- 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