- Atelectasis - Bronchitis - Bronchopneumonia - Lobar pneumonia - Hypostatic pulmonary congestion - Pleurisy
Causes: Infections, toxins, irritants, IMMOBILITY, and
IMPAIRED VENTILATION.
CLINICAL Signs: Increased temperature Cough Expectoration of blood tinged or purulent sputum Dyspnea Chest pain
Causes: Mucous plugs blocking bronchial passageways Inadequate lung expansion Analgesics IMMOBILITYClinical signs: Dyspnea Tachypnea Tachycardia Diaphoresis Anxiety Pleural pain Decraesed chest wall movement Dull or absent breath sounds Decreased oxygen saturation (SPO2)
Causes: stasis of the venous blood from immobility Venous injury from fractures/during surgery Use of oral contraceptives high in estrogen Preexisting coagulation or circulatory
disorderClinical signs: Sudden chest pain Shortness of breath Cyanosis Shock (tachycardia, low blood pressure)
Causes: Fluid deficit Hemorrhage
Clinical signs: Tachycardia Decreased urine output Decreased blood pressure
Causes: Disruption of sutures Insecure ligation of blood vesselsClinical signs: Dressing saturated with bright blood: Bright, free flowing blood in drains or chest tubes Apprehension; restlessness; thirst; cold, moist , pale
skin Deep, rapid RR; low body temperature Low BP, low Hgb Circumoral pallor; spots before the eyes, ringing in
ears
Causes: Severe hypovolemia from fluid deficit or hemorrhageClinical signs: Rapid, weak pulse, Decreased blood pressure Dyspnea Tachypnea Restlessness & anxiety Urine output less than 30 ml/hr Cool clammy skin, Thirst, Pallor Progressive weakness, then death
- often occurs after operations on the lower abdomen or during the course of septic conditions as ruptured ulcer or peritonitis
Causes: Injury: damage to vein Hemorrhage Prolonged immobility Obesity / Debilitation
Clinical Manifestations Pain Redness Swelling Heat / warmth + Homan’s sign
Nursing Interventions Prevention: Hydrate adequately to prevent
hemoconcentration Encourage leg exercises and ambulate early Avoid any restricting devices that can constrict
and impair circulation Prevent use of bed rolls, knee gatches, dangling
over the side of the bed with pressure on popliteal area
Cause: depressed bladder tone from narcotics and
anesthetics Handling of tissues during surgery on adjacent
organs (rectum/vagina) Fluid intake larger than outputClinical signs: Inability to void or frequent voiding of small
amounts Bladder distention Suprapubic discomfort restlessness
Cause: IMMOBILIZATION Limited fluid intake Instrumentation of urinary tract
Clinical signs: Burning sensation during voiding Urgency Cloudy urine Lower abdominal pain
Clinical signs: Complaints of feeling sick to the stomach Retching or gagging Throwing upCause: Pain Abdominal distention Ingesting of food and fluids before return of
peristalsis Certain medication Anxiety
Cause: poor aseptic technique
Clinical signs: Purulent exudates Redness Tenderness Elevated temperature Wound odorLaboratory analysis of wound swab identifies
causative microorganism
Cause: Malnutrition (emaciation, obesity) Poor circulation Excessive strain on suture line
Clinical signs: Increased incision drainage Tissues underlying skin becomes visible
along parts of the incision
Clinical signs: Anorexia Tearfulness Loss of ambition Withdrawal Rejection of others Feelings of dejection Sleep disturbances (insomnia or excessive
sleeping)
Cause: Weakness News of malignancy Severely altered body image Other personal matter Maybe a physiologic response to some
surgeries Surprise nature of emergency surgery
Postop Nursing Care