MEDICAL-SURGICAL NURSING REVIEW
Course Outline
I.
II.
III.
Client in Pain
Perioperative Nursing Care
Alterations in Human Functioning
a. Disturbances in Oxygenation: Respiratory & Cardiovascular Functions
b.
c.
d.
e.
f.
g.
IV.
V.
Disturbances in Metabolic and Endocrine Functions
Disturbances in Elimination: Gastrointestinal Problems
Disturbances in Fluids and Electrolytes: Renal & Genitourinary Functions
Disturbances in Cellular Functioning: Cancer and Hematologic Problems
Disturbances in Auditory & Visual Functions
Disturbances in Musculoskeletal Functions
Client in Biologic Crisis: Life threatening Conditions of the Human Body
- Shock
Emergency & Disaster
- First-aid and Cardiopulmonary Support
-------------------------------------------------------------------------------------------------------------------------------------CLIENT IN PAIN
I.
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.
3.
Chronic Pain (Non-Malignant) – constant, intermittent pain which usually persists even after healing
of the injured tissue
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.
5.
6.
Age – infants are more sensitive
Gender
Placebo Effect
Characteristics of Pain
1. Intensity –mild, moderate, excruciating
2.
3.
4.
5.
6.
7.
Timing – morning or evening, duration may be longer or shorter
Location
Quality – burning, aching, stabbing
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.
Aggravating and Alleviating factors – patient’s environment
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
Nurse’s 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
115
ii.
iii.
2.
3.
Establish Nurse-Patient Relationship and Teaching
a. Acknowledge the verbalization of pain by the client
b. Relieve patient’s anxiety
c. Teach measures how to relieve pain
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
PRN – “Pro Re Nata” – as needed
Preventive – taken before pain is felt
Individualized Dosage
Patient-Controlled Analgesia (PCA) – patient takes medication if pain felt is becoming
intolerable
b.
c.
d.
e.
6.
II.
Harmful effects of pain to the client
Duration of the pain
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
PERIOPERATIVE CARE
o
Phases of Perioperative Nursing
a.
b.
c.
A.
Pre-operative Nursing
Inraoperative Nursing
Post-operative Nursing
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, clothesetc.
b.
c.
d.
e.
f.
Nutritional & Fluid Status – should be well hydrated
Drug or alcohol Use – may experience delirium or intoxication to
anesthetic drugs because ormal doses do not usually take effect to
these patients and require heavier dose to achieve anesthetic effect.
Respiratory Status - teach breathing exercises
Cardiovascular Status – should have controlled and stable
cardiovascular functioning before operation to prevent intraoperative
problems
Hepatic & Renal Functions – normal functioning is important in
absorbing anesthetic drugs
116
g.
h.
i.
j.
Endocrine Functions- important in monitoring to
hypo/hyperglycemia, thyrotoxicosis, acidosis
Immune Functions – allergies esp. to anesthetic drugs
Psychosocial Factors – emotional and psychological preparation to
ensure cooperation fom the patient with the procedures
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 siderails 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-Fowler’s
HOB elevated at 90
degrees
Pneumothorax, hiatus hernia
Supine/ Dorsal
Recumbent
Lying on back w/ small
pillow under head
Spinal cord injury, urinary
catheterization
Lying on abdomen with
head turned to the side
Amputation of legs/feet, post lumbar
puncture, post myelogram, post
tonsillectomy & adenoidectomy (T&A)
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)
Lying on side, weight
on the clavicle,
humerus and anterior
aspect of the iliac.
Unconscious client
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
Lateral / Side lying
prevent
117
Prone
Supine
Lateral Recumbent
Sim’s Position
Reverse
Trendelenburg
Jack-Knife
B.
High-Fowler’s
Lithotomy
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
2.
Ensure safety of client in the operating table- prevent falls, drape the patient properly,
provide warmth
3.
Stay with the client to relieve anxiety and support during anesthesia
Anesthesia Administration:
118
a.
b.
c.
d.
4.
5.
6.
7.
C.
General Anesthesia via Inhalation
General Anestheisia via Intravenous
Regional Anesthesia - local anesthesia
Conduction Blocks/ Spinal Anesthesia – Epidural & Spinal Block
- for operation below the waist line
- patient is awake during operation
Perform sponge count, instrument count and needle count
Aseptic technique in handling and preparing all instruments and supplies
Applies grounding device to prevent electrical burn during use of electrosurgical
equipment
Proper documentation
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
Early ambulation
Health teaching for Independent (self) care upon discharge
5.
6.
III. ALTERATIONS IN HUMAN FUNCTIONING
1.
DISTURBANCES IN OXYGENATION
Arterial Blood Gas
Normal Value
pH
pCO2
pO2
HCO3
Measure of acidity or alkalinity
7.35 – 7.45
Partial pressure of carbon dioxide
parameter influenced by lungs only
respiratory
35 -45
Partial pressure of oxygen; measure of amount
oxygen delivered to lungs
80-100
Bicarbonate, metabolic parameter influenced only by
metabolic factors
22-26
Respiratory
Acidosis
Normal Compensation
a. Administer NaHco3
b. Get rid of CO2
c. Bronchodilators
d. Monitor ABG
Normal Value
pH
7.35 – 7.45
pCO2
35 -45
HCO3
22-26
Nursing Intervention
Respiratory
Alkalosis
Normal Compensation
a. Breathe into paper
bag or cupped
hands
b. Oxygen
119
Metabolic
Acidosis
Normal Value
pH
7.35 – 7.45
pCO2
35 -45
HCO3
22-26
Metabolic
Alkalosis
Normal Compensation
Normal Compensation
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.
2.
3.
4.
Cigarette smoking
Chronic respiratory infections
Family history of COPD
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
 Nicotine Stains
 Pitting edema
 exertional dyspnea or dyspnea at rest
 Enlarged pulsating liver
 Cough- with or without sputum production
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
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
Slight gynecomastia
Petechiae in midsternal area
Dyspnea
120


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)
Nursing Management:
Position: Sit up and lean forward
Pulmonary toilet:
Cough->Breathe deeply->Chest physiotherapy-> turn & position
Frequent rest periods
Nebulization
IPPB – Intermittent Positive Pressure Breathing (aerosolized inhalation)
O2 @ 2LPM
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
Types:
1.
2.
3.
Immunologic asthma
-
occurs in childhood
Non-immunologic asthma occurs in adulthood and assoc w/ recurrent resp infections.
usually >35 y/o
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
Nursing Management:
1.
2.
3.
Promote pulmonary ventilation
Facilitate expectoration
Health teaching
 Breathing techniques
 Stress management
 Avoid allergens
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:
121
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.
2.
3.
Chest pain, irritability, apprehensiveness, irritability, restlessness, nausea, anorexia, hx of exposure
Cough- productive , rusty/ yellowish/greenish sputum, splinting of affected side, chest retration
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

PULMONARY EDEMA
- often occurs when the left side of the heart is distended and fails to pump adequately
o
Clinical Manifestation:
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
- A chronic lung infection that leads to consumption of alveolar tissues
Etiology:
Mycobacterium tuberculosis.
Risk Factors:
Poor living conditions, overcrowded
1. Poor nutritional intake
2. Previous infection
122
3.
Close contact with infected person
4. Inadequate treatment of primary infection
Clinical Manifestations:
Diagnostic Tests:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Productive cough
Hemoptysis
Dypnea
Rales
Malaise
Night Sweats
Weight loss
Anorexia, vomiting
Indigestion, pallor
1.
2.
3.
CXR
Sputum acid-fast
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
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.
-------------------------------------------------------------------------------------------------------------------------------------------------------CARDIOVASCULAR SYSTEM
THE HEART AND MAJOR VESSELS
I. Diagnostic Procedure
Laboratory Test
Electrocardiogram
Echocardiography
Central Venous Pressure
Pulmonary Artery Pressure/ Swan-Ganz
Cardiac Catheterization
Venous Disorders:
II. Diseases of the Vascular System:
Cardiac Disorders
1.
2.
Arterial Disorders:
1. Hypertension
2. Arteriosclerosis
3. Atherosclerosis
4. Aortic Aneurysm
5. Buerger’s Disease (Thromboangitis Obliterans)
6. Raynaud’s Disease
Thrombophlebitis
Varicose Veins
a.
b.
Infarction
c.
Failure
d.
e.
f.
Angina Pectoris
Myocardial
Congestive heart
Valvular Stenosis
AV Heart Block
Pacemakers
A. DIAGNOSTIC PROCEDURES:
Procedure
1. Laboratory Tests
Values / Description
a. Electrolytes – Na, K, Ca,
Chloride , Mg
(see fluids & electrolytes)
Purpose
Determines hyperkalemia, Hypernatremia, etc.
- determine the ability of the heart to affect circulation and
regulatory functions of fluids and electrolytes.
b. PTT – 16-40 sec.
c. PT – 9-12 sec.
- determines ability of the blood to form clot or
thrombus
d. Clotting time – 10 mins.
e. Cholesterol – 150-250 mg/dl
123
.
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.)
- 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
> SGOT – 5-40 u/ml
i. ESR- 0-30.– also rises after MI
2. Electrocardiogram
Procedure
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
Ultrasound of the heart
4. Central Venous
Pressure (CVP)
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)
5. Swan-Ganz
Catheter /
Pulmonary Artery
Pressure (PAP)
 Normal impulses ensures
adequate circulation to
all body organs and
tissues
Values / Description
3. 2-Dimensional
Echocardiography
(2D Echo)
Normal = 5 – 10 cm
Water
 Determines the electrical
impulse of the heart
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
Purpose
 Determines valvular
deformities, thickening of
myocardium, pericardial
effusion,etc
 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
Monitor pressure in the ff:
c.
Right ventricle
Pulmonary artery
e. Distal branches of
the pulmonary
artery
Thermodilution
Obtain blood for O2
saturation
d.
124
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.
2.
3.
Arteries - carries oxygenated blood
Veins - carries unoxygenated blood
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
Etiology:
Essential hypertension
unknown etiology
- most common
- may be caused by an increase in cardiac
output or increase in peripheral resistance
Types of Hypertension
Essential hypertension
Secondary hypertension
caused by other physiologic problems
Secondary hypertension
Risk Factors
Genetic
Obesity
Stress
Loss of elastic tissues
Arteriosclerosis of aorta
Signs & Symptoms
BP=140/90 ; headache, fatigue, weakness, dizziness, palpitations, flushing, blurred vision and
epistaxis
Treatment
Non-pharmacologic:





Weight reduction
Renal problems – Renal Failure, Nephritis
Endocrine problems – Thyroid problem, DM
Neurologic Disorders – Brain tumors, Trauma
Pregnancy-Induced HPN
Many others
√ Sodium restriction
Diet modification
√ Exercise
Alcohol & Smoking cessation
Relaxation Techniques
√ Caffeine Restriction
Potassium, Calcium, Magnesium supplements (to balance sodium and other
electrolytes)
Pharmacologic:
 Calcium Agonist: Nifedipine, Verapamil
 Vasodilators: Hydralazine
 Diuretics: Aldactone, hydrochlorothizide
 Adrenergic inhibitors: Propanolol, Clonidine, Methyldopa
Nursing Interventions
BP monitoring
Correct cause: obesity, diet, stress, etc
Regular exercise
Salt restrictions
Administer medications
Teach risk factors
125
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.
a.
b.
c.
d.
e.
a.
b.
c.
d.
e.
Medical & Surgical Interventions for Athero and Arteriosclerosis:
Lifestyle Modification ; Reduce Risk Factors
Coronary Artery Bypass Graft (CABG
Percutaneous Transluminal Coronary Angioplasty (PTCA)
Directional Coronary Atherectomy (DCA)
Intracoronary Stents
Nursing Intervention:
Health Teaching
Reduce Risk Factors
Restore Blood Supply
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
Dyspnea
Dysphagia
voice hoarseness
Treatment:
Thoracic/chest pain
cough
Abdominal Aortic Aneurysm (AAA)
Abdominal Pain
Low back pain
Pulsating Abdominal Mass
Surgical Removal of Aneurysm
Nursing Intervention:
a. Psychological support
b. Monitor patient for signs of rupture of aneurysm
126
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. Post-operative care: monitor peripheral circulation
BUERGER’S DISEASE
a.k.a. Thromboangitis Obliterans (TAO)
b.
c.
d.
e.
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,
numbness and tingling of toes
sensitivity to cold
Weak or absent pulsations at the dorsalis pedis, posterior tibial
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

RAYNAUD’S 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:
Signs & Symptoms:
hypersensitivity of fingers to colds, congenital vasospasm, Serotonin release



Cyanosis/pallor of the fingers when exposed to cold environment or emotional
stimuli
Numbness and occasional pain
Bilateral or symmetrical involvement
Treatment:
 Nifedipine to decrease vasospasm
 Avoid exposure to cold and keep hands warm
 Avoid smoking
Nursing Intervention

Same as buerger’s disease
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,
(+) Homan’s sign - calf pain upon
dorsiflexion of foot
Nursing Intervention:
a. Use of thromboembolytic (TED) stockings
127
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).
128
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.
b.
c.
d.
Opiate Analgesic – MoSo4
Vasidilators – Nitroglygcerin, Isosorbide Mononitrate/Dinitrate
Calcium Channel Blockers – Dlitiazem, Nifedipine
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:
129
 Age , Male gender, Smoking, DM, Family history, Sedentary lifestyle, obesity, diet, stress,
hypertension, Type A personality
DIAGNOSTICS:
Lab studies:








Creatine kinase–MB (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.

Electrocardiogram (ECG) - ST-segment elevation greater than 1 mm.
- the presence of new Q waves.
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).
-
intermediate probability of MI are ST-segment
depression, T-wave inversion, and other nonspecific ST-T
wave abnormalities.
Immediate 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)
130
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.
a.
b.
c.
d.
e.
f.
Early
Treat arrythmias promptly – lidocaine
Give analgesic- morphine
Provide physical rest
Administer O2 via cannula
Frequent VS
Nifedipine
Propanolol HCL
Emotional Support
g.
h.
2.
a.
b.
c.
d.
e.
Later
Give stool softener
Provide low fat, low cholesterol, low sodium diet, soft food
Commode
Self-care
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
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.
CONGESTIVE HEART FAILURE (CHF)
Definition:
inability of the heart to meet oxygen and metabolic needs of the body
131
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
Left Ventricular Failure
Signs &
Symptoms
Right Ventricular
Causes Pulmonary Congestion:
a.
pnea
b.
yne’s Stroke
Dys
Che
c.
Cou
gh, Rales, wheezing
d.
Orth
opnea
e.
Par
oxysmal Nocturnal Dyspnea
f.
Pul
monary Edema
g.
Cer
ebral hypoxia
h.
Fati
gue &muscular weakness
i. Renal Changes, Nocturia
Peripheral edema
Venous congestion of organs
Hepatomegaly
Cyanosis of the nail beds
Massive swelling of the legs,
genitals and trunk (Anasarca)
f. Anxiety, fear and depression
f.
Management:
 Positioning – High fowler’s 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:
a. Eyes:
b. Gastrointestinal Tract:
c. Cardiovascular:
d. Central Nervous System:
Halo around lights
Diarrhea, anorexia, vomiting, abdominal cramps
Bradycardia, frequent PVC’s
Headache , Fatigue, Lethargy
Nursing Intervention:
1. Sodium restriction
2. Reduce pain and anxiety
3. Improve oxygenation: proper positioning, O2
4.
Reduce congestion and edema: meds, positioning
132
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
Stenosed
AV HEART BLOCK
Definition:
Altered transmission of impulse from SA node through AV node
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
PACEMAKERS
Definition:
Electronic device (battery- operated) that produce electrical stimuli to the heart and controls
heart rate
Types:
a. Temporary Pacemakers - external, device can be held in a belt.
- used for emergency purposes, temporary pacing
- inserted trans thoracic, transvenous, transesophageal,
transcutaneous, transesophageal
b. Permanent Pacemakers – internal, device, sutured within the subcutaneous tissue.
Nursing Intervention:
a.
Check for signs of infection on the site: fever, heat, pain, skin breakdown
b.
Avoid high-energy radar, television, microwave: if dizziness or tachycardia occur, ask
patient to move 4-6 feet away from source.
c.
Remind to wear ID-information bracelet at all times esp. when traveling
d.
Care of Site: > wear loose-fitting around pace-maker
> Encourage bath tubs rather than shower to protect incision site for the first
10 days
> Explain that healing takes place within 3 months
133
---
External Pacemaker
Internal Pacemaker
(sutured subcutaneously)
Appearance of a
person w/ internal pacemaker
-------------------------------------------------------------------------------------------------------------------------------------------------------------Comparison of Chest Pain
Angina Pectoris
Myocardial
Infarction
Type
•
squeezing, pressing,
burning
•
Sudden, severe, crushing,
heavy, tightness
Location
•
Retrosternal,
substernal, left of
sternum, radiates to the
left arm
•
Substernal, radiates to one
or both arms, jaw, neck
•
>30 mins.
•
•
Oxygen, narcotics,
not relieved by rest &
nitroglycerin
Duration
Relief
•
•
Usually 3-5 mins
duration <30 mins
rest, nitroglycerin
Comparison of other signs & symptoms
Angina Pectoris
Myocardial Infarction
Transient Ischemic
Attack
134
Subjective Data:
Dyspnea
Palpitation
Dizziness
Faintness
Subjective Data:
•
Shortness
of breath
•
Apprehens
ion,
fear
of
impending death
•
Nausea
Objective Data:
• Tachycardia
• Pallor
• Diaphoresis
Objective Data:
• Symptoms of shock
• Cyanosis, diaphoresis
Sudden loss of:
•
Visual fxn
•
Sensory fxn
•
Motor fxn
Objective Data:
Loss of functioning
about and returns
normal
• Restless
for
to
Nursing Care Management
Arteriosclerosis
Angina Pectoris
1.
•
Lifestyle Modification
Diet, stress mgt, habits
1.
2.
•
Restore blood supply
Anti-embolic stockings,
anti-coagulants
3.
•
Pre & post-op care
CABG,PTCA, Stents
•
•
•
•
•
4.
•
Health teaching
Modifications, diet,etc.
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
Transient Ischemic Attack
1.
Assess neurologic status
2.
Administer meds
Nursing Care Management
Myocardial Infarction
Reduce pain & discomfort:
Narcotics, O2, Semi-fowler’s 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
4.
•
Facilitate fecal elimination
stool softener, avoid Valsalva, mouth
breathing, bedside commode
3.
6.
Provide emotional support
7.
•
•
Promote sexual functioning
discuss concerns include partner
resume 5-8 wks after uncomplicated MI
1.
•
•
•
•
•
2.
Gland
Decrease oxygen demand/ Promote
oxygenation
O2, Bedrest (24-48 hrs), rest periods
Semi-fowler’s position
Anticipate needs of client: call light,
water
Meds: vasodilators, vasopressors,
Cal.C.Blockers
•
•
•
•
5.
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
8. Health teaching
DISTURBANCES IN METABOLIC & ENDOCRINE FUNCTIONING
Hormone
Functions
135
Pituitary Gland
Anterior Lobe
Posterior lobe
Thyroid Gland
Growth Hormone
Stimulates growth of body tissues and bones
Prolactin
Stimulates mammary tissue growth & lactation
Thyrotropic hormone (TSH)
Stimulates thyroid gland
Gonadotropic hormones (LH &
FSH)
Affect growth, maturity and functioning of primary and
secondary sex organs
Adrenocorticotropic hormone
(ACTH)
Stimulates steroid production by adrenal cortex
Melanocyte-stimulating Hormone
(MSH)
May stimulate adrenal cortex; may affect pigmentation
Anti-diuretic hormones (ADH,
vasopressin)
Promotes reabsorption of water by the distal tubules
and collecting ducts of the kidney, thus decreasing
urine output
Oxytocin
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
Thyroxine (T4)
Increases metabolic activity of almost all cells;
stimulates most aspects of fat, protein and
carbohydrate metabolism
Triiodothyronine (T3)
Thryrocalcitonin
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
Glucocorticoids (primarily
cortisol) -- Sugar
Promotes carbohydrate, protein and fat catabolism,
increases tissue responsiveness to other hormones
Mineralcorticoids (Aldosterone)
-- Salt
Tends to increase sodium retention and potassium
excretion
Androgens (male hormones)
-- Sex
Governs certain secondary sex characteristics; all
corticoids are important for defense against stress or
injury
Epinephrine (Adrenalin)-80%
Elevates blood pressure, converts glycogen to glucose
when needed by muscles for energy; increases heart
rate; increases cardiac contractility; dilates bronchioles
Controls SSS:
SUGAR, SALT,
SEX
Medulla
Norepinephrine- 20%
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
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)
Glucagon
Somatostatin
PITUITARY GLAND PROBLEMS
136
Clinical Manifestations
Acromegaly
Growth
Hormone
IN ADULTS
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
Management
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
Growth
Hormone
In CHILDREN
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
1. Polyuria
2. Polydipsia
3. Dehyration
1. Pharmacology:
a. Desmopressin Acetate nasal spray
b. Vasopressin Tannate – IM injections
c. Hypressin Nasal Spray
Growth
Hormone
In CHILDREN
Diabetes Insipidus
Antidiuretic
Hormone
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
137
Clinical Manifestations
Addison’s Disease
Glucocorticoids
Mineralcorticoids
Sex Hormones
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
Management
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:
Addisonian Crisis:
Sudden profound weakness
Severe abdominal, back and leg pain
Hyperpyrexia followed by hypothermia
Peripheral vascular collapse
Shock
Renal Shutdown -> Death
Cushing’s
Syndrome
Glucocorticoids
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Thin scalp
Moon Face
Acne
Increased body hair
Buffalo hump
Obesity
Hyperpigmentation
Thin extremities
Easy Bruising
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
Conn’s 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
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
Mineralcorticoids
(Aldosterone)
Pheochromocytoma
Epinephrine/
Norepinephrine
THYROID GLAND PROBLEMS
138
Grave’s Disease / Hyperthyroidism/
Thyrotoxicosis
T3, T4,
Thyrocalcitonin
Clinical Manifestations
Management
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:
Lugol’s solution – strains teeth, drink
w/ straw
THYROID STORM:
a. Fever
b. Tachycardia
c. Delirium
d. Irritability
Cretinism
T3, T4,
Thyrocalcitonin
INFANTS
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
1. Physical & mental retardation
2. Sensitive to cold
3. Dry skin
4. Poor appetite and constipated
Treatment:
Hormone
Replacement
Myxedema
T3, T4,
Thyrocalcitonin
ADULT
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
Hypoparathyroid
Parathormone
Bradycardia ,
Fluid retention,
Dry, coarse skin,
Decreased libido,
irregular menses
Easy bruising
Constipation
Fatigue, lethargy
Menorrhagia,
Management
1. Drug therapy: Levothyroxine,
Liothyronine Sodium
2. Avoid stimulus
139
Hyperthyroid
Tachycardia
Palpitations
Increased persitalsis
weight loss
Heat intolerance
Decreased libido
Amenorrhea
Parathormone
1. Drug therapy: Prophylthiuracil
Methimazole, Saturated solution
of Potassium Iodide, Radioactive
Iodine
2. Diet: low calcium, high fiber
3. Force fluid
PANCREATIC PROBLEMS
DIABETES MELLITUS
Type I
Insulin Dependent DM
(IDDM)
Other Name
Type II
Non-Insulin Dependent DM
(NIDDM)
Juvenile DM
Adult DM
Before 30 years old but may occur at
any age
>35 y/o but can occur in children
Abrupt
Insidious
10%
85-90%
Little or none
Below normal
Normal or
Above normal
Required
Necessary for only 20-30% of clients
May occur
Unlikely to occur
Ideal body weight or thin
Usually Obese
Diet, exercise and insulin
Diet, exercise, hypoglycemic agent or
insulin
Age of Onset
Onset
Incidence
Insulin production
Insulin Injections
Ketosis
Body weight at onset
Management
Cardinal Signs & Symptoms:
1. Polydipsia
2.
3.
4.
Polyuria
- excessive thirst
- frequent urination
Polyphagia - excessive hunger
Weight Loss - for IDDM
Treatment:
1. Oral hypoglycemics:
a. Glipizide
b. Glyburide
c. Tolbutamide
d. Tolazamide
e. Acetohexamide
f. Chlorpropamide
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
140
2. Insulin Injections:
Action
Short-Acting
Intermediate
Acting
Long-Acting
Pre-Mixed
Appearance- Preparation
Onset of Effect
Peak
Duration of
Effect
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
Cloudy
- NPH
1 – 2 hrs.
6 – 12 hrs.
18 -26 hrs.
Cloudy
- Lente
1 – 3 hrs.
6 – 12 hrs.
18 -26 hrs.
Cloudy
- Protamine zinc
4 – 6 hrs.
18 – 24 hrs.
28 – 36 hrs.
Cloudy
- Ultralente
4 – 6 hrs.
14 – 24 hrs.
36 hrs.
30 mins.
2 -12 hrs.
18- 24 hrs.
Cloudy - 70% NPH
- 30% regular
Complications of DM:
a.
b.
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
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:
c.
d.
Give regular insulin
Lipodystrophy
Cause:
Indurated areas on skin due to injections
Signs & Symptoms:
Skin indurations
Nursing Interventions:
Teach client to rotate sites of injection
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
141
4.
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
Incidence:
Chronic Gastritis
o Common in age 50-60 years
o Same in Acute
Gastritis
old
o Frequent in male than
female
o Greater incidents in heavy
drinkers and smokers
Cause:
Helicobacter Pylori
o History of or presence of
peptic ulcer disease
o Previous gastric surgery
o Same as acute gastritis
Medicines:
Aspirin, NSAIDS, chemo drugs,
steroids
Food:
Alcohol, coffee, spicy foods
Duration:
Clinical
Manifestations:
Acid
production:
Treatment
Prolonged
Short
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
o May be asymptomatic
o Other symptoms include:
o Dyspepsia, belching,
vague epigastric pain, N/V,
intolerance to spicy or fatty
foods
Epigastric discomfort,
Abdominal pain, cramping,
severe nausea, vomiting and
sometimes hematemesis
Increased hydrochloric acid.
No increase in hydrochloric
acid
Duodenal Ulcer
Gastric Ulcer
Nursing Intervention:
Occurrence:
o 25-50 yrs. old
o Type A personality
(leaders, executives);
o Usually in a wellnourished individual
> 50 yrs. old
a. Relaxation techniques
o
Most
common in
persons like
farmers,
construction
workers
o Usually
affects
malnourished
individuals
Cause:
Stress, Poor food habit
Acid
production:
Hypersecretion
Excessive smoking,
salicylates intake
Pylorus
Normal to
hyposecretion
Location of
Ulcer
Pain:
o Experienced 2-3 hrs
after meal
o Ingestion of FOOD
RELIEVES PAIN
Lesser curvature
o Experienced
½ to 1 hour after
meal
o Ingestion of
FOOD DOES
NOT RELIEVE
PAIN
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

Tetraycline/Clarithromycin

Cytoprotective – binds with
142
Bleeding
diseased tissue and provides a
protective barrier to acid
Melena is more common
than hematemesis
Malignancy:
Hematemesis is more
common than melena
Not possible
Possible
Surgical Treatment
1. Vagotomy
2. Gastric ResectionGastroduodenostomy;
Gastrojejunostomy
GASTRIC CANCER
Incidence:
f.
g.
h.
i.
j.
Common in men than women
History or presence of Pernicious Anemia
Often develops with the occurrence of atrophic gastritis
Low-socio economic status; live in urban area
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 patient’s 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)
o
o
o
o
Risk Factors:
Poor food handling
Poor sanitary conditions
Overcrowding
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
143
Cause:
Fecalith (stone or calculus in the appendix)
Fibrous condition in the bowel wall
.-> Kinking of the appendix
-> 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 Burney’s point (RLQ)
Treatment: Appendectomy
Nursing intervention:
Assess the VS and pain scale carefully
Observe for symptoms of peritonitis , Pre & post-operative care
PERITONITIS
Inflammation of the peritoneal membrane
Cause:
Gangrenous cholecystitis
Ruptured gallbladder
Perforated gastric cancer
Perforated Peptic ulcer
Ruptured spleen
Acute pancreatitis
Penetrating wound
Ulcerative colitis
Gangrenous obstruction of the bowel
Perforated diverticulum
o
o
Ileitis
Appendicitis with perforation
Ruptured retroperitoneal abscess
Strangulated hernia
Salpingitis
Septic Abortion
Ruptured bladder
Puerperal infection
Iatrogenic Cause
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 & CHRON’S DISEASE
CHRON’S DISEASE
ULCERATIVE COLITIS
Pathology &
Anatomy
Involves primarily the ileum & right
colon
Distribution of d’se is segmental
Malignancy is rare
Mucosal ulceration of lower colon
and rectum
Distribution of d’se is continuous
Malignancy may occur after 10 years
Etiology
May be genetic
May be caused by infection or
alteration in immunity
Onset
Usually in the 30’s
Course of Disease
Slowly progressive
Young adults (20-40)
Remissions and relapses
Common
144
Rectal bleeding
Occasional
Anorectal fistula
Common
Other S/S:
Abdominal pain
Weight loss
Diarrhea – soft or semi-liquid
Pain in RLQ, cramping, tenderness,
flatulence, nausea (mimics
Appendicitis)
Medical Treatment
Replacement of fluid loss
Anti-diarrheal: Diphenoxylate HCL
(Lomotil) ; Loperamide HCL
(Imodium)
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 Chron’s D’se
Total Parenteral Nutrition
Bowel Resection, Ileostomy
Surgical
Treatment
Bowel Resection, Ileostomy
Assess Intake and output, weight
Emotionla support
Client teaching regarding surgery
Nursing
interventions:
Same as Chron’s D’se
Post-op intervention:
Observation of the stoma
Teach client re: self-care
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
Increased flatus
Anorexia
Low grade fever
145
(+) 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
Colostomy
o Involves the large
bowel (colon)
o stool is semi-formed
Ileostomy
o Involves the small
bowel (ileum)
o stool is in liquid form
d.
Inflammatory / obstructive
process of the lower
intestinal tract
Trauma
Rectal or sigmoid cancer
Diverticulum
o
o
o
Nursing Intervention
1. Emotional support
2. Psychological
Support
3. Heath Education
regarding:
a.surgery (ileostomy/colostomy)
b. Self-care
Chron’s Disease
Ulcerative Colitis
Hirschprung’s 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.
e. 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.
146
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 / Sith’s bath
Surgical Intervention:
Hemorrhoidectomy, Sclerotheraphy, Rubber band ligation, Laser
Surgery, cryosurgery
f. 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.
b.
5.
Blunt Trauma – injury like vehicular accident
Penetrating Abdominal Trauma – stab wound
DISTURBANCES IN FLUIDS AND ELECTROLYTES
Fluid Content in the Human Body :
a. Women
b. Men
c. Infant
d. Elderly
Electrolytes in the Human Body:
a. Sodium (Na)
b. Potassium (K)
c. Chloride (Cl)
d. Bicarbonate (HCO3 )
50-55% of body weight is water
60-70% of body weight is water
75- 80% of body weight is water
47% of body weight is water
-
135-145 mEq/L
3.5 – 5.5 mEq/L
85-115 mEq/L
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
a.
b.
c.
Actions of the Fluids & Electrolytes
Diffusion – fluids move from area of higher concentration to an area of lower concentration
Osmosis - fluids move from an area of lesser concentration to a higher concentration
Filtration – fluids and substances moves from higher hydrostatic pressure to lesser hydrostatic pressure.
Intravenous Solutions Used to correct imbalance:
e. Isotonic – 0.9 NSS, D5W
f. Hypertonic – has greater concentration of solis substances than the fluid substances
e.g.Total Parenteral Nutrition, D50
g. 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
Cause
fluids exceeds the normal volume
the body needs
- physiologic or over hydration as
Fluid Volume Deficit
fluids and/or electrolytes are
loss
physiologic or dehydration
147
in IV therapy
Illness:
Clinical Manifestations
Nursing Interventions
Renal Disease
Neurologic Diseases
Congestive Heart Failure
Addison’s Disease
Renal Disease
Diarrhea
Post-operative conditions
Burns
Trauma
GIT Suction/Drainage
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
Monitor vital signs
Monitor I & O
Fluid restriction
Low sodium diet
Weight daily
Prevent skin breakdown- skin is
fragile
Keep client in Semi-fowler’s
position to establish good gas
exhange
Administer Diuretics as orderedLasix (Furosemide)
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
( Normal Urine Output =30 cc/hr)
Sources of Electrolytes:
Electrolyte
Potassium
Sodium
Magnesium
Calcium
4.1
Food source
Bananas, peaches, melon, prunes, raisins, apricots, tomato, nuts &
vegetables, red meat, turkey
Iodized or table Salt
Peas, beans, nuts, fruits
Milk, cheese, sardines, fish
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
148
•
•
•
•
•
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
149
g. Anemia
h. Elevated BUN, crea, sodium, potassium
Treatment:
Dialysis
Renal Transplant
Nursing Considerations:
Maintain fluid & electrolyte balance
Bedrest
Diet: low protein, low sodium, high CHO and vitamins
Control HPN
WOF cerebral irritation
a.
b.
c.
d.
e.
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.
a.
b.
c.
d.
e.
2.
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:
Weigh daily
Monitor vital signs
Maintain asepsis at all times
Record intake and output
Monitor for complications: Bleeding, peritonitis, abdominal pain, dyspnea, bowel
perforation
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)
150
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:
Good Nutrition
Clean Environment
Early detection of of the disease
Thorough urinary screening of asymptomatic children
Increase casefinding and treatment for chronic glomerulonephritis
Good glycemic control (w/ DM)
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
DISTURBANCES IN CELLULAR FUNCTIONING
6.
6.1.
CANCER
o
o
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:
Ranks third in leading cause of morbidity and mortality
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
A
U
T
A sore that does not heal
Unusual bleeding or discharge
Thickening or lump in breast or
elsewhere
Indigestion or difficulty in
I
Ex. Gastric Ca, Colon Ca, Rectal Ca ,
Renal Ca, Prostate Ca
Ex. Laryngeal Ca
Ex. Uterine Ca
Ex. Breast Ca, Hodgkin’s Lymphoma
Ex. Esophageal Ca
151
O
N
swallowing
Obvious change in wart or mole
Nagging cough or hoarseness
Ex. Melanoma, Squamous cell Ca
Ex. Lung Ca
U
S
Unexplained Anemia
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.
d.
Radiation Therapy – electromagnetic rays destroys cancer cells
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.
b.
c.
d.
e.
Assist the patient in maintaining self-dignity and integrity by continued and sustained
communication and contact
Allow patient to ventilate feelings such as fear, anger, indifference
Make arrangements for spiritual consolation
Assist in rehabilitation even before treatment and until she recovers and adjust to the
society
Collaborate with other health workers for the patient’s holistic needs
152
f.
Home visits and education about the client’s condition, course of treatment and
alternatives
Priorities for Health Supervision:
a. Newly diagnosed cases
b. Post-operative Cases
c. Indigent Cases
d. Terminal Cases
6.2. HEMATOLOGIC PROBLEMS
Normal Values to Remember:
Blood Component
6.2.1.
a.
b.
Normal Values
RBC – red blood cells
Female:
Male:
4.2 – 5.4 x 106
4.7 – 6.1 x 106
Hgb - hemoglobin
Female:
Male:
11.5 – 15.5 g/dL
13.5 – 17.5 g/dL
Hct
Female:
Male:
36 – 48%
40 -52%
- hematocrit
WBC – white blood cells
4,500 – 11,000/ mm3
PC-
150, 000 – 400,000 / mm3
Platelet count
ANEMIA
Causes:
Sudden or Chronic blood loss
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.
c.
Aplastic Anemia - due to radiation, drugs, toxin
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
153


c.
o 2 x a week for 2 weeks, then
o Once a month
Protect lower extremities
Rest in non-stimulating environment
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:






6.2.2.
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
6.2.3.
POLYCYTHEMIA – neoplasm of myeloid cells
Clinical Manifestations:
 Dizziness, headache, tinnitus, fatige, paresthesia, blurred vision, atherosclerosis
6.2.4.
THROMBOCYTOPHENIA - Increased Bleeding Tendencies
6.2.5.
LYMPHOMAS – neoplasm of lymphatic cells
•
Hodgkin’s Lymphoma
•
Non-Hodgkin’s 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
154
5.2.6. BLOOD TRANSFUSION
Types of Blood Components Transfused
Whole Blood
Packed Red Blood Cells
Fresh Frozen Plasma/ Plasma Concentrate
1.
2.
3.
Transfusion Complications
Non-hemolytic reaction- Fever
Hemolytic Reaction- life threatening: fear, chills, backpain, nausea, chest tightness, dyspnea and anxiety
Allergic reaction –urticaria, flushing, itching
Hypervolemia – neck vein distention, dyspnea, orthopnea, tachycardia, sudden anxiety
Diseases Transmitted through Blood Transfusion
 Hepatitis B or C , AIDS / HIV, Cytomegalovirus
Nursing Interventions:
1.
2.
3.
4.
5.
Check name, ID, blood type, expiration, serial #
Take baseline vitals signs
Blood pack should be at room temperature
Monitor for transfusion reaction

Allergic (pruritus, respiratory distress, urticaria)

Hemolytic (low back pain, fever, chills)
Treat transfusion reaction, if present – symptomatic treatment
155
7.
NEUROLOGIC DISTURBANCES
I. Central Nervous System:
Brain
Spinal Cord
II. Peripheral Nervous System
a.
b.
Cranial Nerves – 12 pairs
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:
Oh, Oh, Oh, To Touch And Feel A Girls Veil So Heaven
I
II
III
IV
V
VI
VII
VIII
Smell
Olfactory
Optic
Oculomotor
Trochlear
Trigeminal
Abducens
Facial
Visual Acuity
Pupil constriction and dilation
Eye movement: Inferior and medial
Jaw muscles
Eye movement: Lateral directions
XI
Auditory
Glossopharyngeal
Vagus
Spinal Accessory
XII
Hypoglossal
IX
X
Symmetrical facial movement, Client
identifies taste, Eyelid reaction to stimulus
Hearing Acuity
Gag Response
Ability to speak clearly
Shoulder’s ability to resist against
pressure
Tongue at midline
Neurologic Status:
a.
b.
c.
d.
Conscious- alert, attentive, and follows command
Lethargic- drowsy but awakens; follows command, but slowly and inattentively
Stuporous - arouses to vigorous and continuous stimulation
-response may be an attempt to remove the painful stimulus.
Coma. – no sounds, no movement
THE GLASGOW COMA SCALE
-
An assessment tool measuring the individual’s neurologic status specifically the spontaneity of
the client’s 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
a. Spontaneous
b. To speech
c. To pain
d. No response
Moto
r
Response
a. Obeys verbal commands
b. Localizes pain
c. Flexion: no withdrawal
d. Flexion: abnormal (decorticate)
e. Extension: abnormal (decerebrate)
f. No response to pain on any limb
Points
4
3
2
1
6
5
4
3
2
1
156
a. Oriented
b. Able to Converse
c. Inappropriate speech
d. Makes incomprehensible sound
e. No response
Best verbal
response
5
4
3
2
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….e…e.” sound
GCS Scoring:
GCS Scoring:
Eye opening
Motor Response
Verbal Response
= 4
= 6
= 5
GCS Score
= 15
Eye opening
Motor Response
Verbal Response
GCS Score
= 3
= 1
= 2
= 6
CEREBROVASCULAR ACCIDENT (CVA)
“Stroke”
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
157
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
C1
C2
C3
C4
C5
C6
C7
C8
Head & Neck
Cervical
Nerve
Injury causes
Quadriplegia/
Tetraplegia
Thoracic
Nerve
T1
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
Injury causes
Paraplegia
Lumbar
Nerve
L1
Paralysis of
legs; loss of
bladder and
bowel control
L3
L4
L5
Sacral Nerve
Sexual,
Bladder &
Bowel conrol
Diaphragm
Deltoid, biceps
Wrist Extenders
Triceps
Paralysis below neck; impaired breathing, bowel & bladder
incontinence, sexual dysfunction
Shoulder elevation possible, ventilation support
Elbow, upper arm, wrist movement
Hand
Loss of hand control, Paralysis below waist
Chest Muscles
Abdominal
Muscles
Trunk and Abdominal control
Hip adduction impaired
L2
S1
S2
S3
S4
S5
Spinal Cord
Injury Effect
Leg muscles
Bladder & Bowel control
Sexual Control
Knee and ankle movement impaired
Bladder/Bowel Incontinence,etc
Decrease sensation in the peineum
158
PARKINSON’S DISEASE
Definition:
-
A disorder affecting control and regulation of movement
Unilateral flexion of arms, shuffling gait, difficulty in walking, weakness, disability
Clinical Manifestations:
Rigidity
Involuntary body tremors
Hips and knees flexion
Masklike facial expression
Slurred speech
Drooling
Constipation
Depression
Retropulsion, propulsion
Medical Management:
Anti-parkinsonian Agent:
Anti-cholinergic:
Levodopa
Cogentin
Surgical Management:
Stereotaxic Thalamotomy – surgery of the thalamus to treat disorder
Nursing Interventions:
a.
b.
c.
d.
e.
Rehabiltation – exercise
Speech therapy
Diet: Low CHIN in am, high CHON in PM
High fiber foods to promote bowel elimination
Prevent Injury – fall, etc
MYASTHENIA GRAVIS
Definition: Severe weakness of one or ore 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:
b.
c.
d.
a. Pyridostigmine Bromine (mestinon)
Ambenomium Chloride
Steroids –Prednisone
Atrophine Sulfate
Nursing Interventions:
Avoid fatigue
Administer meds as ordered
Avoi neomycin and morphine
CATARACT
Definition: - the eye lenses becomes thick and unclear or yellowish.
Clinical Manifestations:
2.
3.
4.
Surgical Treatment:
Gradual visual loss.
Hazy vision / Yellowish haze
Whitish to yellowish eyelense.
Cataract extraction
Drug:
1. Mydriatrics - causes dilation of pupils; increases intraocular pressure (IOP)
a. Atrophine Sulfate
b. Phenylephrine Hydrochloride
Vision
Vision w/
w/ Cataract
Cataract
159
2. Cyclopegics – decreases ciliary muscle accomodation
Side effects: blurred vision, increase BP
Nursing Intervention:
2.
3.
4.
Monitor BP; avoid use to patients with HPN
Teach client that blurring of vision may be experienced.
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
Vision w/ Glaucoma
Surgical Management:
1. Trabeculectomy
2. Thermosclerectomy
3. Iridenclesis
Drugs:
Miotics – causes constriction of pupils
1.
2.
3.
4.
Pilocarpine hydrochloride - Drains aqueous humor
Acetazolamide – decreases production of aqueous humor
Mannitol – reduces IOP
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 can’t cure the disease)
3. Encourage moderate exercise
4. Avoid straining of bowel
5. Encourage low residue, high fiber diet
8.
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
•
•
Pain felt after activity
Synovitis
Pain relieved with rest
160
•
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
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
Drugs:
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
Allopurinol
NSAID’s – 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 Raynaud’s
Management:
NSAID’s
Steroids
Cytotoxic drugs
- Azathioprine, Cyclophosphamide
Nursing Intervenions:
a.
b.
c.
Avoid exposure to sunlight because symptoms aggravate symptoms or wear hats,
umbrella or sunscreen
Adequate nutrition, rest and exercise
Stress management, if possible avoid stress
Fractures
Definition:
A break in the continuity of the bones
Clinical Manifestations:
161
Pain
Loss of function
Deformity
False motion
Edema
Spasm
Crepitus
Hematoma around skin
Breaks for penetrating bone fragments
Management:
First Aid
1.
2.
3.
Maintain airway and circulation
Immobilize joints that may be affected; Splint limb
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.
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
Nursing Management:
1.
2.
3.
4.
5 P’s:
9.
Mainatin positioning
For tractionL maintaing weights and countertraction
Clean wounds to prevent infection
Assess for VASCULAR OCCLUSION
5 signs of Vascular Occlusion due to extremely tight casts / traction
a. Pain
b. Pallor
c. Pulselessness
d. PAresthesia
e. Paralysis
INTEGUMENTARY DISTURBANCES
Burn
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
Epidermis, dermis, subcutaneous
tissue; fat, fascia, muscle and bone
Full thickness
Fourth-degree
Rule of Nines:
a. Head and Neck
b. Anterior Truck
-
9%
18%
162
c. Posterior Trunk
d. Arms
e. Legs
f. Perineum
-
18%
9% each = 18%
18% each = 36%
1%
100%
Rule of
Nine’s
Management:
First-Aid:
1.
2.
3.
4.
Burning person: Ask person to stop, drop and roll ( lie down and roll)
Burning person: Stop burning process such as wrapping the burning part with wet towel or blanket
Check airway
First-degree burn: Run cool water to affected area for 10 minutes
Hospital Interventions:
1. Check ABC, give oxygen and IV fluids
2. Assess client’s 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
SHOCK
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
Non- progressive Stage
- Cardiac output is slightly decreased
- Body compensates
Progressive 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
Hypovolemic Shock
Cause
Etiology
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 intraabdominal fluid, malnutrition, severe
dermatitis, DIC
Crystalloid loss: Dehydration, Protracted
Vomiting, Diarrhea, nasogastric suction
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
163
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
-severe hypersensitivity reaction
resulting in massive systemic
vasodilation
c.
Septic Shock
systemic reaction vasodilation
due to infection
interference with nervous
system control of the blood
vessels
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
III. Signs of Shock
Anxiety
Restlessness
Dizziness
Thirst
Fainting
Pale skin, urticaria in anaphylactic shock
Oliguria, Slow capillary refill
BP- hypotension
Pulse – tachycardia, thready, irregular (Cardio.Shock)
Respiration: increased depth, tachypnea, wheezing
(anaphylactic shock)
Temperature: cold clammy skin, elevated in anaphylactic
LOC
- could be alert, oriented, unresponsive
CVP
– below 5 cm H20 (hypovolemic)
- above 15 cms (cardio & septic)
IV. Nursing Care Management
GOAL: Promote venous return, circulatory perfusion
Position: Feet elevated with head slightly elevated also
Ventilation: loosen restrictive clothing, O2, monitor respiration
Fluids: IV, administer blood/plasma as ordered ( stop blood immediately in anaphylactic s.)
Vital signs: CVP, ECG, U.O.,Swan Ganz
Medications (depends on type)
Antihypotensive (epinephrine, norepinephrine, dopamine)
Anti-arrythmics, Cardiac Glycosides, Antibiotics, Adrenocorticoids
Vasodilators (nitroprusside), Beta-adrenergic (dobutamine)
Mechanical support : Military Anti-shock Trousers(MAST)
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
164
Immune System
IV.
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
FIRST AID
*** FIRST AID: Details from www.redcross.org
Dislocation: First aid***
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.
Cuts and scrapes: First aid***
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
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.
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6. Get stitches for deep wounds. A wound that cuts deeply through the skin or is gaping or jaggededged 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
Burns: First aid***
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.
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: First aid***
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.
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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.
Electrical burns: First aid***
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.
Animal bites: 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.
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 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.
Fall prevention: 6 ways to reduce your falling risk***
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 fallprevention 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.
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.
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


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
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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.
Insect bites and stings: First aid***
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
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.
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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.
http://www.redcross.org
RESPIRATORY ARREST
Respiratory Arrest

(-) RR (+) PR.
A condition of the victim wherein there is no breathing but pulse continues
CAUSES:
1.
2.
3.
4.
5.
6.
7.
8.
Strangulation
Poisoning-Injection, Ingestion, Inhalation
 Injection- Snakebite, Rabies, Scorpions, bees, jellyfish, spiders
Severe Bleeding
Drowning
Electrocution
Suffocation
Choking: Universal Sign of Choking- palms guarding throat
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
Unconscious
1. Abdominal Thrust 10X
Blind Finger sweep for adults
Total Airway Obstruction with No Air
Exchange
2. Artificial Respiration (AR) 2X
3. Check if Air is going backLook, 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.
2.
3.
4.
5.
6.
Mouth to Mouth - usual method
Mouth to Nose - if mouth is obstructed
Mouth to Mouth & Nose – used in infants
Mouth to Stoma - like for patients with tracheostomy
Mouth to Mask
Ambu Bag to Mouth & Nose
Ambu Bag- a device used for artificial mechanical breathing unit
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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.
2.
3.
4.
5.
When the rescuer is exhausted
When the victim is breathing on his own
When the service of the physician is available
When the pulse disappears; artificial respiration is stopped and cardiopulmonary rescucitation begins
When another first aider takes over
CARDIAC ARREST
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
Location Of Chest Compressions
1.
2.
ADULT- 3 fingers above mid xiphoid
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 ½’- 2”
1”- 1 ½”
½” – 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
DON’T’S IN CPR:
1.
2.
3.
4.
5.
6.
Don’t be a double crosser
Don’t be a rocker
Don’t be a jerker
Don’t be a render
Don’t be a bouncer
Don’t be a massager
CPR- start with 2 blows end with 2 blows
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SEQUENCE:
1.
2.
3.
4.
5.
6.
7.
8.
Survey the scene “ the scene is safe”
Check for responsiveness “ Hey 2X, R U Okay”
Position the victim
Open and Clear the airway (head tilt chin lift) “Mouth is clear”
Check breathing for 3-5 seconds (LLF) 1001, 1002, etc. “Breathless”
If Breathless, give 2 blows
Check for Pulse: Carotid 5-10 seconds
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 I’ll do…AR or CPR”
10. After each cycle, check pulse for 5 sec. then deliberate
11. Recovery Position
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