 - 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
 IMMOBILITY
Clinical 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
disorder
Clinical 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 vessels

Clinical 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
Causes:
 Severe hypovolemia from fluid deficit or

hemorrhage
Clinical 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 output

Clinical 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 up

Cause:
 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 odor

Laboratory 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