MEDICAL-SURGICAL NURSING REVIEW

Course Outline

I. Client in Pain
II. Peri-operative Nursing Care
III. Alterations in Human Functioning
a. Disturbances in Oxygenation: Respiratory & Cardiovascular Functions
b. Disturbances in Metabolic and Endocrine Functions
c. Disturbances in Elimination: Gastrointestinal Problems
d. Disturbances in Fluids and Electrolytes: Renal & Genitourinary Functions
e. Disturbances in Cellular Functioning: Cancer and Hematologic Problems
f. Disturbances in Auditory & Visual Functions
g. Disturbances in Musculoskeletal Functions
IV. Client in Biologic Crisis: Life threatening Conditions of the Human Body
- Shock
V. Emergency & Disaster
- First-aid and Cardiopulmonary Support

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I. CLIENT IN PAIN

Pain the fifth vital sign
- an unpleasant sensory and emotional experience associated with actual or potential tissue damage.

Basic Categories of Pain:
1. Acute Pain sudden pain which is usually relieved in seconds or after a few weeks.
2. Chronic Pain (Non-Malignant) constant, intermittent pain which usually persists even after healing of the injured tissue
3. Cancer-Related Pain- May be acute or chronic; may or may not be relieved by medications

Pain Transmission:
1. Nociceptors are called pain receptors. These are the free nerve endings in the skin that respond to intense, potentially
damaging stimuli.
2. Peripheral Nervous System
3. Central Nervous System
4. Descending Control System

Factors Influencing Pain Response
1. Past Experience e.g. trauma
2. Anxiety and Depression
3. Culture - beliefs
4. Age infants are more sensitive
5. Gender
6. Placebo Effect

Characteristics of Pain
1. Intensity mild, moderate, excruciating
2. Timing morning or evening, duration may be longer or shorter
3. Location
4. Quality burning, aching, stabbing
5. Personal Meaning to pain tolerance to pain may be different from one person to the other due to some personal
reasons such as economic reasons, work condition, etc.
6. Aggravating and Alleviating factors patients environment
7. Pain Behaviors - facial expressions with pain

Pain Assessment
1. Evaluate: Cause, Location, Character and Intensity
2. Numeric Pain Scale 5-severe pain - 0 no pain
3. Descriptive Pain Scales mild, moderate, severe
4. Visual Analogue Scales
5. Faces Pain Scale

Nurses Role in Pain Management
1. Identify goals for Pain management
a. Decrease intensity, duration or frequency
b. Factors in identifying goals:
i. Severity of pain
ii. Harmful effects of pain to the client
iii. Duration of the pain

2. Establish Nurse-Patient Relationship and Teaching
a. Acknowledge the verbalization of pain by the client
b. Relieve patients anxiety
c. Teach measures how to relieve pain
3. Provide Physical care
a. Teach and assist in self-care
b. Environmental conditions
c. Application of ice/heat on painful area

4. Manage anxiety related to Pain
a. Teach about the nature of pain that may be felt by the client and reassure him/her
b. Teach alternative measures to relieve pain
c. Stay with the client/ frequent communication with the client

5. Pain Medications may be administered as:
a. Balanced Anesthesia given to avoid experiencing pain
b. PRN Pro Re Nata as needed
c. Preventive taken before pain is felt
d. Individualized Dosage
e. Patient-Controlled Analgesia (PCA) patient takes medication if pain felt is becoming intolerable

6. Non-pharmacologic Interventions
a. Cutaneous Simulation and Massage
b. Ice and heat therapies
c. Transcutaneous Electrical Nerve Stimulation
d. Distraction
e. Relaxation Techniques
f. Guided Imagery
g. Hypnosis

II. PERIOPERATIVE CARE

o Phases of Perioperative Nursing

a. Pre-operative Nursing
b. Intra-operative Nursing
c. Post-operative Nursing

A. Pre-operative Care
Pre-admission and Admission Test
1. Psychological support
2. Client Education:
a. Importance and practice of breathing exercises
b. Location & support of wound
c. Importance of early ambulation
d. Inform and practice leg exercises, positioning, turning
e. Anesthesia and analgesics
f. Educate regarding drains and dressings to be received post-op
g. Recovery room policies and procedures

3. Informed consent
a. At least 18 years of age
b. In sound mind- without psychologic disorder
c. Not under the influence of drugs or alcohol
d. Immediate relative over 18 years old

4. Physical Assessment and preparation
a. Physical Preparation NPO, remove dentures, jewelries, clothes etc.
b. Nutritional & Fluid Status should be well hydrated
c. Drug or alcohol Use may experience delirium or intoxication to anesthetic drugs
because normal doses do not usually take effect to these patients and require
heavier dose to achieve anesthetic effect.
d. Respiratory Status - teach breathing exercises
e. Cardiovascular Status should have controlled and stable cardiovascular
functioning before operation to prevent intra-operative problems
f. Hepatic & Renal Functions normal functioning is important in absorbing
anesthetic drugs
g. Endocrine Functions- important in monitoring to prevent hypo/hyperglycemia,
thyrotoxicosis, acidosis
h. Immune Functions allergies esp. to anesthetic drugs
i. Psychosocial Factors emotional and psychological preparation to ensure
cooperation fom the patient with the procedures
j. Spiritual & Cultural Beliefs - blood transfusions, transplants, ligation, etc are
against other culture & religion.

5. Pre-operative drugs given 20-60 mins. pre-operative
o Makes patient drowsy, keep side-rails up

6. Proper positioning















































Semi-Fowlers

HOB elevated at 30 degrees

Head injury, pot-op cranial surgery, post-op
cataract removal, increased ICP, dyspneic
patients

Fowlers

HOB elevated at 45 degrees

Head injury, pot-op cranial surgery; post-op
abdominal surgery; post-op thyroidectomy, post-
op cataract surgery, increased ICP; dyspnea

High-Fowlers

HOB elevated at 90 degrees

Pneumothorax, hiatus hernia

Supine/ Dorsal
Recumbent

Lying on back w/ small
pillow under head

Spinal cord injury, urinary catheterization

Prone


Lying on abdomen with head
turned to the side

Amputation of legs/feet, post lumbar puncture,
post myelogram, post tonsillectomy &
adenoidectomy (T&A)

Lateral / Side lying

Lying on side, weight on the
lateral side, the lower
scapula and lower iliac.

Post-abominal surgery, post tonsillectomy &
adenoidectomy (T&A), post-liver biopsy ( right
side down), post pyloric stenosis (right)


Sims/ Semi-prone


Lying on side, weight on the
clavicle, humerus and
anterior aspect of the iliac.

Unconscious client

Lithotomy


Lying on back with knees
and legs bent and raised on
a stir up

Perineal, rectal & vaginal procedures

Trendelenburg


Head & body lowered, feet
elevated

Shock

Reverse Tredelenburg

Head elevated , feet
lowered

Cervical traction

Elevate extremity

Support with pillows

Post-op surgical procedure on extremity, cast,
edema, thrombophlebitis


B. Intra-operative Care

1. Ensure sterility of all instruments and supplies at the operating field

Principle: STERILE TO STERILE, CLEAN TO CLEAN
Sterile objects touches only sterile surfaces/objects
Clean objects touches only clean surfaces/objects

Sterilization techniques:
o Autoclave Steam, Ethyl Oxide (Gas)
o Glutaraldehyde Solution- Cidex

7. Ensure safety of client in the operating table- prevent falls, drape the patient properly, provide warmth

8. Stay with the client to relieve anxiety and support during anesthesia
Anesthesia Administration:
a. General Anesthesia via Inhalation
b. General Anestheisia via Intravenous
c. Regional Anesthesia - local anesthesia
d. Conduction Blocks/ Spinal Anesthesia Epidural & Spinal Block
- for operation below the waist line
- patient is awake during operation

9. Perform sponge count, instrument count and needle count
10. Aseptic technique in handling and preparing all instruments and supplies
11. Applies grounding device to prevent electrical burn during use of electrosurgical equipment
12. Proper documentation


C. Post-operative Care
1. Immediate assessment of VS, and Neuro VS, drainages, surgical dressing
2. Monitoring of vital signs q 15mins until stable
3. Post-operative positioning depending on the procedure performed
4. Deep breathing exercises
5. Early ambulation
6. Health teaching for Independent (self) care upon discharge

III. ALTERATIONS IN HUMAN FUNCTIONING


A. DISTURBANCES IN OXYGENATION

Arterial Blood Gas

Normal Value

pH

Measure of acidity or alkalinity


7.35 7.45

pCO2

Partial pressure of carbon dioxide respiratory parameter
influenced by lungs only


35 -45

pO2

Partial pressure of oxygen; measure of amount oxygen delivered
to lungs


80-100

HCO3

Bicarbonate, metabolic parameter influenced only by metabolic
factors


22-26



Respiratory
Acidosis
Normal Value Respiratory
Alkalosis



pH


7.35 7.45


pCO2


35 -45


Normal Compensation

HCO3


22-26

Normal Compensation



a. Administer NaHco3
b. Get rid of CO2
c. Bronchodilators
d. Monitor ABG


Nursing Intervention



a. Breathe into paper
bag or cupped
hands
b. Oxygen

Metabolic
Acidosis
Normal Value Metabolic
Alkalosis



pH


7.35 7.45

Normal Compensation
pCO2


35 -45
Normal Compensation



HCO3


22-26



a. Treat underlying cause
(Starvation, systemic
infections, renal failure,
Diabetic acidosis,
Keratogenic diet,
diarrhea, excessive
exercise)
b. Promote good air
exchange
c. Give NAHCO3 via IV




Nursing Intervention



Restore fluid loss which may be cause by
vomiting, gastric suction, alkali ingestion,
excessive diuretic


CHRONIC OBSTRUCTIVE PULMONARY DISEASE

- A group of conditions assoc. w/ chronic obstruction of airflow entering or leaving the lungs

Major diseases
1. Pulmonary Emphysema airway is obstructed due to destroyed alveolar walls
2. Chronic Bronchitis- increased mucus production that obstructs airway
3. Asthma

Cause:
1. Cigarette smoking
2. Chronic respiratory infections
3. Family history of COPD
4. Air pollution

Clinical Manifestations:
Few words between breaths
Pursed-lip breathing
Cyanosis
Distended neck veins
Barrel chest increased diameter of thorax
Pulsus paradoxus
Clubbing of fingers
Medical Management:
1. Bronchodilators
2. Antihistamines
3. Steroids
4. Antibiotics
5. Expectorants
6. Oxygen therapy at 2LPM use cautiously

Nursing Management:
1. Administer meds and O2 as ordered
2. Promote adequate activities to enhance
cardiovascular fitness
3. Adequate rests
4. Avoid allergens or other irritants
5. Psychological Support

Nicotine Stains
Pitting edema
exertional dyspnea or dyspnea at rest
Enlarged pulsating liver
Cough- with or without sputum production



CHRONIC BRONCHITIS
Blue Bloater


- An inflammation of the bronchi which causes increased mucus production and chronic cough.
- Chronic condition is diagnosed if symptoms occur for 3 months and for 2 consecutive years.

Cause: Cigarette Smoking, infection, pollution

Clinical Manifestations:

Productive cough
Thicker, more tenacious mucus
Decreased exercise tolerance
Wheezes

Medical Management: see COPD

Nursing Management:
1. Reduce or avoid irritants
2. Increase humidity
3. Administer medications as ordered
4. Chest physiotherapy
5. Postural drainage
6. Promote Breathing techniques


EMPHYSEMA
Pink Puffer

- A disorder where the alveolar walls are destroyed causing permanent distention of air spaces.
- (+) dead areas in the lungs that do not participate in gas or blood exchange

Cause: Cigarette smoking, Alpha-anti-trypsin deficiency (an enzyme in the alveolar walls)

Clinical Manifestations:
1. Dyspnea on exertion
2. Tachypnea
3. Barrel-chest
4. Wheezes
5. Pinkish skin color
6. Shallow rapid respirations
7. Pursed lip breathing

ASTHMA

-A condition where there is an increase responsiveness and/or spasm of the trachea and bronchi due to various stimuli which causes
narrowing of airways

Cause and Risk Factors:
1. Family history of asthma
2. Allergens: dust, pollens,
3. Secondary smoke inhalation
4. Air pollution
5. Stress



Slight gynecomastia
Petechiae in midsternal area
Dyspnea

Nursing Management:
1. Position: Sit up and lean forward
2. Pulmonary toilet:
Cough->Breathe deeply->Chest physiotherapy-> turn & position
3. Frequent rest periods
4. Nebulization
5. IPPB Intermittent Positive Pressure Breathing (aerosolized inhalation)
6. O2 @ 2LPM


Types:
1. Immunologic asthma - occurs in childhood
2. Non-immunologic asthma - occurs in adulthood and assoc w/ recurrent resp infections.
- usually >35 y/o
3. Mixed, combined immunologic and non-immunologic

Clinical Manifestations:
Increased tightness of chest, dyspnea
Tachycardia, tachypnea
Dry, hacking, persistent cough
(+) wheezes, crackles
Pallor, cyanosis, diaphoresis
Chronic barrel chest, elevated shoulders
distended neck veins
orthopnea
Tenacious, mucoid sputum
Treatment:
1. Steroids,
2. Antibiotics
3. Bronchodilators, expectorants
4. O2, nebulization, aerosol

Complication: STATUS ASTHMATICUS - a life-threatening asthmatic attack in w/c symptoms of asthma
continues and do not respond to treatment


II. PARENCHYMAL DISORDERS:
PNEUMONIA

- An inflammatory process of lung parenchyma assoc. w/ marked increase in alveolar and interstitial fluids

Etiology:
1. Bacterial / Viral streptococcus pneumoniae, pseudomonas aeruginosa, influenza
2. Aspiration
3. Inhalation of irritating fumes

Risk factors:
1. Age: too young and elderly are most prone to develop
2. Smoking, air pollution
3. URTI
4. Altered conciousness
5. Tracheal intubation
6. Prolonged immobility: post-operative, bed-ridden patients

Clinical Manifestations:

1. Chest pain, irritability, apprehensiveness, irritability, restlessness, nausea, anorexia, hx of exposure
2. Cough- productive , rusty/ yellowish/greenish sputum, splinting of affected side, chest retration
3. CXR, sputum culture, Blood culture, increased WBC, elevated sedimentation rate

Nursing Management:

Promote adequate ventilation- positioning, Chest physiotherapy, IPPB
Provide rest and comfort
Prevent potential complications
Health teaching: skin care, hygiene
Drug therapy:
o Antibiotics: penicillin, cephalosphorin, tetracycline, erythromycin
o Cough suppressants
o Expectorants
Rest and adequate activity
Proper Nutrition




Nursing Management:

1. Promote pulmonary ventilation
2. Facilitate expectoration
3. Health teaching
Breathing techniques
Stress management
Avoid allergens

PULMONARY EDEMA

- often occurs when the left side of the heart is distended and fails to pump adequately

Clinical Manifestation:
o Constant irritating cough, dyspnea, crackles, cyanosis

Pathophysiology:

Fluid accumulation in the alveolar sacs due to hypovolemia, fluid congestions in the lungs, alveoli are congested

Nursing Management:
1. Diuretics, low sodium diet, I&O
2. promote effective airway clearance, breathing patterns and ventilation
3. Monitor VS
4. Psychological support
5. Administer medications

TUBERCULOSIS

Risk Factors:
1. Poor living conditions, overcrowded
2. Poor nutritional intake
3. Previous infection
4. Close contact with infected person
5. Inadequate treatment of primary infection

Clinical Manifestations:

1. Productive cough
2. Hemoptysis
3. Dypnea
4. Rales
5. Malaise
6. Night Sweats
7. Weight loss
8. Anorexia, vomiting
9. Indigestion, pallor

Treatment:
1. Ethambutol
2. Rifampicin
3. Isoniazid
4. Pyrazinamide
5. Streptomycin

Client Education:
1. TB is infectious but can be cured
2. Transmitted by droplet infection and not carried on articles like clothing or eating utensils
3. Individual is generally considered not infectious after 1- 2 weeks of medication.
4. Medication regimen should be continuous and uninterrupted
5. Regimen is usually 6 months.
6. Regular check-up to monitor progress should be done.
7. Sputum samples are obtained first before drug therapy is started.
8. Advise proper handwashing and use of mask for people in contact with infected persons who are not yet under treatment.









- A chronic lung infection that leads to consumption of alveolar tissues
Etiology: Mycobacterium tuberculosis.
Diagnostic Tests:

1. CXR
2. Sputum acid-fast
3. Mantoux Test - .1 ml of PPD (Purified Protein Derivative) ;
Read after 48-72 hrs.
Induration:
10mm > positive exposure to TB bacillus
5 9 mm -> doubtful, may repeat the procedure
> 4 mm -> Negative





































































CARDIOVASCULAR SYSTEM
THE HEART AND MAJOR VESSELS


I. Diagnostic Procedure
1. Laboratory Test
2. Electrocardiogram
3. Echocardiography
4. Central Venous Pressure
5. Pulmonary Artery Pressure/ Swan-Ganz
6. Cardiac Catheterization












Venous Disorders:

1. Thrombophlebitis
2. Varicose Veins
3.
II. Diseases of the Vascular System:

Arterial Disorders:
1. Hypertension
2. Arteriosclerosis
3. Atherosclerosis
4. Aortic Aneurysm
5. Buergers Disease (Thromboangitis Obliterans)
6. Raynauds Disease




































Cardiac Disorders

a. Angina Pectoris
b. Myocardial Infarction
c. Congestive heart Failure
d. Valvular Stenosis
e. AV Heart Block
f. Pacemakers





A. DIAGNOSTIC PROCEDURES:


Procedure

Values / Description

Purpose

1. Laboratory Tests

a. Electrolytes Na, K, Ca,
Chloride , Mg
(see fluids & electrolytes)

b. PTT 16-40 sec.

c. PT 9-12 sec.

d. Clotting time 10 mins.

e. Cholesterol 150-250 mg/dl

f. Triglyceride 50-250 mg/dl
> LDL (bad cholesterol)
60-180 mg/dl
> HDL (good cholesterol)
30-80 mg/dl

g. BUN 6-20 mg/dl



h. Enzymes:
> CPK men- 55-170
- women- 30-135
( rises 3-6 hrs after M.I.)

> LDH 150-450 u/ml
(rises 12 hrs after M.I.)

> SGOT 5-40 u/ml

i. ESR- 0-30. also rises after MI

Determines hyperkalemia, Hypernatremia, etc.
- determine the ability of the heart to affect circulation and regulatory
functions of fluids and electrolytes.



- determines ability of the blood to form clot or
thrombus



.

- determines the development of atherosclerosis
which causes coronary artery disease



- test of renal function; determines adequacy of circulation from the heart
to the kidneys and its ability to excrete protein and urea



- cardiac enzymes are present in high
concentration in the myocardial tissues ;
determines tissue damage in the myocardium






2. Electrocardiogram


P- contraction of the atrium
QRS complex- contraction
of the ventricles
T- Resting state of the
ventricles
PR interval- contraction of
atrium until the beginning
of the contraction of
ventricles
ST- ventricles moves to a
resting state

Determines the electrical
impulse of the heart

Normal impulses ensures
adequate circulation to all
body organs and tissues













Procedure

Values / Description

Purpose

3. 2-Dimensional
Echocardiography
(2D Echo)

Ultrasound of the heart

Determines valvular
deformities, thickening of
myocardium, pericardial
effusion,etc



4. Central Venous
Pressure (CVP)

Normal = 5 10 cm
Water
Measures the right atrial pressure or the
pressure of the greater veins within the
thorax by threading a catheter into a
large central vein.
- Subclavian - Jugular
- Median - Basilic
- Femoral

End of catheter or Tip positioned at
the right atrium or upper portion
superior vena cava

(for femoral insertion, tip is at the
inferior vena cava)
Serves as guide for fluid
replacement

Monitor pressures in the
right atrium and central
veins

Administer blood products,
TPN, drug therapy.

Obtain venous access when
peripheral veins are
inadequate

To insert a temporary
pacemaker
Obtain central venous
samples




5. Swan-Ganz
Catheter /
Pulmonary Artery
Pressure (PAP)


Measures the level of pressure in the
left atrium

4 Ports:
a. Thermodilution port
b. Balloon Port for inflating
balloon used for placement of
catheter
c. Right atrium Port
d. Pulmonary atrium port

Monitor pressure in the ff:
c. Right ventricle
d. Pulmonary artery
e. Distal branches of the
pulmonary artery
Thermodilution
Obtain blood for O2
saturation


6. Cardiac Catheterization

Catheter inserted into the right or left
side of the heart and vessels and a dye
is introduced

Used to determine details on the
structure and performance of the
valves, heart and circulation

a. Measure O2 concentration,
saturation, tension and
pressure in the chambers of
the heart

b. Detect shunts

c. To get blood samples

d. Determine cardiac output &
pulmonary flow

e. Determine need for bypass
surgery



Three types of Blood Vessels:

1. Arteries - carries oxygenated blood
2. Veins - carries unoxygenated blood
3. Capillaries allows the delivery of nutrients, oxygen and fluids to the tissues

B. DISEASES OF THE VASCULAR SYSTEM:

B. 1.ARTERIAL DISORDERS


HYPERTENSION
Persistent BP above 140 /90

Types of Hypertension Essential hypertension Secondary hypertension

Etiology:

unknown etiology

caused by other physiologic problems
- most common
- may be caused by an increase in cardiac output or
increase in peripheral resistance


Types of Hypertension Essential hypertension Secondary hypertension

Risk Factors

Genetic
Obesity
Stress
Loss of elastic tissues
Arteriosclerosis of aorta


Renal problems Renal Failure, Nephritis
Endocrine problems Thyroid problem, DM
Neurologic Disorders Brain tumors, Trauma
Pregnancy-Induced HPN
Many others

Signs & Symptoms

BP=140/90 ; headache, fatigue, weakness, dizziness, palpitations, flushing, blurred vision and epistaxis

Treatment

1. Non-pharmacologic:
Weight reduction Sodium restriction
Diet modification Exercise
Alcohol & Smoking cessation Caffeine Restriction
Relaxation Techniques
Potassium, Calcium, Magnesium supplements (to balance sodium and other electrolytes)

2. Pharmacologic:
Calcium Agonist: Nifedipine, Verapamil
Vasodilators: Hydralazine
Diuretics: Aldactone, hydrochlorothizide
Adrenergic inhibitors: Propanolol, Clonidine, Methyldopa

Nursing Interventions
1. BP monitoring
2. Correct cause: obesity, diet, stress, etc
3. Regular exercise
4. Salt restrictions
5. Administer medications
6. Teach risk factors

ARTERIOSCLEROSIS
Obstruction

- When the arteries become obstructed with plaque and cholesterol, they harden and constrict, and the circulation of blood
through the vessels becomes difficult, forcing the blood through narrower passageways. As a result, blood pressure becomes
elevated.

- Arteriosclerosis occurs when lipids in the blood, including cholesterol, accumulate inside the walls of blood vessels and reduce
the size of the veins or arteries through which blood flows.


ATHEROSCLEROSIS
Thickening


- A degenerative condition of the arteries characterized by thickening due to localized accumulation of fats, mainly cholesterol.
The term atherosclerosis refers to a condition in which fatty deposits build up in and on the artery walls, interfering with the
normal flow of blood and oxygen throughout the body. When this happens, the heart has to work harder to pump blood through
the narrowed blood vessels, and a heart attack or a stroke may result.



Predisposing factors:
cigarette smoking
high fat levels in the blood
high cholesterol
high blood pressure
obesity




Signs and symptoms:
- The symptoms of atherosclerosis depend on the part of the body where the condition is taking place. Sometimes there aren't any noticeable
symptoms until the condition has advanced to a very serious stage. When the arteries of the heart are affected, one of the first symptoms is
chest pain, often called angina. A person with clogged arteries of the heart may also have occasional difficulty in breathing and may experience
unusual fatigue after short periods of exertion.

Medical & Surgical Interventions for Athero and Arteriosclerosis:
a. Lifestyle Modification ; Reduce Risk Factors
b. Coronary Artery Bypass Graft (CABG
c. Percutaneous Transluminal Coronary Angioplasty (PTCA)
d. Directional Coronary Atherectomy (DCA)
e. Intracoronary Stents

Nursing Intervention:
a. Health Teaching
b. Reduce Risk Factors
c. Restore Blood Supply
d. Pre & Post-op Care for Surgical Patients

AORTIC ANEURYSM

-Types of Aneurysm: Thoracic or Abdominal Aortic Aneurysm
Risk Factors: Presence of Atherosclerosis, Infections or a Congenital abnormality

Signs & Symptoms:

Thoracic Aortic Aneurysm

Abdominal Aortic Aneurysm (AAA)

Dyspnea Thoracic/chest pain
Dysphagia cough
voice hoarseness

Abdominal Pain
Low back pain
Pulsating Abdominal Mass

Treatment: Surgical Removal of Aneurysm

Nursing Intervention: a. Psychological support
b. Monitor patient for signs of rupture of aneurysm



Triad of manifestations for ruptured abdominal aneurysm:
1. Abdominal pain
2. Back or Flank pain (scrotal pain may also occur)
3. Shock: Bp= >100 systolic; Pulse Rate >100bpm
c. Pre-operative preparation
d.
e.
f. Post-operative care: monitor peripheral circulation


BUERGERS DISEASE
a.k.a. Thromboangitis Obliterans (TAO)

Definition: Vasculitis of the veins and arteries in the upper & lower extremities

Risk Factors: Men -20-35 y/o, Heavy smokers, hypersensitivity to intradermal injections

Signs & Symptoms: a. pain in legs relieved by immobility,
b. numbness and tingling of toes
c. sensitivity to cold
d. Weak or absent pulsations at the dorsalis pedis, posterior tibial
e. Reddish or Cyanotic extremity which may progress to ulceration or gangrene
Treatment:
Calcium Channel Blockers to promote vasodilation
Rest, Pain Relievers, Avoid exposure to cold
Surgery: Amputation of extremity is delayed until conservative treatments fail to effect.

Nursing Intervention:
Health teaching on lifestyle modifications, spec. smoking
Ensure protection of extremities against cold
Administration of medications as ordered
Protect client from injury
Assessment of extremities


RAYNAUDS DISEASE

Definition: Vasospasm of arteries in the hands (upper extremities only)

Risk Factors: Women, heavy smokers, individuals spec. women with Systemic Lupus
Erythematosus (SLE) or rheumatoid arthritis

Cause: hypersensitivity of fingers to colds, congenital vasospasm, Serotonin release

Signs & Symptoms:
Cyanosis/pallor of the fingers when exposed to cold environment or emotional stimuli
Numbness and occasional pain
Bilateral or symmetrical involvement

Treatment:


B.2.VENOUS DISORDERS:
THROMBOPHLEBITIS
Definition: Clot disorder in the vein usually at the lower extremity

Risk Factors: Trauma of the blood vessels, stasis, Increased coagulability

Signs & Symptoms: Edema of the extremity,
redness, pain, local induration,
(+) Homans sign - calf pain upon
dorsiflexion of foot
Nursing Intervention:
a. Use of thromboembolytic (TED) stockings
b. Elevate legs
c. Heparin therapy, as ordered
d. Bed rest
e. Warm compress

VARICOSE VEINS


Definition: distention, lengthening and totuosity of veins

Cause: loss of valvular competence and constant elevation of venous pressure
most commonly in the veins of the legs.

Risk Factors: Prolonged standing, obesity, pregnancy

Signs & Symptoms:
Aching
Heaviness
Moderate swelling
Enlarged, tortuous veins in the legs

Treatment:
Surgical Management: Sclerotherapy (injection of sclerosing agent to the
vein. Not a treatment, hence, for cosmetic purpose only)

Nursing Intervention
Elevate legs at least 30 mins. After prolonged standing
Wear thromoembolic stockings
Teach client o avoid prolong sitting or standing
Avoid cross-legs while sitting
Post-op Care after Sclerotherapy: a. Maintain firm elastic pressure over the whole limb

b. Regular but careful exercise of the legs to promote
circulation ambulate for short periods 24-48 hrs post-op

c. Assessfor complications such as bleeding, infection, nerve
damage
IV.CARDIAC DISORDERS
ANGINA PECTORIS
Chest pain
insufficient coronary blood flow
inadequate oxygen exchange in the heart causing intermittent chest pain
can be relieved with rest.
It lasts only for 1-5 minutes and taking up of nitroglycerine will be beneficial for the client.
Signs and symptoms:
Patient experiences retrosternal chest discomfort
Pressing, heaviness, squeezing, burning and choking sensation.
Pain in the epigastrium, back neck jaw or in the shoulders.
Radiation of pain in the arms, shoulders and the neck.
Precipitating factor:
over exertion
eating
exposure to cold
emotional stress








Classification of Symptoms:
Class I no limitations of physical activity (ordinary physical activity does not cause symptoms).
Class II slight limitation of physical activity (ordinary physical activity does cause symptoms).
Class III moderate limitation of activity (patient is comfortable at rest, but less than ordinary activity can cause symptoms).
Class IV unable to perform any physical activity without discomfort, therefore severe limitations (patient may be symptomatic even at rest).

Nursing Interventions:
a. Assess pain location, character, ECG (ST elevation), precipitating factors
b. Help client to adjust lifestyle to prevemt angina attack avoid excessive activity in cold weather,
avoid overeating, avoid constipation, rest after meals, exercise
c. Teach patient how to cope with angina attack nitroglycerin every 5 mins upto 3x, if still not
relieved go to the hospital
Diagnostic Assessment:
a. ECG
b. Stress Test
c. Radioisotope Imaging
d. Coronary Angiography

Medical Management:
a. Opiate Analgesic MoSo4
b. Vasidilators Nitroglygcerin, Isosorbide Mononitrate/Dinitrate
c. Calcium Channel Blockers Dlitiazem, Nifedipine
d. Beta Blocking Agents Propanolol


MYOCARDIAL INFARCTION
Destruction of myocardial tissue due to reduced coronary blood flow.
The rapid development of myocardial necrosis caused by imbalance between the oxygen supply and demand of the
myocardium.
Results from plaque rupture with thrombus formation in a coronaryvessel, resulting in an acute reduction of blood
supply to a portion of the myocardium. Causes:
1. Atherosclerotic heart
2. Coronary Artery Embolism
Signs and symptoms:
1. chest pain heavy (viselike, crushing, squeezing)
usually across the anterior pericardium typically is described as tightness, pressure, or squeezing.
Pain may radiate to the jaw, neck, arms, back, and epigastrium. The left arm is affected more
frequently; however, a patient may experience pain in both arms.
2. Dyspnea, Orthopnea sense of suffocation
3. Nausea and/or abdominal pain- gas pains around the heart
4. Anxiety, Apprehension
5. Light headedness with or without syncope
6. Cough , Wheezing
7. Nausea with or without vomiting
8. Cold diaphoresis, gray facial color,
9. Weakness and altered mental status common in elderly patients.
10. Rales may be present in congestive heart failure.
11. Neck vein distention represents right pump failure.
12. Dysrythmias - an irregular heart beat or pulse, usually tachycardic.
13. Oliguria urine less than 30 ml/hr

Risk factors:
Age , Male gender, Smoking, DM, Family history, Sedentary lifestyle, obesity, diet, stress, hypertension, Type A
personality

DIAGNOSTICS:
Lab studies:
Creatine kinaseMB (CK-MB)
Myoglobin
CBC , Trponin
Potassium and magnesium level
Creatinine level
C Reactive protein (CRP)
Erythrocyte sedimentation rate (ESR)
Serum lactate dehydrogenase (LDH)

Imaging studies:
Chest radiography or chest x-ray reveals pulmonary edema secondary to heart failure.
CT scan
Radionuclide Imaging
Positron Emission Imaging
Transesophageal Echocardiography
Magnetic resonance imaging (MRI) - can identify wall thinning, scar, delayed enhancement (infarction), and wall
motion abnormalities (ischemia).
Electrocardiogram (ECG) - ST-segment elevation greater than 1 mm.
- the presence of new Q waves.
-intermediate probability of MI are ST-segment depression, T-wave inversion, and other
nonspecific ST- T -wave abnormalities.

emergency intervention:
IV access thrombolytic agents e.g. heparin
supplemental oxygen
pulse oximetry maintain oxygen saturation at >90%
Immediate administration of aspirin en route
Nitroglycerin for active chest pain, given sublingually or by spray
ECG

Treatment is aimed at:
Restoration of balance between oxygen supply and demand to prevent further
ischemia.
Chest Pain relief
Prevention and treatment of complications.

Drug of choice for patient with MI:

Antithrombotic agents - prevent the formation of thrombus and inhibit platelet function.
(aspirin, -heparin)

Vasodilators - Opposes coronary artery spasm, which augments coronary blood flow and
reduces cardiac work by decreasing preload and afterload

- can be administered sublingually by tablet or spray, topically, or IV.
(nitroglycerine)

Beta-adrenergic blockers - reduce blood pressure, which decreases myocardial oxygen demand. (metoprolol)

Platelet aggregation inhibitors inhibits platelet aggregation clopidogrel (plavix)

Analgesics reduce pain which decreases sympathetic stress (morphine sulfate)

Angiotensin converting enzyme (ACE) inhibitors prevents conversion of angiotensin I to angiotensin II, a potent
vasoconstrictor. -captopril(capoten)

Complications of MI:
Dysrhytmias Cardiogenic Shock
Heart Failure Pulmonary Edema
Pulmonary Embolism Recurrent MI
Complications due to Necrosis VSD, rupture of the heart, ruptured papillary muscles
Pericarditis

Recommendations:
- All MI patients should be admitted in the ICU.
- Patient should remain on complete bed rest during his stay in the hospital and avoid straining activities.

Nursing interventions for MI

1. Early
a. Treat arrythmias promptly lidocaine
b. Give analgesic- morphine
c. Provide physical rest
d. Administer O2 via cannula
e. Frequent VS
f. Nifedipine
g. Propanolol HCL
h. Emotional Support



2. Later
a. Give stool softener
b. Provide low fat, low cholesterol, low sodium diet, soft food
c. Commode
d. Self-care
e. Plan for rehabilitation
Exercise program
Stress management
Teach risk factors
f. Psychological support
g. Long-term drug therapy
Antiarryhtmics- quinidine, lidocaine
Anticoagualnt heparin, aspirin
Antihypertensives propanolol, chlorathiazide

Comparison of Chest Pain



Angina Pectoris Myocardial Infarction
Type


Location




Duration


Relief
squeezing, pressing,
burning

Retrosternal, substernal, left
of sternum, radiates to the
left arm

Usually 3-5 mins duration
<30 mins

rest, nitroglycerin
Sudden, severe, crushing, heavy,
tightness

Substernal, radiates to one or
both arms, jaw, neck

>30 mins.


Oxygen, narcotics,
not relieved by rest &
nitroglycerin


TRANSIENT ISCHEMIC ATTACK (TIA)

temporary episode of neurological dysfunction lasting only a few minutes or seconds (in a day/ 24hrs) due to decreased
blood flow to the brain.

A warning sign of stroke especially in first 4 weeks after TIA

Causes:
1. Atherosclerosis
2. Microemboli from atherosclerotic plaque

Manifestations:
1. Sudden loss of visual function
2. Sudden loss of sensory function
3. Sudden loss of motor function

Management: - Surgical Carotid Endarterectomy (bypass)

1. Post-op focus assess neurologic deficits; avoid flexing neck
Inability to swallow, move tongue, raise arm, smile may indicate problem in the
specific cranial nerve.

2. Anticoagulant therapy: aspirin, etc.


Comparison of other signs & symptoms


Angina Pectoris

Myocardial Infarction

Transient Ischemic Attack

Subjective Data:
Dyspnea
Palpitation
Dizziness
Faintness

Subjective Data:
Shortness of breath
Apprehension, fear of
impending death
Nausea

Sudden loss of:
Visual fxn
Sensory fxn
Motor fxn

Objective Data:
Tachycardia
Pallor
Diaphoresis

Objective Data:
Symptoms of shock
Cyanosis, diaphoresis
Restless

Objective Data:
Loss of functioning for about and returns to
normal

Nursing Care Management


Arteriosclerosis

Angina Pectoris

Transient Ischemic Attack

1. Lifestyle Modification
Diet, stress mgt, habits

2. Restore blood supply
Anti-embolic stockings, anti-
coagulants

3. Pre & post-op care
CABG,PTCA, Stents

4. Health teaching
Modifications, diet,etc.

1. Provide relief from pain:
Rest
Nitroglycerin
Lifestyle modification
Vital signs
Assist w/ ambulation

2. Provide emotional support

3. Health teaching
Pain differentiation
Medication
Dx test
Diet, exercise, CABG

1. Assess neurologic status

2. Administer meds
























NURSING CARE MANAGEMENT

Myocardial Infarction

1. Reduce pain & discomfort:
Narcotics, O2, Semi-fowlers position to improve
ventilation
battery- operated
2. Maintain adequate circulation.
Monitor VS, Urine Output & ECG
Meds: Anti-arrythmics & anticoagulants
Check for edema, cyanosis, dyspnea, cough,
crackles
CVP: normal= 5-15cm H20
ROM, anti-embolic stockings

3. Decrease oxygen demand/ Promote
oxygenation
O2, Bedrest (24-48 hrs), rest periods
Semi-fowlers position
Anticipate needs of client: call light, water
Meds: vasodilators, vasopressors, Cal.C.Blockers

4. Maintain fluid & electrolyte balance / Nutrition
Keep IV open; CVP, VS, UO
Lab data: Na+135-145; K 3.5-5.0 mEq/L
ECG
Diet: low calorie, low sodium, low cholesterol, low
fat

5. Facilitate fecal elimination
stool softener, avoid Valsalva, mouth breathing,
bedside commode

6. Provide emotional support

7. Promote sexual functioning
discuss concerns include partner
resume 5-8 wks after uncomplicated MI

8. Health teaching


CONGESTIVE HEART FAILURE (CHF)
Definition: inability of the heart to meet oxygen and metabolic needs of the body

Causes:
1. Abnormal loading conditions - Congenital defects, ventricular / atrial septal
defect, Patent Ductus Arteriosus, Valvular stenosis, HPN, High
Peripheral Vascular Resistance

2. Abnormal muscle function - Myocardial Infarction, myocarditis, cardiomyopathy,
ventricular aneurysm

3. Diseases that exacerbate or precipitate heart failure Stress, dysrhythmia,
infection, anemia, thyroid disorders, pregnancy, nutritional deficiency,
pulmonary disease, hypervolemia

Management:
Positioning High fowlers position to reduce pulmonary congestion
O2 Administration
Pharmacology: Digitalis, Dopamine & Dobutamine, ACE inhibitors
Digitalis:
increases ventricular contractility
Increases ventricular emptying
Increase Cardiac output
Watch out for Digitalis toxicity

SIGNS OF DIGITALIS TOXICITY
EYES: Halo around lights
GASTROINTESTINAL TRACT: Diarrhea, anorexia, vomiting, abdominal cramps
CARDIOVASCULAR: Bradycardia, Frequent PVCS
CENTRAL NERVOUS SYSTEM: Headache, Fatigue, Letargy

Nursing Intervention:
1. Sodium restriction
2. Reduce pain and anxiety
3. Improve oxygenation: proper positioning, O2
4. Reduce congestion and edema: meds, positioning


VALVULAR STENOSIS


Definition: Narrowing of valve which prevents blood flow or impaired closure of the valves
causing regurgitation

Signs & Symptoms: Murmurs, decreased cardiac output, heart failure

Treatment: Heart valve replacement, mitral commisurotomy
Pharmacology: Anti-coagulant- Coumadin
Management: low sodium, low cholesterol diet

Nursing Intervention: same as CHF


AV HEART BLOCK

Definition: Altered transmission of impulse from SA node through AV node


































Left Ventricular Failure Right Ventricular

Signs &
Symptoms

Causes Pulmonary Congestion:

a. Dyspnea
b. Cheynes Stroke
c. Cough, Rales, wheezing
d. Orthopnea
e. Paroxysmal Nocturnal Dyspnea
f. Pulmonary Edema
g. Cerebral hypoxia
h. Fatigue &muscular weakness
i. Renal Changes, Nocturia


a. Peripheral edema
b. Venous congestion of organs
c. Hepatomegaly
d. Cyanosis of the nail beds
e. Massive swelling of the legs,
genitals and trunk (Anasarca)
f. Anxiety, fear and depression
f.

Degree of Block

Description

Treatment

First-degree AV Block

delayed transmission of impulse to AV
node


None

Second-degree AV Block

not all impulses pass through AV node

Atrophine
Isoproterenol


Third-degree AV Block

No impulse pass through AV node

Ventricular Pacemaker


B. DISTURBANCES IN METABOLIC & ENDOCRINE FUNCTIONING

Gland Hormone Functions

Pituitary Gland
Anterior Lobe


Growth Hormone


Prolactin


Thyrotropic hormone (TSH)

Gonadotropic hormones (LH & FSH)

Adrenocorticotropic hormone (ACTH)

Melanocyte-stimulating Hormone (MSH)



Stimulates growth of body tissues and bones


Stimulates mammary tissue growth & lactation


Stimulates thyroid gland

Affect growth, maturity and functioning of primary and secondary
sex organs

Stimulates steroid production by adrenal cortex


May stimulate adrenal cortex; may affect pigmentation



Posterior lobe

Anti-diuretic hormones (ADH,
vasopressin)


Oxytocin


Promotes reabsorption of water by the distal tubules and collecting
ducts of the kidney, thus decreasing urine output

Stimulates ejection of milk from mammary alveoli into the ducts:
stimulates uterine contractions may possibly be involved in the
transport of sperm in the reproductive tract of the female


Thyroid Gland

Thyroxine (T4)

Triiodothyronine (T3)

Thryrocalcitonin


Increases metabolic activity of almost all cells; stimulates most
aspects of fat, protein and carbohydrate metabolism

Lowers serum calcium levels and elevates phosphate level; opposite
effect from that of PTH


Parathyroid


Parathormone (PTH)


Increases calcium levels and decreases phosphate levels; increases
resorption of bones

Adrenal Cortex

Controls SSS: SUGAR,
SALT, SEX

Glucocorticoids (primarily cortisol) --
Sugar

Mineralcorticoids (Aldosterone)
-- Salt

Androgens (male hormones)
-- Sex

Promotes carbohydrate, protein and fat catabolism, increases tissue
responsiveness to other hormones

Tends to increase sodium retention and potassium excretion

Governs certain secondary sex characteristics; all corticoids are
important for defense against stress or injury

Medulla

Epinephrine (Adrenalin)-80%

Norepinephrine- 20%


Elevates blood pressure, converts glycogen to glucose when needed
by muscles for energy; increases heart rate; increases cardiac
contractility; dilates bronchioles


Ovaries

Estrogens and progesterone


Stimulate development of secondary sex characteristics, effect
repair of the endometrium after menstruation

Testes

Testosterone


Essential for normal functioning of male reproductive organs;
stimulates development of secondary sex characteristics

Pancreas
Islets of Langerhans

Insulin

Glucagon

Somatostatin

Promotes metabolism of carbohydrates, protein and fat thus
decreasing blood glucose
Mobilizes glycogen stores, thus raising blood glucose levels
Decreases secretion of insulin, glucagons, growth hormone and
several gastrointestinal hormones( gastrin, secretin)

PITUITARY GLAND PROBLEMS


Clinical Manifestations

Management

Acromegaly

1. Enlarged extremities
2. Protrusion of jaw and orbit
3. No increase in height and weight but hands and
feet become bigger
4. Increased perspiration
5. Visual problems
6. Hyperglycemia/calcemia


1. Irradiation of pituitary with Bromocriptine to
decrease secretion of growth hormone

2. Surgery: Hypophysectomy-removal of the
pituitary gland

3. Post-op Care:
a. Assess ICP
b. Elevate head of bed (HOB) 30 degrees
c. Avoid coughing, sneezing, blowing nose

Gigantism








Overgrowth of all body tissues and bones


Dwarfism







1. Retarded physical growth
2. Premature body aging
3. Slow intellectual development



1. Removal of cause : tumor
2. Human Growth Hormone Injection
3. Same as acromegaly & gigantism
Growth
Hormone
In CHILDREN

Growth
Hormone
IN ADULTS

Growth
Hormone
In CHILDREN

Diabetes Insipidus







1. Polyuria
2. Polydipsia
3. Dehyration

1. Pharmacology:
a. Desmopressin Acetate nasal spray
b. Vasopressin Tannate IM injections
c. Hypressin Nasal Spray

2. Nursing Interventions;
a. Maintain adequate fluids
b. Sodium Restriction
c. Intake & Output monitoring
d. Teach self-injection techniques
e. Daily weights
f. Specific gravity

SIADH Syndrome of
Inappropriate secretion of
ADH



1. Hyponatremia
2. Mental confusion
3. Personality changes
4. Lethargy, weakness, headache
5. Weight gain
6. Abdominal cramping
7. Anorexia, nausea, vomiting

1. Fluid restriction
2. Treat underlying causes
3. Pharma:
a. Demeclocycline administration as
ordered
b. Lithium Carbonate
c. Butorphanol Tatrate

ADRENAL GLAND PROBLEMS


Clinical Manifestations

Management

Addisons Disease













1. Malaise and general weakness
2. Hypotension, hypovolemia
3. Increased pigmentation of skin
4. Anorexia, nausea, vomiting
5. Electrolyte Imbalance
6. Weight loss
7. Loss of libido
8. Hypoglycemia (60-70)
9. Personality Changes







1. Pharmacology: Steroids (Prednisone,
dexamethasone)
2. Diet: high CHO, CHON diet
3. Observe side effects of hormone replacement
Cushingoid Appearance
4. Monitor fluid & electrolyte
5. Teach importance of lifelong medications
4. WOF Signs of Addisonian Crisis:











Anti-
diuretic
Hormone



Glucocorticoids
Mineralcorticoids
Sex Hormones
Addisonian Crisis:

1. Sudden profound weakness
2. Severe abdominal, back and leg
pain
3. Hyperpyrexia followed by
hypothermia
4. Peripheral vascular collapse
5. Shock
6. Renal Shutdown -> Death

Cushings Syndrome









1. Thin scalp
2. Moon Face
3. Acne
4. Increased body hair
5. Buffalo hump
6. Obesity
7. Hyperpigmentation
8. Thin extremities
9. Easy Bruising
10. Mood swings, male characteristics
appear in women
11. Hypokalemia, Hyperglycemia, HPN
12. Amenorrhea
13. Osteoporosis



1. Surgical Mgt: Adrenalectomy
2. Chemotherapy: Bromocriptine
3. Diet: high CHON, low CHO, low Na diet ,
potassium supplement
4. Nursing Mgt:
> protect from infection
> protect from accidents
> health teaching on self-medication





STEROIDS:
Purpose: Anti-inflammatory and anti-allergy; Stress Tolerance
Medication:
a. Take at the same time everyday
b. Follow regime and do not stop abruptly
c. Causes gastric upset

Side effects: Cushingoid Appearance


Conns Syndrome /
Aldosteronism









1. HPN
2. Hypokalemia

1. Surgery: Removal of tumor
2. Potassium replacement
3. Treatment of hypertension
4. Nursing Mgt: Monitor BP, administer meds, provide quiet
environment

Pheochromocytoma







1. HPN
2. Increase Perspiration
3.Apprehension
4.Palpitations
5. Nausea, Vomiting, Headache
6. Tachycardia
7. Hyperglycema


1. Surgical Mgt: Removal o tumor
2. Medical Management: Symptomatic (Treat
symptoms as it occurs)
3. Nursing Mgt:
> High caloric diet
> Adequate Rest




















Glucocorticoids



Mineralcorticoids
(Aldosterone)



Epinephrine/
Norepinephrine

THYROID GLAND PROBLEMS


Clinical Manifestations

Management

Graves Disease / Hyperthyroidism/
Thyrotoxicosis










1. Exopthalmos- protrusion of eyes
2. Enlargement of the thyroid gland
3. Increase metabolism: weight loss,
diarrhea, diaphoresis
4. Personality changes
5. Cardiac Arrythmias
6. Easy fatigability
7. Muscle weakness
8. HPN
9. Anxiety, Insomnia


1. Surgery: Thyroidectomy
2. Drug Therapy:
a. Methimazole
b. Propyl- Thyracil
c. Iodides:
Lugols solution strains teeth, drink w/ straw

Saturated Solution of Potassium Iodide (SSKI)

d. Propanolol
3. Radioiodine therapy
4. Nursing Mgt:
a. Adequate Rest
b. High caloric, high protein, carbohydrate,
vitamins without stimulants
c. Measure daily weights
d. Eye protection for xopthalmos
e. WOF: Thyroid Storm



Cretinism






1. Physical & mental retardation
2. Sensitive to cold
3. Dry skin
4. Poor appetite and constipated

Treatment:
Hormone
Replacement















Myxedema








1. anorexia and constipation
2. intolerance to cold
3. Slow metabolism: decreased
sweating, edema
4. Dry skin
5. Enlarged thyroid


1. Drug Therapy:
a. Levothyroxine
b. Thyroid Replacement (Desiccated
thyroid)
** taken in empty stomach
** heart rate less than 100 bpm -ok


PARATHYROID GLAND PROBLEMS


Clinical Manifestations

Management

Hypoparathyroid





Bradycardia , Easy bruising
Fluid retention, Constipation
Dry, coarse skin, Fatigue, lethargy
Decreased libido, Menorrhagia, irregular
menses



1. Drug therapy: Levothyroxine, Liothyronine
Sodium
2. Avoid stimulus



T3, T4,
Thyrocalcitonin
THYROID STORM:
a. Fever
b. Tachycardia
c. Delirium
d. Irritability


T3, T4,
Thyrocalcitonin
INFANTS


T3, T4,
Thyrocalcitonin
ADULT



Parathormone
DIABETES MELLITUS

Hyperthyroid









Tachycardia
Palpitations
Increased persitalsis
weight loss
Heat intolerance
Decreased libido
Amenorrhea

1. Drug therapy: Prophylthiuracil
Methimazole, Saturated solution
of Potassium Iodide, Radioactive
Iodine
2. Diet: low calcium, high fiber
1. Force fluid


PANCREATIC PROBLEMS







Type I
Insulin Dependent DM
(IDDM)

Type II
Non-Insulin Dependent DM
(NIDDM)

Other Name

Juvenile DM


Adult DM
Age of Onset
Before 30 years old but may occur at any age

>35 y/o but can occur in children
Onset
Abrupt

Insidious
Incidence
10%

85-90%
Insulin production
Little or none

Below normal
Normal or
Above normal
Insulin Injections
Required

Necessary for only 20-30% of clients

Ketosis
May occur

Unlikely to occur
Body weight at onset
Ideal body weight or thin

Usually Obese
Management
Diet, exercise and insulin

Diet, exercise, hypoglycemic agent or insulin


Cardinal Signs & Symptoms:
1. Polydipsia - excessive thirst
2. Polyuria - frequent urination
3. Polyphagia - excessive hunger
4. Weight Loss - for IDDM

Treatment:

1. Oral hypoglycemics:
a. Glipizide
b. Glyburide
c. Tolbutamide
d. Tolazamide
e. Acetohexamide
f. Chlorpropamide







Parathormone


Side effects:
a. Hypoglycemia
b. Skin rashes
c. GI disturbances
d. Flushing
e. Nausea, vomiting

Administration:
> usually administered 30 mins. before meals to promote
faster absorption of the meds

2. Insulin Injections:

Action Appearance- Preparation
Onset of Effect

Peak

Duration of Effect

Short-Acting

Clear - Regular Insulin

30 mins. 1 hr.

2 4 hrs.

6 8 hrs.

Cloudy - Semilente

30 mins. 1 hr.

2 8 hrs.

8 16 hrs

Intermediate
Acting

Cloudy - NPH

1 2 hrs.

6 12 hrs.

18 -26 hrs.

Cloudy - Lente

1 3 hrs.

6 12 hrs.

18 -26 hrs.

Long-Acting

Cloudy - Protamine zinc

4 6 hrs.

18 24 hrs.

28 36 hrs.

Cloudy - Ultralente

4 6 hrs.

14 24 hrs.

36 hrs.

Pre-Mixed

Cloudy - 70% NPH
- 30% regular

30 mins.

2 -12 hrs.

18- 24 hrs.


Complications of DM:

a. Hypoglycemia

Cause: Hunger, less dietary intake, excessive insulin

Signs & Symptoms: Diaphoresis, Tachycardia, tremors, weakness, irritability, confusion

Nursing Interventions: Give candy, juice or softdrinks, let the patient eat
Check sugar level


b. Diabetic Ketoacidosis

Cause: Lack of insulin , Infection, Stress

Signs & Symptoms: Polyuria, thirst, Nausea, vomiting, dry mucous membranes, Kussmaul resp,
Coma, sunken eyesballs, acetone odor of breath, hypotension, abdominal
rigidity

Nursing Interventions: Give regular insulin


c. Lipodystrophy

Cause: Indurated areas on skin due to injections

Signs & Symptoms: Skin indurations

Nursing Interventions: Teach client to rotate sites of injection

d. Hyperglycemic Hyperosmolar Nonketotic Coma (HHNK)

Cause: Extremely high glucose, no ketosis

Signs & Symptoms: Polyphagia, polydipsia, polyuria, glucosuria, dehydration, abdominal
discomfort, hyperpyrexia, hyperventilation, changes in sensorium, coma,
hypotension, shock

Nursing Interventions: Fluid & electroluyte replacement, Insulin




C. DISTURBANCES IN ELIMINATION

3.1. Inflammatory and Neoplastic Disorders
a. Acute Gastritis
b. Chronic Gastritis
c. Duodenal Ulcer
d. Gastric Ulcer
e. Gastric Cancer

Acute Gastritis Chronic Gastritis Treatment

Incidence:







Cause:








Duration:


Clinical
Manifestations:



Acid production:

o Common in age 50-60 years old
o Frequent in male than female
o Greater incidents in heavy
drinkers and smokers

Helicobacter Pylori

Medicines:
Aspirin, NSAIDS, chemo drugs, steroids

Food:
Alcohol, coffee, spicy foods


Short


Epigastric discomfort,
Abdominal pain, cramping, severe
nausea, vomiting and sometimes
hematemesis

Increased hydrochloric acid.

o Same in Acute Gastritis






o History of or presence of
peptic ulcer disease
o Previous gastric surgery
o Same as acute gastritis



Prolonged


o May be asymptomatic
o Other symptoms include:
o Dyspepsia, belching, vague
epigastric pain, N/V,
intolerance to spicy or fatty
foods


No increase in hydrochloric acid


Medical Management:
a. Antacids
b. Small frequent meals
c. Bland diet
d. May prescribe
anticholinergics in
chronic gastritis

Nursing Interventions/
Health Teaching:
-Avoid spicy
foods
-Avoid alcohol
intake

-Frequent small
meals

Duodenal Ulcer Gastric Ulcer

Occurrence:











Cause:


Acid production:


Location of Ulcer


Pain:




o 25-50 yrs. old

o Type A personality (leaders,
executives);


o Usually in a well-nourished
individual




Stress, Poor food habit


Hypersecretion


Pylorus


o Experienced 2-3 hrs after
meal
o Ingestion of FOOD
RELIEVES PAIN

> 50 yrs. old

o Most common in
persons like farmers,
construction workers

o Usually affects
malnourished
individuals

Excessive smoking,
salicylates intake

Normal to hyposecretion


Lesser curvature


o Experienced to 1
hour after meal
o Ingestion of FOOD
DOES NOT RELIEVE
PAIN

Nursing Intervention:

a. Relaxation techniques

b. Eliminate caffeine, cigarette smoking,
alcohol intake and spicy foods

c. High fat, high carbohydrate

Medical Treatment:
Antacids - avoid administration
within 1-2 hr of other oral meds
- frequent administration ac, pc,
hs
H2 Antagonists - with meals/pc

Anticholinergics

Prostaglandin Analogs -
**misoprostol** & ACID PUMP
INHIBITORS - **inhibits the enzyme
that produces gastric acid

H Pylori
Metronidazole
Omeprazole








Bleeding



Malignancy:








Melena is more common than
hematemesis


Not possible



Hematemesis is more
common than melena



Possible
Tetraycline/Clarithromycin
Cytoprotective binds with
diseased tissue and provides a
protective barrier to acid

Surgical Treatment
1. Vagotomy
2. Gastric Resection-
Gastroduodenostomy;
Gastrojejunostomy



GASTRIC CANCER


Incidence:
f. Common in men than women
g. History or presence of Pernicious Anemia
h. Often develops with the occurrence of atrophic gastritis
i. Low-socio economic status; live in urban area
j. Exposure to radiation or trace metals in soil

Cause: Helicobacter Pylori

Clinical Manifestations:
a. Palpable mass
b. Ascites
c. Weight loss
d. Dysphagia
e. Indigestion and anorexia
f. (+) high lactate dehydrogenase level in gastric juice

Diagnosis: GIT x-ray, gastroscopy

Treatment: Chemotherapy, radiation therapy, gastric resection

Nursing Intervention: Same as with patients with ulcer, emotional support, pre and post-operative health teaching

3.2. Disorders of the Large and Small Bowel

VIRAL AND BACTERIAL GASTROENTERITIS/ DYSENTERY


Gastroenteritis - Inflammation of stomach and intestine usually the small bowel.
S/S: abdominal cramps, diarrhea, vomiting, fever, severe fluid and electrolyte loss,
mild to severe temperature
Cause: Viral

Dysentery - Inflammation in the colon
S/S: severe bloody diarrhea and abdominal cramping, severe fluid and electrolyte loss,
mild to severe temperature
Cause: Bacterial ( E.coli nd/or shigella, salmonella, Clostriduum difficile from
antibiotics)

Risk Factors:
o Poor food handling
o Poor sanitary conditions
o Overcrowding
o Food remaining on high temperature making organisms incubate and colonize easily.

Management:
o Replace fluid loss
o Anti-infective Agent (e.g. Metronidazole spec for amoebiasis, Bactrim)



Nursing Intervention:
o Measure intake and output
o Administer medications
o Replace fluids



APPENDICITIS

o Inflammation of the vermiform appendix

Incidence: Common between 20-30 yrs. old

Cause: Fecalith (stone or calculus in the appendix) .-> Kinking of the appendix
Fibrous condition in the bowel wall -> Bowel adhesion

S/S: Pain starts in the epigastriium the shifts to the the right lower quadrant
Guarding of painful area
Keeps legs bent to relieve tension
May have vomiting, loss of apetite, low grade fever, coated tongue and halitosis

Diagnosis: Increased WBC, (+) pain at Mc Burneys point (RLQ)

Treatment: Appendectomy

Nursing intervention:
Assess the VS and pain scale carefully
Observe for symptoms of peritonitis , Pre & post-operative care



PERITONITIS


o Inflammation of the peritoneal membrane
o Cause:
Gangrenous cholecystitis Ileitis
Ruptured gallbladder Appendicitis with perforation
Perforated gastric cancer Ruptured retroperitoneal abscess
Perforated Peptic ulcer Strangulated hernia
Ruptured spleen Salpingitis
Acute pancreatitis Septic Abortion
Penetrating wound Ruptured bladder
Ulcerative colitis Puerperal infection
Gangrenous obstruction of the bowel Iatrogenic Cause
Perforated diverticulum

o Signs and Symptoms:
Localized pain
Abdominal rigidity
Increased pain upon movement
Nausea, vomiting (N/V)
Absence of bowel sounds
Shallow respirations
Increased WBC , dilation and edema of intestines revealed in GIT x-ray

o Medical Management:
NGT: Lavage to relieve pressure in the abdomen
Fluid & electrolyte replacement

o Surgical Treatment:
Appendectomy or Exploration of the abdomen with drainage

o Nursing intervention:
Careful assessment of history, V/S, fluid & electrolytes




Pre & Post-operative Care

c. Inflammatory Bowel Disease:


ULCERATIVE COLITIS & CHRONS DISEASE


CHRONS DISEASE ULCERATIVE COLITIS

Pathology & Anatomy




Etiology


Onset

Course of Disease

Rectal bleeding

Anorectal fistula

Other S/S:







Medical Treatment






Surgical Treatment


Nursing interventions:

Involves primarily the ileum & right colon
Distribution of dse is segmental
Malignancy is rare


May be genetic


Usually in the 30s

Slowly progressive

Occasional

Common

Abdominal pain
Weight loss
Diarrhea soft or semi-liquid
Pain in RLQ, cramping, tenderness,
flatulence, nausea (mimics Appendicitis)


Replacement of fluid loss
Anti-diarrheal: Diphenoxylate HCL (Lomotil) ;
Loperamide HCL (Imodium)

Total Parenteral Nutrition

Bowel Resection, Ileostomy


Assess Intake and output, weight
Emotionla support
Client teaching regarding surgery

Post-op intervention:
Observation of the stoma
Teach client re: self-care


Mucosal ulceration of lower colon and
rectum
Distribution of dse is continuous
Malignancy may occur after 10 years

May be caused by infection or alteration in
immunity

Young adults (20-40)

Remissions and relapses

Common

Rare

Rectal bleeding, diarrhea (20 stools/day or
more); Stools may occur with blood or pus,
weight loss
Urgency, cramping,
Pain LLQ, abdominal distention, emotional
stress.


Same as Chrons Dse






Bowel Resection, Ileostomy



Same as Chrons Dse




HERNIA


-An abnormal protrusion of an organ or tissue through the structure that contains it.
- Frequently a congenital occurrence or acquired weakness of the abdominal muscles

Types:
1. Indirect Inguinal Hernia
2. Direct Inguinal Hernia
3. Femoral Hernia
4. Umbilical Hernia
5. Incisional Hernia
Medical Treatment: Use of TRUSS if hernia is not strangulated or incarcerated.

Surgical Treatment: Herniorrhaphy

Nursing Intervention: Pre & Post-operative Care
Post-op Care:
a. Make sure the client voids after surgery, urinary retention is common
after herniorrhaphy
b. Resume diet as tolerated by the patient
c. Ice pack over the incisional site to control pain and swelling
d. Instruct patient to avoid heavy lifting from 4-6 weeks post surgery

DIVERTICULUM

Diverticulum an outpouching of intestinal mucosa through the muscular coat of the large
intestine (most commonly the sigmoid colon)
Diverticulosis refers to the presence of non-inflamed out pouching of the intestine
Diverticulitis inflammation of a diverticulum

Incidence: > 45 yrs. old ; Male & Female

Etiology: Lower fiber diet which causes bulk in stools which may cause intraluminal pressure in the bowel causing diverticula

Risk factors: Chronic Constipation

S/S:
Left Quadrant Pain
Anorexia
Increased flatus
Low grade fever
(+) rectal mass on digital rectal examination

Medical Intervention: High-fiber diet and laxatives
NGT insertion to relieve pressure
Control inflammation through antibiotics and advise patient to:
a. Avoid activities that may increase abdominal pressure
(bending, lifting, etc)
b. Intake of 6-8 glasses of water a day
c. Reduce weight if obese

Surgical Intervention:
Indicated for those who developed complications as manifested by hemorrhage, abscess, perforation and obstruction.
o Colon resection with colostomy

Indications

Nursing Intervention

Colostomy
o Involves the large
bowel (colon)

o stool is semi-formed


o Inflammatory / obstructive
process of the lower intestinal
tract
o Trauma
o Rectal or sigmoid cancer
o Diverticulum


1. Emotional support
2. Psychological
Support
3. Heath Education
regarding:
a.surgery (ileostomy/colostomy)
b. Self-care
Ileostomy
o Involves the small
bowel (ileum)
o stool is in liquid form

o Chrons Disease
o Ulcerative Colitis










b. Hirschprungs Disease and Megacolon

Congenital absence of parasympathetic ganglion

Clinical Manifestations:
o

NB fail to pass meconium 24 hrs after birth
o

Older child recurrent abdominal distention, chronic constipation, ribbon-like stool, diarrhea, emesis w/ bile stain
Treatment:
a.

Colostomy
b.

Bowel Resection
c.

Cleansing Enema

Post-op Nursing Intervention;
a.

Teach colostomy care- check color of stoma (should be bright leg)
b.

Check dressing
c.

Monitor intake & output
d.

Avoid incision by keeping diapers low
e.

10-11 yr. old child can already take care of his/her own stoma.

c. Hemorrhoids
o Peri-anal varicosities which is either internal or external

o Types:
a. Internal varicosities above the mucocutaneous border covered by the mucous membrane.
b. External Hemorrhoids- varicosities below the mucocutaneous border covered by the anal skin.

Incidence: Both male and female aged 20-50 y/o.
Pregnancy, CHF, Prolonged sitting or standing, portal hypertension

Risk factors: Increased abdominal pressure, constipation, straining during bowel movement

S/S: Internal bleeding and renal prolapse, bleeding and rectal itching
External enlarged mass at the anus

Present symptoms in both internal & external: Bright red (blood) stain in stool or tissue, Pain

Medical Intervention:
a. Treat constipation
b. Relieve pain through heat application / Siths bath

Surgical Intervention: Hemorrhoidectomy, Sclerotheraphy, Rubber band ligation, Laser Surgery, cryosurgery

d. Fistula-in-ano
Tiny, tubular fibrous tract that extends into the anal canal
May develop from trauma, fissures or regional enteritis
Fistulectomy is recommended.

3.3. Abdominal Trauma :

a. Blunt Trauma injury like vehicular accident
b. Penetrating Abdominal Trauma stab wound

D. DISTURBANCES IN FLUIDS AND ELECTROLYTES

Fluid Content in the Human Body :
a. Women - 50-55% of body weight is water
b. Men - 60-70% of body weight is water
c. Infant - 75- 80% of body weight is water
d. Elderly - 47% of body weight is water

Electrolytes in the Human Body:
a. Sodium (Na) - 135-145 mEq/L
b. Potassium (K) - 3.5 5.5 mEq/L
c. Chloride (Cl) - 85-115 mEq/L
d. Bicarbonate (HCO3 ) - 22-29 mEq/L

Functions of the Fluid & Electrolytes in the Human Body:
a. Regulates acid-base balance in the body
b. Maintains fluid volume
c. Regulates exchange of water between fluid compartments

Actions of the Fluids & Electrolytes
a. Diffusion fluids move from area of higher concentration to an area of lower concentration
b. Osmosis - fluids move from an area of lesser concentration to a higher concentration
c. Filtration fluids and substances moves from higher hydrostatic pressure to lesser hydrostatic pressure.

Intravenous Solutions Used to correct imbalance:
a. Isotonic 0.9 NSS, D5W
b. Hypertonic has greater concentration of solis substances than the fluid substances
e.g.Total Parenteral Nutrition, D50
c. Hypotonic has fewer solid and has higher fluid content, e.g. 0.45 NaCl


System of Fluid Balance in the body:
a. Kidneys responsible in controlling the balance of fluid & electrolytes
b. Lungs- controls the Carbondioxide levels in the body and water vapor
c. Skin means of elimination of fluid in the body through perspiration
d. Endocrine Controls hormones which regulates normal functioning of systems

Imbalances in Fluids & Electrolytes

Fluid Volume Excess Fluid Volume Deficit

Cause

fluids exceeds the normal volume the body
needs
- physiologic or over hydration as in IV
therapy

fluids and/or electrolytes are loss
physiologic or dehydration
Illness:
Renal Disease
Neurologic Diseases
Congestive Heart Failure
Addisons Disease


Renal Disease
Diarrhea
Post-operative conditions
Burns
Trauma
GIT Suction/Drainage

Clinical Manifestations

Weight gain
Edema
Flushed skin
Tachycardia
Increased BP, RR
Rales
Neck Vein distention
Increased Central Venous Pressure
Decreased Hct
Urine output: > 1,500 ml/day

Weight loss
Dry skin and mucous
Membrane
Tachycardia (same w/ excess)
Poor skin turgor
Decreased urine output
Decreased Central Venous Pressure
Increased hematocrit
Urine output: < 30 cc/hr
( Normal Urine Output =30 cc/hr)


Nursing Interventions

Monitor vital signs
Monitor I & O
Fluid restriction
Low sodium diet
Weight daily
Prevent skin breakdown- skin is
fragile
Keep client in Semi-fowlers

Monitor vital signs
Monitor I & O
Replace fluids, Rehydration
Weight daily
Administer medications as ordered (
depending on electrolytes loss)
Encourage proper nutrition an fluid
intake
position to establish good gas
exhange
Administer Diuretics as ordered-
Lasix (Furosemide)



Sources of Electrolytes:

Electrolyte Food source
Potassium Bananas, peaches, melon, prunes, raisins, apricots, tomato, nuts & vegetables, red
meat, turkey
Sodium Iodized or table Salt
Magnesium Peas, beans, nuts, fruits
Calcium Milk, cheese, sardines, fish


4.1 Genitourinary & Renal Problems
Renal Function Tests Normal Values:
a. Blood Urea Nitrogen (BUN) 10-20 mg/dl
b. Serum Creatinine- 0-1 mg/dL
c. Creatinine Clearance 100-120 ml/ minute (24 hr. urine collection)
d. Serum Uric Acid -3.5 -7.8 mg/dL
e. Urine Uric Acid 250-750 mg/ 24 hrs. (24 hr. urine collection)



4.1.2. Cystitis / Urethritis/ Urinary Tract Infection usually caused by E.Coli

Signs & Symptoms
a. Frequency & Urgency of urination
b. Dysuria
c. Suprapubic pain
d. Hematuria
e. Fever, chills
f. Cloudy urine

Nursing Considerations:
a. Collect urine for testing
b. Antibiotic treatment, as ordered
c. Force fluids
d. Good hygiene

4.1.3. Glomerulonephritis inflammatory damage of the glomeruli usually Streptococcus

Signs & Symptoms:
Hematuria, proteinuria, fever, chills, weakness, nausea, vomiting
Edema
Oliguria
HPN
Headache
Increased Urea Nitrogen
Flank Pain
Anemia

Nursing Considerations:
a. Penicillin, as ordered
b. Proper dietary intake
c. Sodium & fluid restriction
d. Bed rest


4.1.4. Nephrotic Sydrome glomeruli disorder due to other diseases like DM, SLE, etc.

Signs & Sypmtoms:
a. Proteinuria
b. Hypoalbunimemia
c. Hyperbilirubinemia
d. Edema

Nursing Considerations:
a. bed rest
b. high calorie, high protein, low sodium
c. Monitor I & O
d. Protect from infection
e. Administer meds as ordered: Diuretics, Steroids, Immunosuppresiove agents,
anticoagulants

4.1.5. Urolithiasis - stones in the urinary system

Signs & Symptoms:
a. Dull aching pain
b. Nausea, vomiting, diarrhea
c. Hematuria
d. UTI symptoms

Nursing Considerations:
a. Force fluids: at least 3L of water in a day
b. Strain Urine for stones
c. Administer meds as ordered

4.1.6. Acute Renal Failure sudden and reversible malfunction of the kidney due to trauma, allergies, stones or benign
Prostatic hyperplasia

Signs & Symptoms: 3 Phases
a. Oliguric Phase sudden , (+) edema
- urine is less than 400 cc in 24 hrs.
b. Period of Diuresis urine is 1000 ml in 24 hrs and is diluted
c. Recovery Period

Nursing Intervention:
a. Treat cause of sudden occurrence
b. Maintain Fluid & electrolyte balance
c. Prevent hypokalemia
d. Administer insulin or IV glucose as ordered to promote potassium absorption
e. Proper diet :
Oliguric low CHON, High CHO, high fat, less potassium
Diuresis high CHON, high calorie, less fluid
f. Weigh daily
g. Monitor I & O
h. Dialysis if indicated
i. Psychological & emotional support

4.1.7. Chronic Renal Failure progressive failure of kidney function which may result to death, caused
by chronic gomerulonephritis (CGN), pyelopnephritis, DM, uncontrolled HPN

Signs & Symptoms:
a. fatigue
b. Headache
c. Gastrointestinal symptoms
d. HPN
e. Irritability
f. Convulsions
g. Anemia
h. Elevated BUN, crea, sodium, potassium

Treatment:
Dialysis
Renal Transplant

Nursing Considerations:
a. Maintain fluid & electrolyte balance
b. Bedrest
c. Diet: low protein, low sodium, high CHO and vitamins
d. Control HPN
e. WOF cerebral irritation

4.1.8. Benign Prostatic Hyperplasia enlargement of the prostate with unknown etiology usually in
older males
Signs & Symptoms:
Difficulty in urinating
Nocturia, hematuria, dribbling sensation



Surgical Treatment:
Prostatectomy

Post-operative Nursing Consideration:
a. Observe for shock and hemorrhage
b. Bladder Drainage; monitor bladder irrigation
c. Avoid lifting heavy objects x 6 weeks and avoid strenuous activities
d. Increase fluid intake
e. Decrease pain, administer meds as odered

TREATMENT FOR GENITOURINARY PROBLEMS:
1. Dialysis
a. Hemodialysis
Process of cleansing the blood of waste products which the GUT is unable to eliminate
Cathether inserted via a small incision on the neck (intrajugular), arms or at the femoral area.

b. Peritoneal Dialysis
Use of peritoneum via a catheter for proper exchange of fluids and electrolytes and drainage of
fluids
Catheter inserted just below the umbilicus with small incision

c. Continuous Ambulatory Peritoneal Dialysis

Nursing Interventions:
a. Weigh daily
b. Monitor vital signs
c. Maintain asepsis at all times
d. Record intake and output
e. Monitor for complications: Bleeding, peritonitis, abdominal pain, dyspnea, bowel
perforation
2. Urinary Tract Surgery
a. Transurethral Removal of the Prostate
b. Prostatectomy

Nursing Interventions:
Weigh daily , monitor I&O
Monitor vital signs
Maintain asepsis at all times
Monitor for complications: Bleeding, peritonitis, abdominal pain, dyspnea, bowel
Replace fluids
Proper irrigation


3. Kidney Transplant

KIDNEY DISEASE IN THE PHILIPPINE HEALTH SITUATION

6,000 new cases of renal disease per year
Affects all ages
Adult: End-Stage Renal Disease (ESRD)
Children and young: Chronic Glomrulonephritis
Causes:
1. Chronic Glomerulonephritis 47%
2. Chronic Pyelopnephritis 17%
3. Diabetes Mellitus- 13%
4. Hypertensive Nephrosclerosis- 5%

Kidney Disease Prevention:
1. Good Nutrition
2. Clean Environment
3. Early detection of of the disease
4. Thorough urinary screening of asymptomatic children
5. Increase casefinding and treatment for chronic glomerulonephritis
6. Good glycemic control (w/ DM)
7. Optimum Blood Pressure Control

Nursing Health Education:

1. Increase awareness and prevent renal disease:
Adequate water intake
Balanced diet
Good personal hygiene
Regular exercise
Regular BP check-up
Complete immunization for infants and children
Proper management of throat and skin infections
Yearly urinalysis

2. Increase awareness of signs & symptoms of kidney disease as edema and HPN

3. Routine screening for UTI, diabetes and kidney disease

E. DISTURBANCES IN CELLULAR FUNCTIONING

5.1 CANCER

o Abnormal growth of tissues
a. Carcinoma - epithelial cells lining the internal and external surfaces of the body.
b. Leukemia - cancer from blood-forming organs
c. Lymphoma cancer from reticulo-endothelial lymph node organs
d. Sacrcoma- cancer from connective tissues

Cancer in the Philippines:
o Ranks third in leading cause of morbidity and mortality
o 75% of cancers occur at age 50 y/o

Staging of Tumors
a. Extent of tumor
T= primary tumor
N= regional nodes
M= metastasis

b. Extent of Malignancy
T0 = no evidence of primary tumor
TIS= Carcinoma in Situ
T1, T2, T3, T4 = progressive tumor in size and involvement
TX = tumor cannot be assessed

c. Involvement of Regional Nodes
NO = regional lymph nodes not abnormal
N1, N2,N3, N4 = increasing degree of abnormal regional lymph nodes

d. Metastatic Development
MO= no evidence of distant metastasis
M1, M2, M3 = increasing degree of distant metastasis

Clinical Manifestations of Tumor Presence
(based on Community Health Nursing Services in the Philippines by the DOH)

C Change in bowel or bladder habits Ex. Gastric Ca, Colon Ca, Rectal Ca , Renal Ca,
Prostate Ca
A A sore that does not heal Ex. Laryngeal Ca
U Unusual bleeding or discharge Ex. Uterine Ca
T Thickening or lump in breast or elsewhere Ex. Breast Ca, Hodgkins Lymphoma
I Indigestion or difficulty in swallowing Ex. Esophageal Ca
O Obvious change in wart or mole Ex. Melanoma, Squamous cell Ca
N Nagging cough or hoarseness Ex. Lung Ca

U Unexplained Anemia
S Sudden uexplained weight loss Most Ca conditions

Risk Factors
Age Health Habits
Sex Family History
Race Socio-Economic Status
Occupation Lifestyle
Cancer Therapy
a. Surgery
b. Chemotherapy chemical/ medication
c. Radiation Therapy electromagnetic rays destroys cancer cells
d. Palliative/ Supportive Care- for end-stage or terminal stage
- given if chemo, surgery or radiation therapy cannot assure treatment of
the patient ; it is a holistic care for the patient and family
- management o f care is geared towards a symptom-free individual with
psychologic and spiritual support

Cancer Prevention & Early Detection


Type of Cancer

Early Prevention

Early Detection


Oral Cancer

Avoid Smoking tobacco, Betel quid
Nganga chewing, Proper cavity
and dental chewing


Thorough dental check-up each year

Breast

No conclusive evidence for early
prevention

Monthly self-exam and annual exam with physician;

Mammography:
o Initially at age 40 and then 1-2 yrs thereafter
o High risk women- should consult a doctor
before age 40


Lung


Avoid smoking

Annual check-up

Uterine / Cervix

Clean, safe sex
Single partner reduces risk

Regular pap smear: Once sexually active then every 3
years if findings are normal


Liver

Hepa. vaccine, Minimal alcohol
intake, Avoid moldy foods

None

Colon and Rectum

Maintenance of a high fiber and low
fat diet

Regular medical check-up after 40 years, yearly occult
blood tests in stools, rectal exams and sigmoidoscopy

Skin

Avoid excessive sun exposure

Self skin assessment

Prostate

No conclusive evidence for early
prevention

Rectal Exam

Nursing Intervention

a. Assist the patient in maintaining self-dignity and integrity by continued and sustained communication
and contact
b. Allow patient to ventilate feelings such as fear, anger, indifference
c. Make arrangements for spiritual consolation
d. Assist in rehabilitation even before treatment and until she recovers and adjust to the society
e. Collaborate with other health workers for the patients holistic needs
f. Home visits and education about the clients condition, course of treatment and alternatives

Priorities for Health Supervision:
a. Newly diagnosed cases
b. Post-operative Cases
c. Indigent Cases
d. Terminal Cases

5.2 HEMATOLOGIC PROBLEMS

Normal Values to Remember:

Blood Component Normal Values

RBC red blood cells

Female: 4.2 5.4 x 10
6
Male: 4.7 6.1 x 10
6

Hgb - hemoglobin

Female: 11.5 15.5 g/dL
Male: 13.5 17.5 g/dL

Hct - hematocrit

Female: 36 48%
Male: 40 -52%

WBC white blood cells

4,500 11,000/ mm
3

PC- Platelet count

150, 000 400,000 / mm
3


ANEMIA

Causes:
a. Sudden or Chronic blood loss
b. Abnormal bone marrow function
c. RBC fails to mature adequately

Signs & Symptoms:
Fatigue, Weakness, Dizziness, Pallor, Decreased RBC, hemoglobin & hematocrit

Types of Anemia:

a. Hypoproliferation Anemia bone marrow fails to produce adequate blood cells
a. Iron Deficiency Anemia nutritional deficiency, blood loss
b. Aplastic Anemia - due to radiation, drugs, toxin
c. Anemia due to Renal Disease

Clinical Manifestations:
Hypoxia
Prone to infection
Fatigue
Easy bruising

Nursing Intervention:
Proper nutrition
Psychological support
Protect against infection and injury

b. Megaloblastic Anemia due to previous gastric surgery, malabsorption or atrophy of the
gastric mucosa

Pernicious Anemia Vit. B12 and Folic acid deficiency in gastric juice

Clinical Manifestations:
Paresthesia
Tingling or numbness of extremities
Gait disturbances
Behavioral Disturbances

Nursing Intervention:
Intake of Vit. B12 following this regimen:
o 3x a week for 2 weeks, then
o 2 x a week for 2 weeks, then
o Once a month
Protect lower extremities
Rest in non-stimulating environment





c. Hemolytic Anemia
Sickle Cell Anemia- defective hemoglobin, turns to sickle cell when oxygen in venous blood is low
Thalassemia
Glucose-6 Phosphate Dehydrogenase Deficiency

Clinical Manifestations:
Thalassemia & G6PD usually asymptomatic
Sickle Cell Anemia:
o Severe Pain
o Swelling
o Fever
o Jaundice
o Prone to infection

Nursing Intervention:
Proper oxygenation
Hydration
Analgesics
Adequate Rest
Refer to genetic counseling
Avoid cold places to prevent sickle cell proliferation

LEUKOCYTOSIS & LEUKEMIA

Leukocytosis increase level of WBC, persistent increased can be malignant

Leukemia - proliferation of neoplastic white blood cells in the bone marrow affecting the
different tissues and organs in the body

Acute & Chronic Myeloid Leukemia (AML / CML)
Acute & Chronic Lymphocytic Leukemia (ALL / CML)
Angiogenic Myeloid Metaplasia (AMM)

Clinical Manifestations:
Fever
Prone to Infection
Pain
Weight Loss
Fatigue

Nursing Interventions:
Energy conservation
Reverse Isolation
Blood Transfusion

POLYCYTHEMIA neoplasm of myeloid cells
Clinical Manifestations:
Dizziness, headache, tinnitus, fatige, paresthesia, blurred vision, atherosclerosis

THROMBOCYTOPHENIA - Increased Bleeding Tendencies

LYMPHOMAS neoplasm of lymphatic cells
Hodgkins Lymphoma
Non-Hodgkins Lymphoma
Multiple Myeloma
Thrombocytophenia low platelet , bleeding

Management: Chemotherapy, Blood Transfusions, Reverse Isolation, Radiation therapy,
Steroids

Nursing Interventions:
Emotional Support
Reverse isolation
Adequate Rest and Nutrition
Strict Medication Regimen


BLOOD TRANSFUSION

Types of Blood Components Transfused
1. Whole Blood
2. Packed Red Blood Cells
3. Fresh Frozen Plasma/ Plasma Concentrate

Transfusion Complications
1. Non-hemolytic reaction- Fever
2. Hemolytic Reaction- life threatening: fear, chills, backpain, nausea, chest tightness, dyspnea and anxiety
3. Allergic reaction urticaria, flushing, itching
4. Hypervolemia neck vein distention, dyspnea, orthopnea, tachycardia, sudden anxiety

Diseases Transmitted through Blood Transfusion
Hepatitis B or C , AIDS / HIV, Cytomegalovirus

Nursing Interventions:

1. Check name, ID, blood type, expiration, serial #
2. Take baseline vitals signs
3. Blood pack should be at room temperature
4. Monitor for transfusion reaction
Allergic (pruritus, respiratory distress, urticaria)
Hemolytic (low back pain, fever, chills)
5. Treat transfusion reaction, if present symptomatic treatment


F. NEUROLOGIC DISTURBANCES

I. Central Nervous System:

a. Brain
b. Spinal Cord

II. Peripheral Nervous System

a. Cranial Nerves 12 pairs
b. Spinal Nerves 31 pairs
Cervical 8
Thoracic 12
Lumbar 5
Sacral 5
Coccygeal - 1
c. Autonomic Nervous System
Sympathetic Nervous System
Parasympathetic Nervous System


The Cranial Nerves:
o Oh, Oh, Oh, To Touch And Feel A Girls Veil So Heaven

I Olfactory Smell
II Optic Visual Acuity
III Oculomotor Pupil constriction and dilation
IV Trochlear Eye movement: Inferior and medial
V Trigeminal Jaw muscles
VI Abducens Eye movement: Lateral directions
VII Facial Symmetrical facial movement, Client identifies
taste, Eyelid reaction to stimulus
VIII Auditory Hearing Acuity
IX Glossopharyngeal Gag Response
X Vagus Ability to speak clearly
XI Spinal Accessory Shoulders ability to resist against pressure
XII Hypoglossal Tongue at midline

Neurologic Status:

a. Conscious- alert, attentive, and follows command
b. Lethargic- drowsy but awakens; follows command, but slowly and inattentively
c. Stuporous - arouses to vigorous and continuous stimulation
-response may be an attempt to remove the painful stimulus.
d. Coma. no sounds, no movement

THE GLASGOW COMA SCALE

- An assessment tool measuring the individuals neurologic status specifically the spontaneity of the clients eye
movement , speaking ability and motor abilities in response to a stimuli.

Perfect score is 15 points - Spontaneous/ Normal eye, motor and verbal response
Lowest score is 3 points - No response



Eye Opening
Response
Points
a. Spontaneous 4
b. To speech 3
c. To pain 2
d. No response 1



Motor
Response

a. Obeys verbal commands 6
b. Localizes pain 5
c. Flexion: no withdrawal 4
d. Flexion: abnormal (decorticate) 3
e. Extension: abnormal (decerebrate) 2
f. No response to pain on any limb 1



Best verbal
response

a. Oriented 5
b. Able to Converse 4
c. Inappropriate speech 3
d. Makes incomprehensible sound 2
e. No response 1





Example:


Patient s conscious, coherent. Can tell
where he is, can look at surroundings,
can raise hands when asked to, and can
express self through words, answer
questions appropriately.

Eye slightly opens when name is called ;
No movement/response when skin is
Pinched ;
When calling the nurse: can only say
ne.ee. sound


GCS Scoring:

Eye opening = 4
Motor Response = 6
Verbal Response = 5

GCS Score = 15



GCS Scoring:

Eye opening = 3
Motor Response = 1
Verbal Response = 2

GCS Score = 6



o A sudden disruption of blood supply to the brain which may lead to temporary or permanent dysfunction.

Risks Factors: HPN, Obesity, peripheral vascular disease, obesity, aneurysm

Signs & Syptoms:
a. Speech problem / Aphasia - a loss or impairment of the ability
to produce and/or comprehend language
b. Hemiparesis- weakness of one side of the body
c. Hemiplegia - total paralysis of the arm, leg and trunk on the
same side f the body.
d. Decreased awareness of body space
Types of stroke:

1. Transient Ischaemic Attack (TIA)
- short-term stroke that lasts for less than 24 hours ( seconds or minutes in a day)
- oxygen supply to the brain is restored quickly
- transient stroke needs prompt medical attention as it is a warning of serious risk of
a major stroke.

2. Cerebral thrombosis
- a blood clot (thrombus) forms in an artery (blood vessel) supplying blood to the brain.
- brain cells are starved of oxygen.

3. Cerebral embolism
- blood clot that forms and then travel to the brain.

4. Cerebral hemorrhage
- occurs when a blood vessel bursts inside the brain and bleeds (haemorrhages). With a hemorrhage,
extra damage is done to the brain tissue by the blood that seeps into it.

Nursing Interventions:

1. Maintain adequate airway
2. Monitor neuro vital signs: Vital signs and Glasgow coma scale including intake and output
3. Maintain fluid & electrolyte balance





CEREBROVASCULAR ACCIDENT (CVA)
Stroke
SPINAL CORD INJURY
Definition: A damage in the nerve structure causing dysfunction resulting to paralysis, sensory loss and altered activity.

Cause:
Vehicular accidents, Violence, Falls,
Sports, Infection, Tumor

The Spinal Nerves:
1. Cervical Nerve
2. Thoracic Nerve
3. Lumbar Nerve
4. Sacral Nerve

Etiology:
1. Spinal Shock (Areflexia)
2. Autonomic Hyperreflexia
- Injury in T6 and above
- Life-threatening

Nursing Interventions:
1. Immobilization specially after injury or trauma
2. Maintain respiratory function, ABC
3. Bladder & bowel management
4. Rehabilitation





Nerves

Level

Body part affected

Spinal Cord
Injury Effect


Cervical Nerve

Injury causes
Quadriplegia/
Tetraplegia

C1

Head & Neck

Paralysis below neck; impaired breathing, bowel & bladder incontinence,
sexual dysfunction
C2
C3
C4
Diaphragm

Shoulder elevation possible, ventilation support
C5
C6 Deltoid, biceps
Elbow, upper arm, wrist movement
C7 Wrist Extenders
C8 Triceps


Thoracic Nerve

Injury causes
Paraplegia


T1


Hand



Loss of hand control, Paralysis below waist





T2
T3
T4
Chest Muscles
T5
T6
T7
Abdominal
Muscles

Trunk and Abdominal control
T8
T9
T10
T11
T12










Lumbar Nerve

Paralysis of legs;
loss of bladder and
bowel control

L1


Leg muscles

Hip adduction impaired
L2

Knee and ankle movement impaired
L3
L4
L5


Sacral Nerve
Sexual, Bladder &
Bowel conrol

S1
Bladder & Bowel control

Bladder/Bowel Incontinence,etc
S2
S3
S4 Sexual Control Decrease sensation in the peineum
S5


PARKINSONS DISEASE

Definition: A disorder affecting control and regulation of movement
- Unilateral flexion of arms, shuffling gait, difficulty in walking, weakness, disability

Clinical Manifestations:

a. Rigidity
b. Involuntary body tremors
c. Hips and knees flexion
d. Masklike facial expression
e. Slurred speech
f. Drooling
g. Constipation
h. Depression
i. Retropulsion, propulsion

Medical Management: Anti-parkinsonian Agent: Levodopa
Anti-cholinergic: Cogentin

Surgical Management: Stereotaxic Thalamotomy surgery of the thalamus to treat disorder

Nursing Interventions:
a. Rehabiltation exercise
b. Speech therapy
c. Diet: Low CHIN in am, high CHON in PM
d. High fiber foods to promote bowel elimination
e. Prevent Injury fall, etc

MYASTHENIA GRAVIS

Definition: Severe weakness of one or more groups of skeletal muscles;
Severe weakness of the neuro functions most commonly affecting the
Seventh cranial nerve- Facial Nerve

Clinical Manifestation:
1. Mask-like facial expression
2. Diplopia- double-vision
3. Ptosis- difficulty opening of the eye
4. Dyphagia

Management:
a. Pyridostigmine Bromine (mestinon)
b. Ambenomium Chloride
c. Steroids Prednisone
d. Atrophine Sulfate

Nursing Interventions: Avoid fatigue, Administer meds as ordered, Avoid neomycin and morphine

G. DISTURBANCE IN AUDITORY AND VISUAL FUNCTION
CATARACT
Definition: - the eye lenses becomes thick and unclear or yellowish.

Clinical Manifestations:
2. Gradual visual loss.
3. Hazy vision / Yellowish haze
4. Whitish to yellowish eyelense.

Surgical Treatment: Cataract extraction

Drug:
1. Mydriatrics - causes dilation of pupils; increases intraocular pressure (IOP)
a. Atrophine Sulfate
b. Phenylephrine Hydrochloride

2. Cyclopegics decreases ciliary muscle accomodation


Side effects: blurred vision, increase BP

Nursing Intervention:
1. Monitor BP; avoid use to patients with HPN
2. Teach client that blurring of vision may be experienced.
3. Post-op intervention:
keep eye covered
head of bed elevated at 30-45 degreed, supine position
Avoid bending or lifting heavy objects, coughing and sneezing as it may further increase
IOP

GLAUCOMA
- A non-curable condition of the eye due to increase in intraocular pressure causing
deterioration of the optic nerve.

2 types of Glaucoma:

1. Acute or Closed- Angle Glaucoma
a. Rainbow around lights
b. Pain around the eye
c. Cloudy and blurred vision
d. Nausea & vomiting
e. Dilation of pupils

2. Chronic or Open-Angle Glaucoma
a. Halo around lights
b. Progressive loss of vision
c. Tired feeling in the eye
d. Slowly diminishing peripheral vision

Surgical Management:
1. Trabeculectomy
2. Thermosclerectomy
3. Iridenclesis

Drugs:
Miotics causes constriction of pupils

1. Pilocarpine hydrochloride - Drains aqueous humor
2. Acetazolamide decreases production of aqueous humor
3. Mannitol reduces IOP
4. Isosorbid also decreases production of aqueous humor

Nursing Intervention:
1. Administer drugs as ordered
2. Teach client that glaucoma can be controlled but not curable (even surgery cant cure the disease)
3. Encourage moderate exercise
4. Avoid straining of bowel
5. Encourage low residue, high fiber diet


H. MUSCULOSKELETAL DISTURBANCES


JOINT DISORDERS

RHEUMATOID ARTHRITIS

OSTEOARTHRITIS

Definition

A systemic inflammatory disorder of connective tissues
and/ or joints characterized by exacerbation &
remission.

Degeneration of the articular cartilage
Wear & Tear of joints

Kinds of Joints

Cervical, finger joints, ulnar, can also be involved:heart
and lung (as in rheumatic heart disease)

Weight-bearing joints: knees, hips, spine

Incidence

Chronic disease; early to mid-adulthood, common in
women

Older women

Clinical Manifestations

Synovitis
Pain relieved with rest
Intermittent bone pain, swelling, redness, warm
feeling due to vasodialtion and increased blood
flow
Pannus formation- granulation of tissue causing
destruction of adjacent cartilage, joints and bones
fatigue, anorexia, malaise, weight loss

Pain felt after activity

Management

Rest, exercise, ASA, NSAIDs, Steroids, heat

Balanced rest and activity, heat packs, steroids in joist
only

Drug: Steroid, ASA, Indomethacin, Phenylbutazone


Nursing Intervention

Maintain body alignment, Balance rest and exercise, proper diet




Gout / Gouty Arthritis
Defintion: painful metabolic disorder due to inflammation of the joints due to
high uric acid

Risk Factors: Hereditary, most common in men

Clinical Manifestations A salt of uric acid (Urate) crystallizes in soft and bony tissues causing local inflammation and
irritation.
Severe pain, usually in great toe
Red, painful and swollen joints
Tophi (crystal formation in joints) are palapated around great toes, fingers,
earlobes
Drugs: Allopurinol
NSAIDs Ibubrofen , Indomethacin
Probenecid
Colchicine
Sulfinpyrazone

Nursing Management:
a. Bedrest during attacks
b. Heat or cold compress
c. Increase fluid intake to flush out uric acid
d. Avoid eating organ meats, shellfish, sardines - - - food with high purine / uric acid content





































































Systemic Lupous Erythematosus (SLE)

Definition: Diffuse connective tissue disease affecting skin, joints, kidney, serous membranes of the heart and
lungs, lymph nodes and GI tract.

Risk factors: Children, middle-aged and elderly; hereditary

Clinical Manifestations: Butterfly rash in the face ( across both cheeks and nose)
Manifests symptoms same as that of arthritis and Raynauds

Management: NSAIDs
Steroids
Cytotoxic drugs - Azathioprine, Cyclophosphamide

Nursing Intervenions:
a. Avoid exposure to sunlight because symptoms aggravate symptoms or wear hats, umbrella or sunscreen
b. Adequate nutrition, rest and exercise
c. Stress management, if possible avoid stress


FRACTURE
Definition: A break in the continuity of the bones

Clinical Manifestations:

Pain Edema
Loss of function Spasm
Deformity Crepitus
False motion


















Management:
Hematoma around skin
Breaks for penetrating bone
fragments






















First Aid

1. Maintain airway and circulation
2. Immobilize joints that may be affected; Splint limb
3. Bring to nearest hospital/medical institution


Traction

-balanced pulling of the musculoskeletal structure to align bones; requires
countertraction

Closed Reduction

- external manipulation such as manually aligning bones by pulling. For patients
who have lower pain tolerance (elderly, children) reduction may be done under
sedation anesthesia.











Nursing Management:
1. Maintain positioning
2. For tractions maintain weights and counter traction
3. Clean wounds to prevent infection
4. Assess for VASCULAR OCCLUSION


5 Ps: 5 signs of Vascular Occlusion due to extremely tight casts / traction
a. Pain
b. Pallor
c. Pulselessness
d. Paresthesia
e. Paralysis


I. INTEGUMENTARY DISTURBANCES


Depth of Injury

Manifestation

Level of Skin Affected


First-degree

Painful, pink to reddish, subsides
quickly

Epidermis and part of dermis

Superficial

Second-degree

Pain, pink to red, with blisters (fluid
formation)

Epidermis and dermis hair follicle intact

Superficial partial
thickness; Deep partial
thickness

Third- degree

Reddish, brownish or whitish, painless,
eschar formation (Leather-like skin)

Epidermis, dermis, subcutaneous tissue

Full thickness

Fourth-degree

Epidermis, dermis, subcutaneous tissue;
fat, fascia, muscle and bone

Full thickness


Rule of Nines:
a. Head and Neck - 9%
b. Anterior Truck - 18%
c. Posterior Trunk - 18%
d. Arms - 9% each = 18%
e. Legs - 18% each = 36%
f. Perineum - 1%

100%











Open Reduction - internal manipulation of bones requiring surgical operation

Internal Fixation

- surgically applying screws, plates, pins, nails to align bones (opening of the skin
and exposing bones affected); skin is closed after the procedure.

External Fixation

- applying nails and metal screws to bones through the skin surface

Casts

- -a rigid mold used to immobilize an injured structure to promote healing

Burn
Rule of
Nines
Management:

First-Aid:
1. Burning person: Ask person to stop, drop and roll ( lie down and roll)
2. Burning person: Stop burning process such as wrapping the burning part with wet towel or blanket
3. Check airway
4. First-degree burn: Run cool water to affected area for 10 minutes

Hospital Interventions:
1. Check ABC, give oxygen and IV fluids
2. Assess clients data, history of injury (time, cause,etc)
3. Maintain asepsis- burn patients are very prone to infections
4. Medical Surgical Management:
a. Tetanus toxoid
b. Topical Anti-microbial agent: Silver Nitrate, Silver Sulfadiazine, Gentamicin Sulfate, Mafenide acetate
c. Debridement


Failure of the circulatory system to maintain adequate perfusion of vital organs.
Critically severe deficiency in nutrients, oxygen and electrolytes delivered to body tissues, plus deficiency in removal of cellular wastes,
resulting to cardiac failure
I. Stages of Shock
1. Non- progressive Stage
- Cardiac output is slightly decreased
- Body compensates

2Progressive Stage
- Compensatory mechanism is not adequate
- blood flow to the heart is not adequate thus heart begins to deteriorate

3. Irreversible Stage
- Inadequate tissue perfusion
- Cellular ischemia & necrosis lead to organ failure
II. Types of Shock



Cause Etiology

Hypovolemic Shock

due to inadequate circulating blood volume Blood loss: Massive Trauma, GI Bleeding,
Ruptured Aortic Aneurysm, Surgery, Erosion of
Vessesl due to lesion, tubes or other devices,
Disseminated Intravascular Coaguation
Plasma loss: Burns, Accumulation of intra-
abdominal fluid, malnutrition, severe dermatitis,
DIC
Crystalloid loss: Dehydration, Protracted Vomiting,
Diarrhea, nasogastric suction

SHOCK


Cardiogenic Shock


due to inadequate pumping action of the
heart because of primary cardiac muscle
dysfunction or mechanical obstruction of
blood flow caused by MI or valvular
insufficiency


Myocardial disease:
Acute MI, Myocardial Contusion

Cardiomypathies Valvular Disease or injury: Ruptured
Aortic Cusp, Ruptured Papillary muscle, Ball thrombus

External Pressure on the Heart interferes with heart filling
or emptying: Pericardial
Tamponade due to Trauma, aneurysm,
cardiac surgery, pericarditis, massive pulmonary
embolus, tension pneumothorax

Cardiac Dysrhtymias:
Tachyarrhythmias, Bradyarrythmias,
Electromechanical dissociation


3. Distributive Shock

a. Neurogenic Shock




b. Anaphylactic Shock




c. Septic Shock




- interference with nervous system
control of the blood vessels



-severe hypersensitivity reaction resulting
in massive systemic vasodilation



- systemic reaction vasodilation due to
infection



III. Signs of Shock

Anxiety BP- hypotension
Restlessness Pulse tachycardia, thready, irregular (Cardio.Shock)
Dizziness
Thirst
Respiration: increased depth, tachypnea, wheezing
(anaphylactic shock)
Fainting Temperature: cold clammy skin, elevated in anaphylactic
Pale skin, urticaria in anaphylactic shock LOC - could be alert, oriented, unresponsive
Oliguria, Slow capillary refill CVP below 5 cm H20 (hypovolemic)
- above 15 cms (cardio & septic)

IV. Nursing Care Management
GOAL: Promote venous return, circulatory perfusion

1. Position: Feet elevated with head slightly elevated also
2. Ventilation: loosen restrictive clothing, O2, monitor respiration
3. Fluids: IV, administer blood/plasma as ordered ( stop blood immediately in anaphylactic s.)
4. Vital signs: CVP, ECG, U.O.,Swan Ganz
5. Medications (depends on type)
6. Antihypotensive (epinephrine, norepinephrine, dopamine)



Spinal: Spinal anesthesia, spinal
cord injury
Vaso-vagal reaction: Severe pain,
severe emotional stress
Allergy to food, medicines, dye, insect bites or
stings

Gram-negative septicemia but also caused by
other organisms

7. Anti-arrythmics, Cardiac Glycosides, Antibiotics, Adrenocorticoids
8. Vasodilators (nitroprusside), Beta-adrenergic (dobutamine)
9. Mechanical support : Military Anti-shock Trousers(MAST)

IV. Effects of Shock in Different Organs


Respiratory System


Hypoxia
Lactic acid accumulates tissue necrosis

Cardiovascular System


Myocardial deterioration
Disseminated Intravascular Coagulation

Neuroendocrine System


Stage of resistance
o ADH is released causing kidneys to retain sodium and
water
o Increase in adrenocorticoid mineralcorticoid hormones


Immune System


Macrophages in bloodstream and tissues are depressed
Increased susceptibility to shock


GI System


GIT vagal stimulation stops/slow down
no peristalsis
Liver ability to detoxify is lost; blood is pooled in the
liver or portal bed

Renal System


Altered capillary blood pressure and glomerular filtration
Renal ischemia



V. FIRST AID

*** FIRST AID: Details from www.redcross.org


1. Get medical help immediately.
2. Don't move the joint. Splint the affected joint into its fixed position. Don't try to move a dislocated joint or force it back into place.
This can damage the joint and its surrounding muscles, ligaments, nerves or blood vessels.
3. Put ice on the injured joint. This can help reduce swelling by controlling internal bleeding and the buildup of fluids in and around the
injured joint.
Minor cuts and scrapes usually don't require a trip to the emergency room. Yet proper care is essential to avoid infection or other
complications. These guidelines can help you care for simple wounds:
1. Stop the bleeding. Minor cuts and scrapes usually stop bleeding on their own. If they don't, apply gentle pressure with a clean cloth
or bandage. Hold the pressure continuously for 20 to 30 minutes. Don't keep checking to see if the bleeding has stopped because
this may damage or dislodge the fresh clot that's forming and cause bleeding to resume. If the blood spurts or continues to flow
after continuous pressure, seek medical assistance.
2. Clean the wound. Rinse out the wound with clear water. Soap can irritate the wound, so try to keep it out of the actual wound. If
dirt or debris remains in the wound after washing, use tweezers cleaned with alcohol to remove the particles. If debris remains
embedded in the wound after cleaning, see your doctor. Thorough wound cleaning reduces the risk of tetanus. To clean the area
Dislocation: First aid***
Cuts and scrapes: First aid***
around the wound, use soap and a washcloth. There's no need to use hydrogen peroxide, iodine or an iodine-containing cleanser.
These substances irritate living cells. If you choose to use them, don't apply them directly on the wound.
3. Apply an antibiotic. After you clean the wound, apply a thin layer of an antibiotic cream or ointment such as Neosporin or
Polysporin to help keep the surface moist. The products don't make the wound heal faster, but they can discourage infection and
allow your body's healing process to close the wound more efficiently. Certain ingredients in some ointments can cause a mild rash
in some people. If a rash appears, stop using the ointment.
4. Cover the wound. Bandages can help keep the wound clean and keep harmful bacteria out. After the wound has healed enough to
make infection unlikely, exposure to the air will speed wound healing.
5. Change the dressing. Change the dressing at least daily or whenever it becomes wet or dirty. If you're allergic to the adhesive used
in most bandages, switch to adhesive-free dressings or sterile gauze held in place with paper tape, gauze roll or a loosely applied
elastic bandage. These supplies generally are available at pharmacies.
6. Get stitches for deep wounds. A wound that cuts deeply through the skin or is gaping or jagged-edged and has fat or muscle
protruding usually requires stitches. A strip or two of surgical tape may hold a minor cut together, but if you can't easily close the
mouth of the wound, see your doctor as soon as possible. Proper closure within a few hours minimizes the risk of infection.
7. Watch for signs of infection. See your doctor if the wound isn't healing or you notice any redness, drainage, warmth or swelling.
8. Get a tetanus shot. Doctors recommend you get a tetanus shot every 10 years. If your wound is deep or dirty and your last shot was
more than five years ago, your doctor may recommend a tetanus shot booster. Get the booster within 48 hours of the injury


For minor burns, including second-degree burns limited to an area no larger than 2 to 3 inches in diameter, take the following action:
Cool the burn. Hold the burned area under cold running water for at least 5 minutes, or until the pain subsides. If this is impractical,
immerse the burn in cold water or cool it with cold compresses. Cooling the burn reduces swelling by conducting heat away from the
skin. Don't put ice on the burn.
Cover the burn with a sterile gauze bandage. Don't use fluffy cotton, which may irritate the skin. Wrap the gauze loosely to avoid
putting pressure on burned skin. Bandaging keeps air off the burned skin, reduces pain and protects blistered skin.
Take an over-the-counter pain reliever. These include aspirin, ibuprofen (Advil, Motrin, others), naproxen (Aleve) or acetaminophen
(Tylenol, others). Never give aspirin to children or teenagers.
Minor burns usually heal without further treatment. They may heal with pigment changes, meaning the healed area may be a different color
from the surrounding skin. Watch for signs of infection, such as increased pain, redness, fever, swelling or oozing. If infection develops, seek
medical help. Avoid re-injuring or tanning if the burns are less than a year old doing so may cause more extensive pigmentation changes. Use
sunscreen on the area for at least a year.
Caution
Don't use ice. Putting ice directly on a burn can cause frostbite, further damaging your skin.
Don't break blisters. Broken blisters are vulnerable to infection.
Third-degree burn
The most serious burns are painless and involve all layers of the skin. Fat, muscle and even bone may be affected. Areas may be charred black
or appear dry and white. Difficulty inhaling and exhaling, carbon monoxide poisoning or other toxic effects may occur if smoke inhalation
accompanies the burn.
For major burns, dial 911 or call for emergency medical assistance. Until an emergency unit arrives, follow these steps:
1. Don't remove burnt clothing. However, do make sure the victim is no longer in contact with smoldering materials or exposed to
smoke or heat.
2. Don't immerse severe large burns in cold water. Doing so could cause shock.
Burns: First aid***
3. Check for signs of circulation (breathing, coughing or movement). If there is no breathing or other sign of circulation, begin
cardiopulmonary resuscitation (CPR).
4. Cover the area of the burn. Use a cool, moist, sterile bandage; clean, moist cloth; or moist towels.
If a chemical burns the skin, follow these steps:
1. Remove the cause of the burn by flushing the chemicals off the skin surface with cool, running water for 15 minutes or more. If the
burning chemical is a powder-like substance such as lime, brush it off the skin before flushing.
2. Remove clothing or jewelry that has been contaminated by the chemical.
3. Wrap the burned area loosely with a dry, sterile dressing or a clean cloth.
Minor chemical burns usually heal without further treatment.
Seek emergency medical assistance if:
The victim has signs of shock, such as fainting, pale complexion or breathing in a notably shallow manner.
The chemical burn penetrated through the first layer of skin, and the resulting second-degree burn covers an area more than 2 to 3
inches in diameter.
The chemical burn occurred on the eye, hands, feet, face, groin or buttocks, or over a major joint.
If you're unsure whether a substance is toxic, call the poison center.



An electrical burn may appear minor or not show on the skin at all, but the damage can extend deep into the tissues beneath your skin. If a
strong electrical current passes through your body, internal damage, such as a heart rhythm disturbance or cardiac arrest, can occur.
Sometimes the jolt associated with the electrical burn can cause you to be thrown or to fall, resulting in fractures or other associated injuries.
Dial 911 or call for emergency medical assistance if the person who has been burned is in pain, is confused, or is experiencing changes in his or
her breathing, heartbeat or consciousness.
While helping someone with an electrical burn and waiting for medical help, follow these steps:
1. Look first. Don't touch. The person may still be in contact with the electrical source. Touching the person may pass the current
through you.
2. Turn off the source of electricity if possible. If not, move the source away from both you and the injured person using a
nonconducting object made of cardboard, plastic or wood.
3. Check for signs of circulation (breathing, coughing or movement). If absent, begin cardiopulmonary resuscitation (CPR)
immediately.
4. Prevent shock. Lay the person down with the head slightly lower than the trunk and the legs elevated.
5. Cover the affected areas. If the person is breathing, cover any burned areas with a sterile gauze bandage, if available, or a clean
cloth. Don't use a blanket or towel. Loose fibers can stick to the burns.
Chemical burns: First aid***
Electrical burns: First aid***
Domestic pets cause most animal bites. Dogs are more likely to bite than cats. Cat bites, however, are more likely to cause infection. Bites from
nonimmunized domestic animals and wild animals carry the risk of rabies. Rabies is more common in raccoons, skunks, bats and foxes than in
cats and dogs. Rabbits, squirrels and other rodents rarely carry rabies. If an animal bites you or your child, follow these guidelines:
For minor wounds. If the bite barely breaks the skin and there is no danger of rabies, treat it as a minor wound. Wash the wound
thoroughly with soap and water. Apply an antibiotic cream to prevent infection and cover the bite with a clean bandage.
For deep wounds. If the animal bite creates a deep puncture of the skin or the skin is badly torn and bleeding, apply pressure with a
clean, dry cloth to stop the bleeding and see your doctor.
For infection. If you notice signs of infection such as swelling, redness, increased pain or oozing, see your doctor immediately.
For suspected rabies. If you suspect the bite was caused by an animal that might carry rabies any bite from a wild or domestic
animal of unknown immunization status see your doctor immediately.
Doctors recommend getting a tetanus shot every 10 years. If your last one was more than five years ago and your wound is deep or dirty, your
doctor may recommend a booster. You should have the booster within 48 hours of the injury.




Falls put you at risk of serious injury. Prevent falls with these fall-prevention measures.
Your odds of falling each year after age 65 are about one in three. Fortunately, most of these falls aren't serious. Still, falls are the leading cause
of injury and injury-related death among older adults. You're more likely to fall as you get older because of common, age-related physical
changes and medical conditions and the medications you take to treat such conditions.
You needn't let the fear of falling rule your life. Many falls and fall-related injuries are preventable with fall-prevention measures. Here's a look
at six fall-prevention approaches that can help you avoid falls.
Fall-prevention step 1: Make an appointment with your doctor
Begin your fall-prevention plan by making an appointment with your doctor. You and your doctor can take a comprehensive look at your
environment, your health and your medications to identify situations when you're vulnerable to falling. In order to devise a fall-prevention plan,
your doctor will want to know:
What medications are you taking? Include all the prescription and over-the-counter medications you take, along with the dosages. Or
bring them all with you. Your doctor can review your medications for side effects and interactions that may increase your risk of falling.
To help with fall prevention, he or she may decide to wean you off certain medications, especially those used to treat anxiety and
insomnia.
Have you fallen before? Write down the details, including when, where and how you fell. Be prepared to discuss instances when you
almost fell but managed to grab hold of something just in time or were caught by someone.
Could your health conditions cause a fall? Your doctor likely wants to know about eye and ear disorders that may increase your risk of
falls. Be prepared to discuss these and to tell him or her how you walk describe any dizziness, joint pain, numbness or shortness of
breath that affects your walk. Your doctor may then evaluate your muscle strength, balance and individual walking style (gait).
Fall-prevention step 2: Keep moving
If you aren't already getting regular physical activity, consider starting a general exercise program as part of your fall-prevention plan. Consider
activities such as walking, water workouts or tai chi a gentle exercise that involves slow and graceful dance-like movements. Such activities
reduce your risk of falls by improving your strength, balance, coordination and flexibility. Be sure to get your doctor's OK first, though.
Animal bites: First aid***
Fall prevention: 6 ways to reduce your falling risk***
If you avoid exercise because you're afraid it will make a fall more likely, bring this concern to your doctor. He or she may recommend carefully
monitored exercise programs or give you a referral to a physical therapist who can devise a custom exercise program aimed at improving your
balance, muscle strength and gait. To improve your flexibility, the physical therapist may use techniques such as electrical stimulation, massage
or ultrasound. If you have inner ear problems that affect your balance, he or she may also teach you balance retraining exercises (vestibular
rehabilitation) which involve specific head and body movements to correct loss of balance.

Fall-prevention step 3: Wear sensible shoes
Consider changing your footwear as part of your fall-prevention plan. High heels, floppy slippers and shoes with slick soles can make you slip,
stumble and fall. So can walking in your stocking feet. Instead:
Have your feet measured each time you buy shoes, since your size can change.
Buy properly fitting, sturdy shoes with nonskid soles.
Avoid shoes with extra-thick soles.
Choose lace-up shoes instead of slip-ons, and keep the laces tied.
Select footwear with fabric fasteners if you have trouble tying laces.
Shop in the men's department if you're a woman who can't find wide enough shoes.
If bending over to put on your shoes puts you off balance, consider a long shoehorn that helps you slip your shoes on without bending over.
Fall-prevention step 4: Remove home hazards
As part of your fall-prevention measures, take a look around you your living room, kitchen, bedroom, bathroom, hallways and stairways may
be filled with booby traps. Clutter can get in your way, but so can the decorative accents you add to your home. To make your home safer, you
might try these tips:
Remove boxes, newspapers, electrical cords and phone cords from walkways.
Move coffee tables, magazine racks and plant stands from high-traffic areas.
Secure loose rugs with double-faced tape, tacks or a slip-resistant backing.
Repair loose, wooden floorboards and carpeting right away.
Store clothing, dishes, food and other household necessities within easy reach.
Immediately clean spilled liquids, grease or food.
Use nonskid floor wax.
Use nonslip mats in your bathtub or shower.
Fall-prevention step 5: Light up your living space
As you get older, less light reaches the back of your eyes where you sense color and motion. So keep your home brightly lit with 100-watt bulbs
or higher to avoid tripping on objects that are hard to see. Don't use bulbs that exceed the wattage rating on lamps and lighting fixtures,
however, since this can present a fire hazard. Also:
Place a lamp near your bed and within reach so that you can use it if you get up at night.
Make light switches more easily accessible in rooms. Make a clear path to the switch if it isn't right near the room entrance. Consider
installing glow-in-the-dark or illuminated switches.
Place night lights in your bedroom, bathroom and hallways.
Turn on the lights before going up or down stairs. This might require installing switches at the top and bottom of stairs.
Store flashlights in easy-to-find places in case of power outages.
Fall-prevention step 6: Use assistive devices
Your doctor might recommend using a cane or walker to keep you steady. Other assistive devices can help, too. All sorts of gadgets have been
invented to make everyday tasks easier. Some you might consider:
Grab bars mounted inside and just outside your shower or bathtub.
A raised toilet seat or one with armrests to stabilize yourself.
A sturdy plastic seat placed in your shower or tub so that you can sit down if you need to. Buy a hand-held shower nozzle so that you
can shower sitting down.
Handrails on both sides of stairways.
Nonslip treads on bare-wood steps.
Ask your doctor for a referral to an occupational therapist who can help you devise other ways to prevent falls in your home. Some solutions
are easily installed and relatively inexpensive. Others may require professional help and more of an investment. If you plan on staying in your
home for many more years, an investment in safety and fall prevention now may make that possible.

Signs and symptoms of an insect bite result from the injection of venom or other substances into your skin. The venom triggers an allergic
reaction. The severity of your reaction depends on your sensitivity to the insect venom or substance.
Most reactions to insect bites are mild, causing little more than an annoying itching or stinging sensation and mild swelling that disappear
within a day or so. A delayed reaction may cause fever, hives, painful joints and swollen glands. You might experience both the immediate and
the delayed reactions from the same insect bite or sting. Only a small percentage of people develop severe reactions (anaphylaxis) to insect
venom. Signs and symptoms of a severe reaction include facial swelling, difficulty breathing and shock.
Bites from bees, wasps, hornets, yellow jackets and fire ants are typically the most troublesome. Bites from mosquitoes, ticks, biting flies and
some spiders also can cause reactions, but these are generally milder.
For mild reactions:
Move to a safe area to avoid more stings.
Scrape or brush off the stinger with a straight-edged object, such as a credit card or the back of a knife. Wash the affected area with
soap and water. Don't try to pull out the stinger; doing so may release more venom.
To reduce pain and swelling, apply a cold pack or cloth filled with ice.
Apply 0.5 percent or 1 percent hydrocortisone cream, calamine lotion or a baking soda paste with a ratio of 3 teaspoons baking soda
to 1 teaspoon water to the bite or sting several times a day until your symptoms subside.
Take an antihistamine containing diphenhydramine (Benadryl, Tylenol Severe Allergy) or chlorpheniramine maleate (Chlor-Trimeton,
Teldrin).
Allergic reactions may include mild nausea and intestinal cramps, diarrhea or swelling larger than 2 inches in diameter at the site. See your
doctor promptly if you experience any of these signs and symptoms.
For severe reactions:
Severe reactions may progress rapidly. Dial 911 or call for emergency medical assistance if the following signs or symptoms occur:
Difficulty breathing
Swelling of your lips or throat
Faintness
Insect bites and stings: First aid***
Dizziness
Confusion
Rapid heartbeat
Hives
Nausea, cramps and vomiting
Take these actions immediately while waiting with an affected person for medical help:
1. Check for special medications that the person might be carrying to treat an allergic attack, such as an auto-injector of epinephrine
(for example, EpiPen). Administer the drug as directed usually by pressing the auto-injector against the person's thigh and holding
it in place for several seconds. Massage the injection site for 10 seconds to enhance absorption.
2. After administering epinephrine, have the person take an antihistamine pill if he or she is able to do so without choking.
3. Have the person lie still on his or her back with feet higher than the head.
4. Loosen tight clothing and cover the person with a blanket. Don't give anything to drink.
5. If there's vomiting or bleeding from the mouth, turn the person on his or her side to prevent choking.
6. If there are no signs of circulation (breathing, coughing or movement), begin CPR.
RESPIRATORY ARREST

Respiratory Arrest (-) RR (+) PR.

A condition of the victim wherein there is no breathing but pulse continues

CAUSES:

1. Strangulation
2. Poisoning-Injection, Ingestion, Inhalation
Injection- Snakebite, Rabies, Scorpions, bees, jellyfish, spiders
3. Severe Bleeding
4. Drowning
5. Electrocution
6. Suffocation
7. Choking: Universal Sign of Choking- palms guarding throat
8. Disease

THREE (3) KINDS OF AIRWAY OBSTRUCTION


Kind OF Airway Obstruction

Signs

First Aid

With Good Air Exchange

Victim can still TALK

Observe the victim as he cough out
obstruction

With Poor Air Exchange

Victim produces wheezing sound

Abdominal Thrust / Heimlich Maneuver

Total Airway Obstruction with No Air
Exchange

Unconscious

1. Abdominal Thrust 10X
Blind Finger sweep for adults

2. Artificial Respiration (AR) 2X

3. Check if Air is going back-
Look, Listen & Feel (LLF)

4. Repeat blind finger sweep

5. Artificial Respiration 2X if effective

First Aid: Artificial Respiration (AR) Giving of artificial air only either through a blow or ambubag
- chest compression not indicated because there is pulse rate


METHODS IN GIVING ARTIFICIAL RESPIRATION

1. Mouth to Mouth - usual method
2. Mouth to Nose - if mouth is obstructed
3. Mouth to Mouth & Nose used in infants
4. Mouth to Stoma - like for patients with tracheostomy
5. Mouth to Mask
6. Ambu Bag to Mouth & Nose

Ambu Bag- a device used for artificial mechanical breathing unit


ADULT

CHILD

INFANT

METHOD

Mouth TO Mouth

Mouth TO Mouth

Mouth TO Mouth & Nose

Manner of Breathing

Full and Slow

Regulated

Puff

Rate of Blows

1 Blow every 5 secs
12 blows per min

1 Blow every 4 secs
15 blows per min

1 Blow every 3 seconds 20
blows per min




START WITH A BLOW AND END WITH A BLOW

WHEN TO STOP

1. When the rescuer is exhausted
2. When the victim is breathing on his own
3. When the service of the physician is available
4. When the pulse disappears; artificial respiration is stopped and cardiopulmonary rescucitation begins
5. When another first aider takes over





Condition of the victim when the pulse and breathing is absent.

Intervention for Cardiac Arrest: CPR

CPR- Cardio Pulmonary Resuscitation
- A combination of external chest compression and artificial ventilations to
revive the heart and the lungs

CAUSES
All causes of Respiratory Arrest, Heart Attack, Stroke















CARDIAC ARREST


Location Of Chest Compressions

1. ADULT- 3 fingers above mid xiphoid
2. INFANT- along nipple line
Danger of Failure to revive Patient:

1. CLINICAL DEATH- may occur if
heart rate is not revived within 4-6
minutes

2. BIOLOGICAL DEATH- usually
occurs after 4-6 mins of cardiac
arrest


ADULT

CHILD

INFANT

Method

2 Heels of 2 Hands

1 Heel of 1 hand

2 Fingers (ring and mid finger)

Depth

1 - 2

1- 1

1

Rate

15 ECC/2 blows 4X/min

5ECC/1 blow 15X/min

5ECC/1 blow 20X/min

Speed

60-80 ECC/min 12X/min

80-100 ECC/min

100-120 ECC/min

2 RESCUERS 5 ECC/1 blow

DONTS IN CPR:

1. Dont be a double crosser
2. Dont be a rocker
3. Dont be a jerker
4. Dont be a render
5. Dont be a bouncer
6. Dont be a massager

CPR- start with 2 blows end with 2 blows

SEQUENCE:

1. Survey the scene the scene is safe
2. Check for responsiveness Hey 2X, R U Okay
3. Position the victim
4. Open and Clear the airway (head tilt chin lift) Mouth is clear
5. Check breathing for 3-5 seconds (LLF) 1001, 1002, etc. Breathless
6. If Breathless, give 2 blows
7. Check for Pulse: Carotid 5-10 seconds
8. State the condition of the victim
Victim is breathless with pulse or
Victim is breathless & pulse less
9. Activate medical assistance Arrange transfer facilities and Ill doAR or CPR
10. After each cycle, check pulse for 5 sec. then deliberate
11. Recovery Position