CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION,
FLUID & ELECTROLYTES, INFECTIOUS, INFLAMMATORY &
IMMUNOLOGIC RESPONSE, CELLULAR ABBERRATIONS,
ACUTE & CHRONIC
INTRODUCTION TO MED-SURG NURSING
 Medical-surgical nursing is a nursing specialty to
promote health and prevent illness or injury in
patients in a broad range of settings.
 The primary focus of medical-surgical nursing
care is to meet the biologic, cultural,
psychosocial and spiritual needs of the adult
patient in a mutually trusting, respectful and
caring relationship.
CONCEPTS IN THE CARE OF AT RISK AND SICK ADULT
CLIENT OBJECTIVES:
At the end of this lecture, the students must be able to:
 Integrate relevant principles of social, physical,
natural and health science and humanities in
given health and nursing situations based on
epidemiologic profile.
 Apply appropriate nursing concepts and actions
holistically and comprehensively
HEALTHCARE SITUATIONS
GLOBAL HEALTH
 Global health is the understanding of health care
in an international and interdisciplinary context.
Includes the study, research and practice of
medicine with a focus on improving health care
equity for populations worldwide.
 Medical and non-medical disciplines
 World Health Organization
IMPORTANCE OF GLOBAL HEALTH
 Plays an increasingly crucial role in both global
security and security of the world population.
 Ensures healthy future for everyone
 Global health and development is all about
improving the wellbeing of people across the
world through treating and preventing disease,
 helping people out of poverty, and saving lives.
EMERGING ISSUES IN GLOBAL HEALTH
 Increase death rate from noncommunicable
causes
 Decrease death rate from infectious diseases
 Changes in social and economic conditions in
developing countries
 Expanding international trade introduces new
health risks
6 GLOBAL HEALTH ISSUES
 Pandemic
 Environmental Factors
 Economic Disparities and Access to Health Care
 Political Factors
 Noncommunicable Diseases
 Animal Health, Food Sourcing and Supply
SAMPLE GLOBAL HEALTH SITUATIONS AND TRENDS FROM
1955 TO 2025
 The global population was 2.8 billion in 1955. It
will increase by nearly 80 million people a year,
reaching 8 billion in 2025
 By 2025, a 300% increase in elderly population is
expected [ Latin America and Asia ]
 Average life expectancy at birth in 1955 was just
48 years; in 1995 its 65 years and in 2025, 73
years.
 There are still 24 low birth babies born every
year. More likely to die early and those who
survive may suffer illness, stunted growth or
problems into adult life.
 Cancer will remain one of the leading causes of
death worldwide. One third will be cured due to
earlier detection combined with effective
treatment.
 The risk of developing dementia rises steeply
with age in people over 60.
LOCAL HEALTH SITUATION AND CONDITION
 Existence of numerous Pharmacies in the
Philippines
 Health Hazards : Mosquito Borne Diseases
[ Malaria, Dengue Chikungunya Virus )
 911 is the general national emergency number in
the Philippines
 Philhealth membership is mandatory even with
expats.
CHRONIC ILLNESS
 Long lasting , lingering or recurrent disease
 Based on the course of the disease or its rate of
onset and development
 Health conditions : 1 year or more requiring
medical attention or limit ADL or both.
 Leading cause of death and disability : heart
disease, cancer and diabetes
 Risk Behaviors for Chronic Diseases: tobacco use
and exposure to secondhand smoke, poor
nutrition including diets low in fruits and
vegetables and high in sodium and saturated
fats, lack of physical activity and excessive
alcohol use]
CULTURAL AND HEALTH ETHNIC DISPARITIES AND
CULTURALLY COMPETENT CARE
 Racial and ethnic disparities in health and health
care are receiving increasing national attention
both in the fields of public health and medicine.
 Approach to reduce disparities should adopt a
life span approach and recognize the role of
gender.
Young people are making independent decisions on health-
related behaviors and health care while developing gender
identity.
PERIOPERATIVE NURSING
PERIOPERATIVE NURSE
 Defined as the registered nurse who, using the
nursing process, develops a plan of nursing care
and then coordinates and delivers care to pts
undergoing operative and other invasive
procedures.
 With requisite skills and knowledge to assess,
diagnose, plan, intervene and evaluate the
outcomes of interventions
 Called as operating room nurse or surgical nurse
and serves as scrub nurse or circulating room
nurse inside the OR
RESPONSIBILITIES & DUTIES
 Perioperative nurses use a comprehensive,
multidisciplinary approach to pt care, assisting
surgeons & surgical teams to care for a pt before,
during and after surgery.
 Working with pts prior to surgery to complete
paperwork & help answer questions or calm
fears about surgery.
 Monitoring a pt’s condition during & after
surgery
 Selecting & passing instruments & supplies to the
surgeon during operation (scrub nurse)
 Managing the overall nursing care in the OR to
help maintain a safe & comfortable environment
(circulating nurse)
 Educating pts on best practices for recovery,
including pain management & keeping wounds
clean (health teaching)
 Cleaning surgical equipment & operating rooms
to maintain a sterile environment (after care)
WORKING ENVIRONMENT OF PERIOPERATIVE NURSES
 Hospital Operating Rooms, Outpatient Centers,
Doctor’s Offices
 Relate with Patients across all age groups,
surgeon, and surgical team
 Different patients everyday thus cannot establish
long term relationships with patients
 Stressful environment due to the roles and
responsibilities of being a perioperative nurse
SPECIAL CONSIDERATIONS DURING PERIOPERATIVE
PERIOD
 Gerontologic Considerations [ Elderly ] less
physiologic reserve.
 Elderly may suffer from respiratory and cardiac
compensation, dehydration, constipation and
malnutrition.
 Elderly have sensory limitations [ susceptible to
temperature changes ]
 Patients/Persons with Disabilities [ PWD ] need
assistive devices, modifications in preoperative
teachings and additional assistance and attention
to positioning and transferring
 Patients who are obese may be prone to wound
separation [ Dehiscence] and wound infections.
May increase risk of hypoventilation and
postoperative pulmonary complications. Difficult
intubation that increases demand of the heart.
INFORMED CONSENT
 Patient’s autonomous decision about whether to
undergo a surgical procedure ( VOLUNTARY )
 WRITTEN INFORMED CONSENT : protect patient
from unsanctioned surgery and protect the
surgeon from claims of unauthorized operation
 Helps in the patient’s preparation prior to
surgery
 Informed Consent necessary for all INVASIVE
PROCEDURES
Procedures requiring sedation and/ or anesthesia. Involves
slight risk to the patient. Radiation treatments.
TYPES OF SURGERY ACCORDING TO PURPOSE
 Diagnostic - confirmation or establishment of
diagnosis (BIOPSY, ENDOSCOPY,
BRONSCHOSCOPY)
 Palliative - Relieve or Reduce Intensity of Illness
but not curative ( COLOSTOMY, NERVE ROOT
RESECTION )
 Ablative - Removal of body part ( AMPUTATION,
APPENDECTOMY )
 Constructive or Reconstructive - Restore function
to traumatized or malfunctioning tissue ( PLASTIC
SURGERY, BREAST RECONSTRUCTION )
 Transplant - Diseased or Malfunctioned organs
are replaced (KIDNEY, LIVER, HEART TRANSPLANT
)
TYPES OF SURGERY ACCORDING TO URGENCY
 Elective - Preplanned based on patients choice
and availability. Delay no ill effects. (HERNIA
REPAIR, TONSILLECTOMY )
 Urgent - Short Time Frame: 24-48 hours
 Emergency - Immediate to preserve life, body
part or function (CONTROL OF HEMORRHAGE,
TRAUMA REPAIR)
TYPES OF SURGERY ACCORDING TO RISK
Minor
  Brief SKILLS TRAINING
 Low Risk • Moving
 Few Complications • Deep breathing
 Considered Elective • Coughing
 Examples: Tooth Extraction and Cataract • Splinting decision
Extraction PHYSICAL PREPARATION
Major • Nutrition and Fluids - ( NPO: Nothing Per Orem )
 Admission & Hospitalization • Elimination - Enema or Urinary Catheters
 Prolonged & Specialized Care • Hygiene - Shower, Trimmed Nails, No Nail Polish,
 High Risk Cosmetics, Remove Dentures and Jewelries
 Involves Major Body Organs • Rest and Sleep : Sedatives
 Life Threatening Situations • Medications
 Greater Risk for Postoperative Complications • Vital Signs
 Examples: Open Cholecystectomy, Nephrectomy, • Skin Preparation (Shaving)
Hysterectomy, Mastectomy PREOPERATIVE ASSESSMENT
PHASES OF SURGICAL EXPERIENCE Establish a baseline data of patient to identify risk factors
 Pre operative – begins when the pt decides to leading to complications and hinder wellness and recovery
proceed for surgery until transfer to the ( Health History, Physical Examinations, Blood Tests, Xrays
operating room and other Diagnostic Tests )
NUTRITION & FLUID STATUS
 Postoperative – begins when the pt is transferred
• Essential factor in promoting healing, resisting
to the operating table and ends with admission
infection and other surgical complications
to the PACU
• Obesity
 Intraoperative – begins when the pt is admitted
• Weight Loss
to the post anesthesia care unit and ends with
• Malnutrition
follow up evaluation
• Nutrient Deficiency
• Metabolic Abnormalities
PREOPERATIVE PHASE
• Effects of Medications
PREOPERATIVE NURSING CARE
Body Mass Index and Waist Circumference
Begins with decision to proceed with surgery until transfer
DENTITION
to operating room
• Decayed Teeth or Dental Prostheses may be
INFORMED CONSENT
dislodged and can occlude airway.
 Nature and Intent of Surgery
DRUG OR ALCOHOL
 Name & Qualification of Surgeon
• Alcohol abuse lead to cardiac arrythmias,
 Risk includes damage, disfigurement even death
cardiomyopathy and bleeding tendencies.
 Chances of Success
• Alcohol withdrawal syndrome increase
 Possible alternative measure
mortality
 Right of Patient to refuse Consent
• Susceptibility to injury
ROUTINE LAB & DIAGNOSTIC TESTS
Nasogastric Tube Insertion prior to general anesthesia to
• CBC
prevent vomiting and potential aspiration
• Blood and Crossmatching
RESPIRATORY STATUS
• Serum Electrolytes
• Patients with underlying respiratory disease
• FBS
( asthma and COPD ) may pose threats to their
• Urea and Creatinine
pulmonary status.
• Liver Profile Test or Function Test
• Postpone of surgery if there is respiratory
• Urine Analysis ( U/A )
infection
• Chest Xray ( PA view )
• Smoking stop 4 to 8 weeks prior to surgery
• ECG
reduce pulmonary functions and tend to have
PREOPERATIVE TEACHING
would healing complications
• Health Teaching ( What will happen, when,
CARDIOVASCULAR STATUS
expected outcomes and discomforts )
• A well-functioning cardiovascular system is a
• Psychosocial Support
must to meet oxygen, fluid and nutritional needs.
• Roles of Patient and Family before, during and
• Uncontrolled hypertension is a risk.
after surgery
HEPATIC AND RENAL FUNCTION
• Skills Training
 • Liver and urinary systems should be well • Inform family that patient might have additional
functioning to metabolize medications, drains or devices attached.
anesthetics, body wastes and toxins.
• Monitoring of urine output is essential. SUMMARY OVERVIEW OF PREOPERATIVE PHASE
ENDOCRINE FUNCTION Admission to Surgical Unit or Center
• Hypoglycemia may develop during anesthesia or • Complete Preoperative Assessment
postoperative period • Assess for Risk of Complications
• Hyperglycemia can increase risk for wound • Report Abnormal Findings
infection. • Verify Informed Consent
• Stress of Surgery may increase sugar levels. • Answer family questions
• Patients receiving corticosteroids prone to • Develop plan of care
infection. Prior to Surgery
IMMUNE FUNCTION • Review Patient Chart
• Allergies : medications, blood transfusions, • Identify patient
contrast agents, latex and food products • Verify surgical site
• Ensure Strict Asepsis • Establish IV Line
PREVIOUS MEDICATION USE • Administer prescribed medications
• Medication History • Provide emotional support
• Prevent Bleeding, Drug Interactions Preoperative Teachings
• Aspirin stop 7 to 10 days prior to surgery • Deep Breathing Exercises
PSYCHOSOCIAL FACTORS • Promote mobility and active movement
• Subjective and objective cues • Leg exercise
• Nurse must be empathetic, listens well and • Pain Management
provide adequate information to lessen anxiety • Coping Strategies
SPIRITUAL AND CULTURAL BELIEFS • Reduce fear and anxiety
• Spiritual beliefs play an important role on how • Maintain patient safety at all times
people cope with fear and anxiety • Manage fluid status
• Prepare bowel
PREOPERATIVE NURSING INTERVENTIONS • Skin Preparation
IMMEDIATE
• Changes to hospital gown INTRAOPERATIVE PHASE
• Disposable head cap INTRAOPERATIVE NURSING CARE - Begins when patient is
• Removal of dentures, jewelries and prosthesis transferred to operating table and ends with the admission
• Clean nails to PACU ( Post Anesthesia Care Unit or Recovery Room)
ADMINISTERING PREANESTHETIC MEDICATION • Surgical Skin Preparation
• Patient’s siderails up when anesthetic is already • Positioning
administered. o Visualization and access to surgical site
• Observe for effects of anesthetic o Optimal access for assessing anesthesia
• Maintain quiet and relaxing environment and vital functions
PREOPERATIVE RECORD o Protection from harm
• Check for Informed consent • Main Nursing Activities
• Laboratory records o Maintain Safety
• Preoperative Checklist o Transfer Patient to Operating Table
• Vital Signs Prior to transport to Operating Room o Proper counting of Instruments are
• Proper Documentation and Endorsement correct
o Maintain Aseptic Technique
PATIENT TRANSPORT o Correct positioning and alignment of
• Use standard process or procedure to verify patient
patient identification, the surgical procedure, and o Complete documentation
surgical site • Physiologic Monitoring
• Cover patient with blanket o Calculate fluid loss or gain
ATTENDING TO FAMILY NEEDS
o Report Changes in Vital Signs
• Provide information as to duration of operation
o Distinguish Normal and Abnormal Data
and recovery room time
COMPLICATIONS IN INTRAOPERATIVE NURSING PHASE
NAUSEA, VOMITING • Level of Comfort
• Effects of anesthetics • Location of Pain
• Gagging : Turn head to side and provide kidney • Dressing and Bed Clothes
basin • Fluid Balance : Fluid Intake and Output, Amount
• Suction removing saliva and secretions of Drainage
• Administer is antiemetic is prescribed • Drains and Tubes : Color, Consistency and
ANAPHYLAXIS amount of drainage
• Anaphylactic reactions to medications, latex or • Check Suction equipment
other substances. POTENTIAL PROBLEMS
• Monitor Vital Signs • Pneumonia
• Report and Document Symptoms • Pulmonary Embolism
• Atelectasis
COMPLICATIONS IN INTRAOPERATIVE NURSING PHASE • Hemorrhage
HYPOXIA AND RESPIRATORY COMPLICATIONS • Thrombophlebitis
• Inadequate ventilation • Urinary Retention
• Occlusion of Airway • Nausea and Vomiting
• Inadvertent intubation of Esophagus • Constipation
• Hypoxia • Depression
• Respiratory Depression • Wound Complication ( Infection, Dehiscence and
• Aspiration of Respiratory tract secretions Evisceration )
*** Hypothermia - rapid change in body temperature NURSING ACTIVITIES POSTOPERATIVE PHASE
lower than 36 • Maintain Airway
• Monitor Vital Signs
MEDICAL MANAGEMENT • Assess effects of anesthetics
• Recognize the symptoms of complications and • Assess for Pain ( Pain Scale )
discontinue anesthesia • Assess for Complications
• Goals of Treatment • Promote Recovery and initiate teaching
o Decrease Metabolism • Initiate discharge plan
o Reverse Metabolic and Respiratory FACTORS AFFECTING WOUND HEALING
Acidosis • Age
o Correct Dysrhythmias • Hemorrhage
o Decrease Body Temperature • Hypovolemia
o Provide oxygen and nutrition to tissues • Nutritional Deficits
o Correct Electrolyte Imbalances • Oxygen Deficit
POSTOPERATIVE PHASE • Drainage
POSTOPERATIVE NURSING CARE - Begins when patient is • Medications
admitted to Post Anesthesia Care Unit ( PACU ) or Recovery • Systemic Disorders
Room and end with follow up at home or clinical settings • Wound Stressors
• Patients admitted to PACU
• Discharged to standard unit when:
o Conscious and Coherent
o Maintain clear airway, deep breathe
cough
o Stable Vital Signs
o Protective Reflex ( Swallowing )
o Movement of extremities
o Adequate Intake and Output ( Urine
output : 30cc per hour )
o Afebrile
o Dry and Intact Dressings
o No signs of bleeding
ON GOING POST OPERATIVE CARE ASSESSMENT
• Vital Signs
• Skin Color and Temperature