objectives of General Anesthesia 1. Oxygenation: Ensuring adequate oxygen delivery to tissues. 2. Unconsciousness: The patient is completely unaware and unresponsive to surgical stimuli. 3. Analgesia: Providing pain relief to prevent discomfort during and after the procedure. 4. Muscle Relaxation: Facilitating surgical access by relaxing skeletal muscles. 5. Control of Autonomic Reflexes: Minimizing involuntary responses that could interfere with surgery (e.g., cardiovascular responses to incision). 2. Regional Anesthesia Regional anesthesia blocks sensation in a specific area of the body. Common techniques include nerve blocks, spinal, and epidural anesthesia. Nerve Block: An anesthetic agent is injected near a nerve to block sensation in the area it innervates. This is commonly used for procedures on the extremities. Spinal Anesthesia: Involves the injection of anesthetic into the cerebrospinal fluid in the lumbar region. It is often used for lower abdominal and pelvic surgeries. Epidural Anesthesia: Involves the injection of anesthetic into the epidural space surrounding the spinal cord. This technique is frequently used during labor and for certain surgical procedures. Characteristics Absorption: The absorption rate of anesthetics varies; spinal anesthetics act quickly due to direct delivery into the cerebrospinal fluid, while epidurals may take longer. Classification of Space: ○ Epidural Space: The area outside the dura mater, where epidural anesthesia is administered. ○ Subarachnoid Space: The area where spinal anesthesia is injected, directly affecting the cerebrospinal fluid. Advantages and Disadvantages Advantages: ○ Reduced systemic effects compared to general anesthesia. ○ Provides excellent analgesia for the surgical area and postoperative pain control. Disadvantages: ○ Risk of complications such as infection, nerve injury, or hematoma. ○ Possible inadequate analgesia if the block is not performed correctly. 3. Local Anesthesia Local anesthesia is used for minor surgical procedures, providing numbness in a small, localized area. Advantages Quick onset and minimal systemic effects. Suitable for outpatient procedures, allowing for rapid recovery. Disadvantages Limited to surface-level procedures; not suitable for extensive surgeries. Patient remains fully conscious, which may induce anxiety in some. Contraindications  Allergies to local anesthetics. Certain medical conditions that may affect drug metabolism. 4. Moderate Sedation Also known as conscious sedation, this technique allows the patient to remain awake and responsive while providing sedation and analgesia. Applications: Commonly used for procedures such as colonoscopy or minor surgeries. Monitoring: Requires careful monitoring of vital signs and the patient’s level of consciousness, as there is a risk of airway compromise. Complications of Anesthesia 1. Anesthesia Awareness ○ Description: This occurs when a patient becomes conscious during surgery and can experience awareness of their surroundings despite being unable to move or communicate. ○ Greatest Risk: High-risk procedures under general anesthesia, particularly in patients with certain medical conditions or those requiring lighter anesthesia. ○ Prevention: Using appropriate anesthetic agents and doses, monitoring depth of anesthesia (e.g., via bispectral index monitoring), and ensuring clear communication about risks with patients. 2. Nausea, Vomiting, and Pain ○ Causes: Nausea and vomiting can be triggered by anesthetic agents, pain, or anxiety. Pain may result from surgical trauma or inadequate analgesia. ○ Management: Prophylactic antiemetics (e.g., ondansetron) before surgery. Postoperative pain management strategies, including opioids, NSAIDs, or regional anesthesia techniques. 3. Spinal Headache ○ Cause: Results from a dural puncture, which can cause leakage of cerebrospinal fluid (CSF) and decreased intracranial pressure. ○ Management: Conservative treatment includes hydration, caffeine, and lying flat. An epidural blood patch may be performed to seal the leak and alleviate symptoms. 4. Severe Hypotension and Respiratory Depression ○ Causes: Hypotension can result from vasodilation caused by anesthetic agents or blood loss during surgery.  Respiratory depression may occur due to the effects of anesthetics on the central nervous system. ○ Management: Administer IV fluids and medications (e.g., vasopressors) to stabilize blood pressure. Monitor respiratory function closely; supplemental oxygen or airway management may be necessary. 5. Anaphylaxis ○ Cause: Severe allergic reactions to anesthetic agents, antibiotics, or other medications used during surgery. ○ Management: Immediate administration of epinephrine and airway support. IV fluids and additional medications (e.g., antihistamines, corticosteroids) to stabilize the patient. 6. Hypoxia, Respiratory and Cardiac Arrest, Urinary Retention, Paralysis ○ Causes: Hypoxia can result from airway obstruction, inadequate ventilation, or respiratory depression. Cardiac arrest may be due to severe hypotension, anaphylaxis, or other complications. Urinary retention can result from spinal anesthesia affecting bladder function. Paralysis may occur due to nerve injury or the effects of anesthesia. ○ Management: Ensure airway patency and provide supplemental oxygen. CPR and advanced cardiac life support protocols in case of cardiac arrest. Catheterization may be needed for urinary retention, and monitoring for nerve injuries is essential. 7. Hypothermia ○ Cause: Exposure to cold operating room temperatures and the effects of anesthetics that impair thermoregulation. ○ Management: Use of warm blankets, forced-air warming devices, or heated intravenous fluids to maintain normothermia. 8. Malignant Hyperthermia ○ Cause: A genetic predisposition leading to a hypermetabolic state triggered by certain anesthetic agents (e.g., succinylcholine, inhalational anesthetics). ○ Management: Immediate discontinuation of triggering agents, administration of dantrolene, cooling measures, and supportive care. Types of Surgical Incisions  1. Butterfly Incision: ○ Used primarily for access to the thoracic cavity or chest wall, resembling butterfly wings. It's a horizontal incision made in the chest. 2. Limbal Incision: ○ Typically used in ophthalmic surgery; it follows the contour of the limbus (the border between the cornea and sclera). 3. Halstead/Elliptical Incision: ○ This incision is commonly used for skin lesions or tumor excisions, following an elliptical shape to minimize scarring. 4. Abdominal Incision: ○ A broad term that encompasses various incisions made in the abdominal wall to access intra-abdominal structures. 5. McBurney Incision: ○ A specific incision for appendectomy, made in the right lower quadrant to access the appendix. 6. Lumbotomy/Transverse Incision: ○ Used for accessing the kidney or retroperitoneal structures, this incision runs horizontally along the flank. 7. Subcostal Incision: ○ A curved incision made below the ribcage, often used for gallbladder surgeries (cholecystectomy) or other upper abdominal procedures. 8. Paramedian Incision (Right and Left Side): ○ Vertical incisions made parallel to the midline, providing access to the abdominal cavity with reduced risk of nerve damage. 9. Midline Incision: ○ A vertical incision along the midline of the abdomen, offering wide access for various abdominal surgeries. 10. Pfannenstiel Incision: A transverse incision made just above the pubic symphysis, commonly used in gynecological surgeries and cesarean sections for optimal cosmetic results. Positioning the Client for surgery 1. Supine Position Description: The patient lies flat on their back with arms positioned comfortably at their sides or on armboards. Uses: Commonly used for abdominal, thoracic, and many other types of surgeries. Considerations: ○ Ensure proper padding to prevent pressure ulcers. ○ Monitor for potential complications such as respiratory distress or circulation issues in the arms. 2. Lithotomy Position Description: The patient lies on their back with legs elevated and supported in stirrups. Uses: Frequently used for gynecological surgeries, urological procedures, and rectal examinations. Considerations: ○ Maintain safety by ensuring the legs are raised and lowered gently to prevent strain. ○ Monitor for potential nerve damage or circulation issues in the legs, and ensure the patient is properly draped to maintain modesty. 3. Trendelenburg Position Description: The patient's head is lowered, and the legs are elevated, creating a sloping effect. Uses: Often used in cases of shock to increase venous return to the heart or for certain abdominal and pelvic surgeries. Considerations: ○ Monitor for increased intracranial pressure or respiratory complications. ○ Ensure secure positioning to prevent sliding down the table. 4. Reverse Trendelenburg Position Description: The head is elevated while the feet remain lower, creating a reverse sloping effect. Uses: Used for upper abdominal surgeries, to facilitate respiratory function, or to reduce pressure on the diaphragm. Considerations: ○ Monitor for hypotension as blood flow may be affected. ○ Ensure the patient is well-secured to prevent slipping. 5. Modified Fowler's/Sitting Position Description: The patient is seated at a 45 to 60-degree angle, with support for the back and legs. Uses: Often used for head, neck, and upper respiratory surgeries. Considerations: ○ Ensure adequate support to the back to prevent strain. ○ Monitor for respiratory function, as this position can affect breathing. 6. Lateral/Side Lying Position Description: The patient lies on their side, with support under the head and lower arm, often using a pillow between the legs.  Uses: Commonly used for kidney surgeries, thoracotomies, and certain orthopedic procedures. Considerations: ○ Ensure proper alignment of the spine to prevent strain. ○ Monitor for pressure points on the dependent side to prevent skin breakdown. 7. Prone Position Description: The patient lies flat on their stomach, with the head turned to one side and arms positioned alongside the body or above the head. Uses: Often used for spine surgeries, certain orthopedic procedures, and for accessing the posterior structures. Considerations: ○ Ensure proper padding to protect the face, breasts, and genitalia. ○ Monitor respiratory function closely, as this position can impair ventilation. 8. Jackknife (Kraske Position) Description: The patient is placed face down, with the hips elevated and the legs bent at the knees, creating a “V” shape. Uses: Typically used for procedures involving the rectum or spine. Considerations: ○ Ensure proper support for the abdomen to prevent pressure on the diaphragm. ○ Monitor circulation and respiratory function, as the position can affect both. Postoperative Key Nursing Goals in the Postoperative Phase Re-establishing Physiologic Equilibrium: The primary goal is to help the patient regain their normal body functions after surgery and anesthesia. This includes monitoring vital signs, managing pain, and ensuring adequate respiratory function. Pain Management: Effective pain management is crucial for patient comfort and recovery. Nurses assess pain levels and administer appropriate analgesics.  Preventing Complications: Postoperative complications are a significant concern. Nurses play a vital role in identifying and preventing these complications through vigilant monitoring and early intervention. Patient Education: Educating patients about self-care, medication regimens, and potential complications is essential for successful recovery and adherence to post-operative instructions. Postoperative Nursing Care: A Step-by-Step Approach The presentation outlines a detailed nursing care plan for the postoperative phase, broken down into distinct stages: 1. Nursing Care in the Post-Anesthesia Care Unit (PACU) Communication of Intraoperative Information: The nurse communicates critical information from the operating room to the PACU team, including the patient's identity, type of surgery, anesthesia used, and any intraoperative events. Monitoring Vital Signs: Vital signs are closely monitored every 15 minutes for the first hour, every 30 minutes for the next two hours, and then hourly if stable. Neurological Assessment: The nurse assesses the patient's level of consciousness (LOC) to ensure they are recovering from anesthesia appropriately. Safety Checks: Safety measures are implemented, including positioning, side rails, and restraints for blood transfusions and intravenous fluids. Airway Management: Maintaining a patent airway and adequate respiratory function is a top priority. 2. Parameters for Discharge from PACU  Activity: The patient should be able to follow simple commands. Vital Signs: Vital signs should be stable. ABCs: Airway, breathing, and circulation should be uncompromised or stable. LOC: The patient should be responsive and oriented. Other: Urine output should be at least 30 ml/hour, pain should be minimal, and nausea and vomiting should be controlled. 3. Nursing Care on Admission to the Surgical Unit Initial Assessment: The nurse records the time of return to the unit, takes baseline vital signs, assesses pain, airway, breath sounds, neurological status, wound, dressing, drainage tubes, skin color, urinary status, and IV infusion. Safety and Comfort: The nurse ensures the call light is within reach, determines the patient's emotional condition and support needs, and carries out postoperative orders. Postoperative Complications: A Detailed Overview The presentation emphasizes the importance of recognizing and managing potential postoperative complications: 1. Hypotension and Shock Signs and Symptoms: Monitor closely for signs of shock, such as low blood pressure, rapid heart rate, and pale, clammy skin. Management: Administer intravenous fluids, blood transfusions, and medications as needed. Place the patient flat on the bed with legs elevated. Monitor vital signs, oxygen saturation, input and output, LOC, respiratory status, and cardiovascular status. 2. Hemorrhage Signs and Symptoms: Note signs of extreme blood loss, such as apprehension, restlessness, thirst, and a rapid, weak pulse. Management: Administer blood and blood products, determine the cause of hemorrhage, administer vitamin K and hemostatic agents, and inspect the surgical site for bleeding. 3. Deep Vein Thrombosis (DVT) Causes: DVT can be caused by damage to a vein, prolonged immobility, and hemorrhage. Signs and Symptoms: Monitor for symptoms such as pain or cramping in the calf (positive Homans' sign), tenderness, chills, and perspiration. Management: Encourage adequate hydration, leg exercises, and early ambulation. Administer anticoagulant therapy. Wear thigh-high elastic pressure stockings or external pneumatic compression devices. Avoid massaging the calf of the leg. 4. Pulmonary Complications Types: Potential pulmonary complications include atelectasis, bronchitis, and bronchopneumonia. Management: Reinforce deep breathing, coughing, turning exercises, and incentive spirometry. Encourage early ambulation. 5. Urinary Difficulties  Types: Urinary retention and incontinence are common postoperative complications. Causes: These issues are often caused by bladder spasm or loss of bladder sphincter tone. Management: Implement measures to induce voiding, such as running water or providing privacy. 6. Intestinal Obstruction Causes: A loop of intestine may kink due to inflammatory adhesions. Signs and Symptoms: Symptoms include nausea, vomiting, abdominal distention, hiccups, diarrhea (incomplete), and absence of bowel movements (complete). Management: Insert a nasogastric tube, administer electrolytes and intravenous fluids, and prepare for possible surgery. 7. Wound Complications Infection (Wound Sepsis): ○ Signs and Symptoms: Fever (within the first 48 hours is a pyretic response), redness, swelling, pain, warmth, pus, and foul odor from the wound. ○ Management: Maintain aseptic techniques, provide wound care, and administer antibiotic therapy. Hematoma: ○ Signs and Symptoms: Monitor for bleeding at the surgical site. ○ Management: Prepare for evacuation of clots if they are large. Wound Dehiscence: Disruption of the surgical incision (wound breakdown). Wound Evisceration: Dehiscence with protrusion of abdominal organs. ○ Signs and Symptoms: Gush of bloody peritoneal fluid from the wound (earliest sign).  ○ Management: Place the patient in a supine or low-Fowler's position with bent knees. Cover exposed organs with a sterile, moist saline dressing. Notify the surgeon immediately. Apply an abdominal binder. Prepare for surgery for repair. Encourage proper nutrition (increased protein and vitamin C). Nursing Care for Discharge and Follow-up Patient Education: The nurse provides instructions on: ○ Wound care and dressing changes ○ Medication regimen (action and side effects) ○ Allowed and prohibited activities ○ Dietary restrictions and modifications ○ Symptoms to report ○ When and where to return for follow-up care Addressing Concerns: The nurse answers any individual questions and concerns the patient may have. Oxygenation Concept The Respiratory system Subjective Data: Nursing History 1. Chest Pain Characteristics of Pulmonary Chest Pain: ○ Chest Wall: This pain is usually well-localized, feels like a constant ache, and worsens with movement. Possible causes include trauma and muscle strain from coughing. ○ Pleura: This pain is sharp and has an abrupt onset. It worsens with inspiration (breathing in) or during coughing and sneezing. Possible  causes include pleurisy (inflammation of the lining of the lungs) and connective tissue diseases. ○ Lung Parenchyma: (The lung tissue itself): ○ Dull, constant ache, poorly localized: This could be a sign of a benign or malignant lung tumor. ○ Well-localized, sharp, sudden onset: This could indicate a pneumothorax (collapsed lung). ○ Sudden onset, sharp stabbing pain on inspiration, may radiate:This could be a pulmonary embolus (blood clot in the lungs) or pulmonary infarction (lung tissue death). 2. Dyspnea (Shortness of Breath) Nature of Dyspnea: It's important to understand: ○ Acute vs. Chronic: Is the shortness of breath new or has it been ongoing? ○ Sudden vs. Gradual: Did the dyspnea come on suddenly or develop gradually? ○ Duration and Frequency: How long does the dyspnea last, and how often does it occur? Effect on ADLs: How does the dyspnea affect the patient's ability to perform daily activities? 3. Cough Characterizing Cough: ○ Productive vs. Nonproductive: Does the cough produce sputum (mucus), or is it dry? ○ Onset, Duration, and Frequency: When did the cough start? How long does it last? How often does it occur? Significance: A cough lasting 2-3 weeks or longer could indicate a more serious underlying problem. 4. Sputum Production  Color: ○ Creamy yellow or rusty: Could indicate Staphylococcal pneumonia. ○ Green: Could indicate Pseudomonas pneumonia. ○ Profuse, pink, frothy: Could indicate pulmonary edema (fluid in the lungs). ○ Scant, pink-tinged, mucoid: Could indicate a lung tumor. ○ Thin, mucoid: Could indicate viral bronchitis. ○ Foul-smelling: Could indicate a lung abscess. Consistency: Describe the sputum as thick, viscous (gelatinous), watery, mucoid, or mucopurulent. Amount: Estimate the amount of sputum produced, using terms like teaspoons, tablespoons, or cups. "Scant" or "moderate" is subjective. 5. Cyanosis Bluish Discoloration: Cyanosis appears when the level of unoxygenated hemoglobin in the blood is high. It's a late indicator of hypoxia (low oxygen levels) and not always a reliable sign. Central Cyanosis: Observe the color on the undersurface of the tongue and lips. Peripheral Cyanosis: Observe the nail beds and earlobes. 6. Hemoptysis (Coughing Up Blood) Common Causes: Pulmonary infection, lung cancer, abnormalities of the pulmonary arteries or veins, pulmonary emboli. Source: Determine the source of bleeding: nose or nasopharynx, lung, or stomach. 7. Wheezing Definition: A continuous, high-pitched, whistling sound produced by narrowed or obstructed airways. It's mainly heard during expiration (breathing out).  Causes: Bronchospasm, asthma, exposure to irritants, stress, or anxiety. 8. Stridor Definition: A loud, high-pitched, whistling sound, often described as "snoring," that's caused by airway obstruction. Significance: Patients who awaken frequently during the night may have sleep apnea syndrome. 9. Nose & Sinuses Inspection: ○ External Nose: Inspect for lesions, asymmetry, or inflammation by tilting the head back. ○ Internal Nose: Gently push the tip of the nose to inspect the internal nose for color, swelling, exudates, or bleeding. Palpation: Palpate the frontal (supraorbital ridges) and maxillary sinuses (cheek area) for tenderness using your thumbs. Transillumination (passing light through a bony area) can also be used. Objective Data: Physical Assessment This involves using your senses to observe and examine the patient. 1. Inspection Normal: ○ Quiet Respiration: Breathing should be quiet and effortless. ○ Nail Beds: Nail beds should be pink. ○ Eupnea: Normal respiratory rate (12-20 breaths per minute). ○ Thoracic Configuration:  ○ Symmetric Appearance: The chest should be symmetrical. ○ Straight Spine: The spine should be straight. Abnormal: ○ Thoracic Configuration: ○ Barrel Chest: Increased anteroposterior (AP) diameter of the chest, giving it a rounded appearance. ○ Funnel Chest (Pectus Excavatum): A depression in the lower sternum. ○ Pigeon Chest (Pectus Carinatum): Displacement of the sternum, making it protrude forward. ○ Kyphoscoliosis: Elevation of the scapula (shoulder blade) and an S-shaped spine. 2. Palpation Skin and Chest Wall: ○ Normal: Skin should be nontender, smooth, and warm. ○ Abnormal: ○ Crepitation: A "crackling" sensation felt when palpating the chest, caused by air leaking into the subcutaneous tissues. ○ Respiratory Excursion: Thoracic expansion should be about 1 inch. Asymmetry in expansion could indicate a pleural effusion (fluid in the space between the lungs and chest wall). Chest Palpation: Used to detect asymmetry of chest expansion, another sign of pleural effusion. Fremitus: Vibration of the chest wall produced by vocalization. ○ Normal: Symmetrical, mild vibration. ○ Abnormal: ○ Increased Fremitus: Could indicate a more solid mass, such as a tumor. ○ Decreased Fremitus: Could indicate increased air in the chest space, such as with a pneumothorax. Tactile Fremitus: The examiner asks the patient to say specific words repeatedly (e.g., "ninety-nine"). 3. Percussion Lung Fields: ○ Normal: Resonance: A low-pitched, hollow sound. ○ Abnormal: ○ Hyperresonance: Heard with air trapping, such as in a pneumothorax. ○ Dull/Flat: Indicates decreased air in the lung, such as with a tumor or fluid. Chest Percussion: The examiner taps the patient's chest on alternating sides to detect the characteristic dullness of a pleural effusion. 4. Auscultation Normal Breath Sounds: ○ Vesicular: Heard over most of the lung fields, with inspiration longer than expiration (I > E). ○ Bronchovesicular: Heard over the 1st and 2nd intercostal spaces and between the scapulae, with inspiration equal to expiration (I = E). ○ Bronchial: Heard over the manubrium, with expiration longer than inspiration (I < E). Adventitious Breath Sounds: Abnormal sounds heard during auscultation. ○ Crackles: Air passing through fluid in small airways, a popping sound commonly heard during inspiration. Heard in patients with pneumonia, heart failure, and atelectasis. ○ Rhonchi: Large airway obstruction by fluid, a low-pitched continuous snoring sound commonly heard during expiration. Heard in patients with COPD, bronchospasm, and pneumonia. ○ Pleural Friction Rub: A grating sound caused by inflamed pleura, best heard at the base of the lung at the end of expiration. Heard in patients with inflamed pleura and pulmonary infarction. ○ Wheezes: High-pitched whistling sounds caused by airway narrowing. Voice Sounds: ○ Normal: Voice sounds are usually muffled and indistinct. ○ Abnormal:  ○ Egophony: When the patient says "E," it sounds like "A." ○ Whispered Pectoriloquy: When the patient whispers "99," it sounds loud and clear. ○ Bronchophony: The same result as whispered pectoriloquy. Upper Airway Infections 1. Upper Airway Infections (URIs) Definition: URIs are common illnesses affecting the upper respiratory tract, including the nose, sinuses, throat, and larynx. Most Frequent Cause: The common cold is the most frequent example of a URI. Viral Cause: Viruses are the most common cause of URIs, with rhinoviruses being the most prevalent. Impact: URIs are a leading cause of healthcare visits and absences from school or work. 2. Rhinitis Definition: A group of disorders characterized by inflammation and irritation of the nasal mucous membranes. Common Co-occurrence: Rhinitis often coexists with other respiratory disorders like asthma. Types: ○ Acute: Sudden onset, usually caused by a virus. ○ Chronic: Persistent inflammation, often caused by allergies or irritants. ○ Allergic: Triggered by allergens like pollen, dust mites, or pet dander. ○ Non-allergic: Caused by irritants like smoke, fumes, or dry air. Symptoms: Rhinorrhea (runny nose), nasal congestion, purulent discharge, sneezing, and nasal itching. Management: ○ Viral Rhinitis: Medications to manage symptoms. ○ Allergic Rhinitis: Allergy testing to identify allergens, corticosteroids, and antihistamines. ○ Bacterial Infection: Antibiotics if present. ○ Common Treatments: Antihistamines, nasal sprays, and decongestants. 3. Viral Rhinitis (Common Cold) Prevalence: The most frequent viral infection in the general population. Cause: Caused by a variety of viruses, with rhinoviruses being the most common. Symptoms: Low-grade fever, nasal congestion, rhinorrhea, halitosis (bad breath), sneezing, tearing watery eyes, "scratchy" sore throat, general malaise, and chills. Management: Fluid intake, rest, prevention of chilling, expectorants, warm salt-water gargles, NSAIDs (nonsteroidal anti-inflammatory drugs), antihistamines, and guaifenesin (expectorant). Antibiotics are not effective against viral infections. Infection Control: Avoid direct contact with infected secretions, practice hand hygiene, and cover coughs and sneezes. 4. Tonsillitis Location: Tonsils are lymphatic tissue located on each side of the oropharynx (back of the throat). Infection Site: Tonsils are frequently the site of acute infection. Causes: ○ Bacterial: Group A beta-hemolytic streptococcus (GABHS) is the most common bacterial pathogen. ○ Viral: Epstein-Barr virus is the most common viral pathogen. Symptoms: Sore throat, fever, snoring, dysphagia (difficulty swallowing), mouth breathing, noisy respiration, and halitosis. Diagnosis: Primarily clinical, with throat swab culture for confirmation. Management: ○ Supportive Measures: Rest, fluids, pain relievers. ○ Bacterial Infections: Penicillins. ○ Tonsillectomy: Surgery to remove the tonsils, considered for chronic tonsillitis (repeated episodes of tonsillitis 5 to 6 times per year). Nursing Management Post-Tonsillectomy: ○ Hemorrhage Risk: Monitor for bleeding. ○ Positioning: Lateral or prone position with the head turned to the side. ○ Ice Collar: Apply to the neck. ○ Ice Chips: Provide for hydration.  ○ Complications: Fever, throat pain, and bleeding. ○ Postoperative Care: Warm saline gargles, avoid milk products, no vigorous brushing or heavy lifting, avoid dark-colored foods. 5. Obstruction & Trauma of the Upper Respiratory Airway: Epistaxis (Nosebleed) Definition: Hemorrhage from the nose, caused by rupture of tiny blood vessels in the nasal mucous membrane. Common Site: Anterior septum (the dividing wall between the nostrils). Risk Factors: ○ Trauma: Digital trauma (picking the nose), blunt trauma (a blow to the nose). ○ Local Infection: Rhinitis, sinusitis. ○ Drug Use: Inhalation of illicit drugs. ○ Hypertension: High blood pressure. ○ Tumors: Growths in the nasal cavity. ○ Thrombocytopenia: Low platelet count. ○ Aspirin Use: Aspirin can thin the blood. ○ Hereditary Conditions: Redu-Osler-Weber syndrome. Initial Treatment: ○ Position: Sitting position with the head tilted forward. ○ Pressure: Apply direct pressure to the nose against the midline septum for 5-10 minutes. ○ Cold Compress: Apply to the bridge of the nose. ○ Packing: Partially insert a small gauze pad into the nostril. ○ Medical Assistance: Seek medical help if bleeding doesn't stop. Medical Management: ○ Cause and Location: Identify the cause and location of the bleeding using a penlight. ○ Vasoconstricting Solution: Use cotton pledgets soaked in a vasoconstricting solution to stop bleeding. ○ Suction: Suction excess blood if necessary. ○ Packing: If the origin of the bleeding can't be identified, pack the nose with gauze soaked in petrolatum jelly or antibiotic ointment for 3-4 days. Nursing Management: ○ Monitoring: Monitor vital signs. ○ Bleeding Control: Assist with bleeding control.  ○ Comfort: Provide an emesis basin and tissues. ○ Intravenous Fluids: Rarely, IV fluids may be needed. ○ Cardiac and Pulse Monitoring: May be needed for severe cases. Discharge Instructions: ○ Prevention: Avoid forceful blowing, straining, and nasal trauma.