Scope of Nle1116
Scope of Nle1116
Scope of Nle1116
Dear Lord, as I take this exam, I thank you that my value is not based on my performance, but on your
great love for me.
Come into my heart so that we can walk through this time together.
Help me not only with this test, but the many tests of life that are sure to come my way.
As I take this exam, bring back to my mind everything I studied and be gracious with what I have
overlooked. Help me to remain focused and calm,confident in the facts and in my bility, and firm in the
knowledge that no matter what happens today you are there with me. Amen
2. APPRENTICE NURSING
*Extends from the founding of religious orders in the 6th century through the
crusades which began in the 11th century to 1836.
*The Deacons School of Nursing at Kaisserwerth, Germany established by pastor
Fliedner and his wife.
*Period of on the job training- desired of person to be trained
3. EDUCATED NURSING
*Began in 1860.
*Florence Nightingale School of Nursing opened at St. Thomas in London.
First program of formal education for nurses started.
4. CONTEMPORARY NURSING
*Began at the end of World War II (1945)
*Scientific and Technological developments of many social changes occurs.
INTUITIVE NURSING
*Cause of illness was believed to be the invasion of the victims body by an evil spirit.
*Uses black magic or voodoo to harm or driven out by using supernatural power.
*Believed in medicine man (shaman or witch doctor) that had the power to heal by using
white magic.
They made use of hypnosis, charms, dances, incantations, purgatives, massage,fire,
water, herbs or other vegetations and even animals.
*Performing a trephine
Drilling a hole in the skull with a rock or stone without benefit of anesthesia.
Goal of this therapy is to drive the evil spirit from the victims body.
*Nurses role was instinctive directive toward comforting, practicing midwifery and being
wet nurse to a child.
*Act performed without training and direction.
Babylonia
*Practice of medicine is far advanced.
*Code of Hammurabi.
-Legal and Civil measures is establish
-Regulate the practice of physicians
-Greater safety of patient provided
*No mention of Nurses or nursing this time
Egypt
*Art of embalming enhance their knowledge of human anatomy
*Developed the ability to make keen clinical observations and left a record of 250
recognized diseases.
*Control of health was in the hands of Gods. The first acknowledged physicians was
Imhotep.
*Made great progress in the field of hygiene and sanitation.
*Reference to nurses in Moses 5th book is a midwife and wet nurse.
Palestine
*The Hebrews book of genesis emphazised the teachings of Judaism regarding
hospitality to the stranger and acts of charity.
*Implementation of laws like
-controlling the spread of communicable disease
-cleanliness
-preparation of food
-purification of man (bathing and his food.
*The ritual of circumcision of the male child on the 8th day
*The established of the High Priest Aaron as the physician of people.
China
*Culture was imbued with the belief in spirits and demons.
*Gave the world the knowledge of material medica (pharmacology); method of treating
wounds, infection and muscular afflictions.
*Chan Chun Ching Chinese Hippocrates.
*Emperor Shen Nung said to be the father of Chinese medicine and the inventor of
acupuncture technique.
*No mention of nursing in Chinese writings so it is assumed that care of the sick will fall
to the female members of the household.
India
*First recorded reference to the nurses taking care of patients on the writings of
shushurutu.
*Functions and Qualifications of nurse includes:
- Knowledge in drug preparation and administration.
- Cleverness.
- Devotedness to the patient.
- Purity of both mind and body.
*King Asoke, a Buddhist, published an edict to established hospitals throughout India
where nurses were employed.
Greece
*Made contribution in the area aesthetic arts and clinical medicine, but nursing was the
task of the untrained slave.
*Aesculapius, The Father of Medicine in Greek mythology to whom we associate the
Caduceus, (known insignia of medical profession today)
*Hippocrates, the Father of Medicine insisted that magic and philosophical theories had
no place in medicine.
*The work of women was restricted to the household. Where mistress of the mansion
gave nursing care to the sick slaves.
Rome
*Acquired their knowledge of medicine from the Greeks.
*Emperor Vespasian opened schools to teach medicine.
*Developed military medicine First aid, field ambulance service and hospitals for
wounded soldiers.
*Translated Greek medical terminologies into Latin terms which has been used in
medicine ever since.
APPRENTICE NURSING
*Religious orders of Christian Church played a major role in this kind of nursing.
The Crusades (11th Century)
*Series of holy wars were conducted by Christian in an attempt to recapture the Holy land
from the Turks.
*Military religious orders founded during the crusades established hospitals and staffed
them with men who served as nurses. Among these were:
- The knights of St. John of Jerusalem served both as warriors in battle and nurses
in the hospital and was called Knights Hospitallers.
- The Teutonic Knights built hospitals cared for sick and denfended the faith.
- The Knights of St. Lazarus established primarily for the nursing of lepers,
forerunners of our now known communicable diseases hospital (also called lazarettos).
Nursing Saints
* St. Hildegarde a Benedictine abbess in Germany, actually prescribed cures in her 2
books on medicine and natural history.
* St. Francis and Clara took vows of poverty, obedience, service and chastity and took
care of the sick and the afflicted; founders of the Franciscan Order and the Order of the
Poor Clares respectively.
* St. Elizabeth of Hungary the patroness of nurses; built a hospital for the sick and the
needy.
* St. Catherine of Siena the 1st lady with a lamp; became a tertiary of St. Dominic
and engaged in works of mercy among the sick and of the Church.
The Reformation
* St. Vincent de Paul set up the first program of social service in France and organized
the Community of the Sisters of Charity. His 1st superior and co-founder was Louise
de Gras (nee de Marillac).
England
* June 15, 1860 marked the day when 15 probationers entered St. Thomas Hospital
in London to establish the Nightingale system of Nursing, founded by Florence
Nightingale (May 12, 1820). Among the highlights in her life are the following:
- At age of 31, obtained parental consent to enter the Deaconess School at
Kaisserwerth.
- Had 3 months training at Kaisserwerth; later superintendent of the Establishment
for Gentlewomen During Illness (1853) during which time she initiated the policy of
admitting and visiting the patients of all faiths.
- In 1854 a Volunteered for Crimean war service together with 38 women at Scutari in
the Crimea upon the request of Sir Sidney Herbert, Minister of War in England. At first
their work is not accepted because it consisted of cleaning the area, thus reducing the
infections, clothing for the men, writing letters to their families; their work served as
inspiration for the Red Cross later on.
- In 1860 started the Nightingale System of Nursing at the St. Thomas Hospital in
London believed that schools should be self-supporting; that schools of nursing should
have decent living quarters for their student; that they should have paid nurse
instructors; that the school should correlate theory to practice and these students should
be taught the why not just how in nursing.
- 2 books written Note on Nursing and Notes on Hospital, contain many timely
portions applicable in the 1970s as they were in 1859.
United States
* At the time that Florence Nightingale was opening her school in London; the U.S was
on the brink of the civil war. However though the country was in a condition of chaos,
nursing had many supporters and the needs to train nurses were recognized.
- Linda Richards is the first graduate nurse in the U.S completed her training at the
New England Hospital for Women and Children in Boston, Massachusetts, patterned
after the DeaconessesSchool of Kaisserwerth.
- In 1873 3 schools of nursing opened, patterned after the Nightingale plan the
Bellevue Training School for Nurse in the New York City , the Connecticut training.
School in New Haven and the Massachusetts General Hospital in Boston.
- In 1881 founding of American Red Cross by Clara Barton.
- In 1889 John Hopkins hospital opened a school of Nursing with Isabel Hampton
Robb as its 1st principal and the person most influential in directing the development of
nursing in the U.S.
- In 1893 the groundwork for the estimate of the 2 new nursing organization was
lad:
1. The Associated Alumnae, later known as the American Nurses Association was
begun at the Chicago Worlds fair and
2. The American Society of Superintendent of Training Schools for Nurses, later
known as the National League for Nursing Education, also began.
- During the Spanish American War (1898 1899) nurse were concerned with the
care of the wounded as well as care of those inflected with malaria and yellow fever.
Nurse Clara Louise Maas gave her life for the advancement of medical science in the
search for control yellow fever.
* 1913 1937
- a standard curriculum for schools of nursing was prepared by the National League
for Nursing Education.
- the practice of nursing was gradually infiltrated with educational objectives.
CONTEMPORARY NURSING
* Creation of United Nations in San Francisco California in 1945.
2 folds purpose are:
- International peace and international security with provisions for equal justice,
Machinery for peaceful disputes and provisions.
- Provisions for assuring human rights, social justice and economic progress.
*Fray Juan Clemente was one of the 1st members of the Mission of the Order of St.
Francis in the Philippines in 1578.
- Collected native herbs for medicine later set a little pharmacy which he filled with
various medical remedies.
- Performed both the function of a physician and those of a nurse.
*Persons who really did nursing care of the sick were religious group (called
hospitallers) but they were assisted by Filipino attendants.
*In the early development of nursing, the work of the nurse and those of the physician
were not clearly defined.
* The Filipino Red Cross had its own constitution approved by the revolutionary
government. This was founded on February 17, 1899 with Dona Hilaria Aguinaldo as
president and Dona Sabina Herrera as secretary.
22. St. Rita Hospital and School of Midwifery (1956) and Nursing (1960)
1. Nursing Leaders
Florence Nightingale (1820-1910)
-recognized as nursings first scientist-theorist for her work, Notes on Nursing:
What It is, and What It is Not
-considered the founder of modern nursing.
-developed the Nightingale Training School of Nurses, which operated in 1860.
The scchool served as a model for other training schools. Its graduates traveled to
other countries to manage hospitals and institute nurse-training programs.
-Nightingales vision of nursing, which include public health and healt promotion
roles for nurses, was only partially addressed in the early days of nursing. The
focus tended to be on developing the profession within hospitals.
Clara Barton (1812-1921)
-organized the American Red Cross, which linked with the International Red
Cross when the U.S Congress ratified the Geneva Convention in 1882.
Lilian Wald (1867-1941)
-considered the founder of Public Health Nursing.
Lavinia L. Dock (1858-1956)
-active in the protest movement for womens right that resulted in the U.S
Constitution amendment in 1920, allowing women to vote.
Margaret Sanger (1879-1966)
-a nurse activist; considered the founder of planned Parenthood, was imprisoned
for opening the first birth control information clinic in Baltimore in 1916.
Lydia Hall
-developed the Care, Core, and Cure Theory
-Goal: To Care, and Cure Cores disease.
-Care for the patients BODY. Cure the DISEASE. Treat the PERSON ( or patient)
as the Core.
B. Nursing as a Profession
NURSING AS A PROFESSION
Criteria of Profession:
1. To provide a needed service to the society.
2. To advance knowledge in its field.
3. To protect its memebers and make it possible to practice effectively.
Characteristics of a Profession:
1. A basic profession requires an extended education of its members, as well as a basic
liberal foundation.
2. A profession has a theoretical body of knowledge leaing to defined skills, abilities and
norms.
3. A profession provides a specific service.
4. Members of a profession have autonomy in decision-making and practice.
5. The profesion has a code of ethics for practice.
NURSING
- is a desciplined involved in the delivery of health care to the society.
- is a helping profession.
- is service-oriented to maintain health and well-being of people.
- is an art and science.
Characteristics of Nursing:
1. Nursing is caring.
2. Nursing involves close personal contact with the recipient of care.
3. Nursing is concerned with services that take humans into account as physiological,
psychological, and sociological organism.
4. Nursing is committed to promoting individual, family, community, and national health
goals in its best manner possible.
5. Nursing is committed to personalized services for all persons without regard to color,
creed, social or economic status.
6. Nursing is committed to involvement in ethical, legal, and political issues in the delivery
of health care.
Roles of a Professional
1. Caregiver/Care provider
- the traditional and most essential role.
- functions as nurturer, comforter, provider.
- mothering actions of the nurse.
- provides direct care and promotes comfort of client.
- activities involves knowledge and sensitivity to what matters and what is important to
clients.
- show concern for client welfare and acceptance of the client as a person.
2. Teacher
- provides information and helps the client to learn or acquire new knowledge and
technical skills.
- encourages compliance with prescribed therapy.
Promotes healthy lifestyle.
- interprets information to the client.
3. Counselor
- helps client to recognize and cope with stressful psychologic or social problems; to
develop an improve interpersonal relationships and to promote personal growth.
- Encourages the client to look at alternative behaviors recognize the choices and
develop a sense of control.
4. Change agent
- initiate changes or assist clients to make modifications in themselves or in the system of
care.
5. Client advocate
- involves concern for and actions in behalf of the client to bring about a change.
- promotes what is best for the client, ensuring that the clients needs are met and
protecting the clients right.
- provides explanation in clients ;anguage and support clients decisions.
6. Manager
- makes decisions, coordinates activities of others, allocate resource evaluate care and
personnel.
- plans, give direction, develop staff, monitor operations, give the reward fairly and
represent both staff and administrations as needed.
7. Researcher
- participates in identifying significant researchable problems.
- participates in scientific investigation and must be a consumer of research findings.
-must be aware of the research process, language of research, a sensitive to issues
related to protecting the rights of human subjects.
1. Clinical Specialists
- is a nurse who has completed a masters degree in specialty and has considerable
clinical expertise in that specialty. She provides expert care to individuals, participates in
education health care professionals and ancillary, acts as a clinical consultant and
participates in research.
2. Nurse Practitioner
-is a nurse who has completed either as a certificate program or a masters degree in a
specialty and is also cerified by the appropriate specialty organization. She is skilled at
making nursing assessments, performing P.E., counselling, teaching and treating minor
and self-limiting illness.
3. Nurse-Midwife
- a nurse who has completed a program in midwifery; provides prenatal and postnatal
care and delivers babies to woman with uncomplicated pregnancies.
4. Nurse Anesthetist
- a nurse who completed the course of study in an anesthesia school and carries out pre-
operative status of clients.
5. Nurse Educator
- a nurse usually with advanced degree, who beaches in clinical or educational settings,
teaches theoretical knowledge, clinical skills and conduct research.
6. Nurse Entrepreneur -
- a nurse who has an advanced degree, and manages health-related business.
7. Nurse Administrator
- a nurse who functions at various levels of management in health settings; responsible
for the management and administration of resources and personnel involved in giving
patient care.
2. Public Health Nursing/Community Health Nursing usually deals with families and
communities. ( no confinement, OPD only ).
Example: brgy, Health Center.
5. Nursing Education nurses working in school, review center and hospital as a C.I.
Roper, Logan, and Tierney - Model for Nursing Based on a Model of Living
Conceptual Components
o 12 Activities of Living (AL) - complex process of living in the view of an amalgam of
activities
1. Maintain safe environment 7. Temperature
2. Communicate 8. Mobility
3. Breathe 9. Work and play
4. Eat and drink 10. Express sexuality
5. Eliminate 11. Sleep
6. Personal cleansing and dressing 12. Dying
III. Theories
*Group of related concepts that proposes actions that guide practice. May be broad but
limited only to particular aspects
Middle-range Theories
*The least abstract level because they include specific details in nursing practice like
population, condition and location.
C. HEALTH EDUCATION
1. Assess the learning needs of the patient and family.
2. Develops health education plan based on assessed and anticipated needs.
3. Develops learning materials for health education.
4. Implements the healtheducation plan.
5. Evaluates the outcome of health education.
D. LEGAL RESPONSIBILITY
1. Adheres to practice in accordance with the nursing law and other relevant legislation
including contracts, informed consent.
2. Adheres to organizational policies and procedures, local and national.
3. Documents care rendered to patients.
E. Ethico-Moral Responsibility
1. Respects the rights of individuals/groups.
2.Accepts responsibility and accountability for own decisions and actions.
3. Adheres to the national and international code pf ethics for nurses.
G. Quality Improvement
1. Utilizes data for quality improvement
2. Participtaes in nursing audits and rounds.
3. Identifies and reports variances.
4. Recommends solutions to identified causes of the problems.
5. Recommends improvement of systems and processes.
H. Reasearch
1. Utilizes varied methods of inquiry in solving problems.
2. Recommends actions for implementation.
3. Disseminates results of research findings.
4. Applies research findings in nursing practice.
I. Record Management
1. Maintains accurate and updated documentation of patient care.
2. Records outcome of patient care.
3. Observes legal imperatives in record keeping.
4. Maintains an effective recording and reporing system.
J. Communication
1. Utilizes effective communication in relating with clients, members with the team and
the public in general.
2. Utilizes effective communicationin therapeutic use of self to meet the needs of clients.
3. Utilizes formal and informal channels.
4. Responds to needs of individuals, families, groups and communities.
5. Uses appropriate information technology to facilitate communication.
K. Collaboration and Teamwork
1. Establishes collaborative relationship with colleagues and other members of the health
team for the health plan.
2. Functions effectively as a team player.
2. Fields of Nursing
3. Roles and Functions
V. Legal Responsibility
A. Legal Aspects in the Practice of Nursing
B. The Philippine Nursing Law of 2002 (R.A 9173)
C. Related Laws Affecting the Practice of Nursing
IX. Research
A. Problem Identification
B. Ethics and Science of Research
C. The Scientific Approach
D. Research Process
E. Research Designs and Methodology
1. Qualitative
2. Quantitative
F. Utilization and Dissemination of Research Findings
X. Communication
A. Dynamics of Communication
B. Nurse-Client Relationship
C. Professional-Professional Relationship
D. Therapeutic Use of Self
E. Use of Information Technology
I. Safe and Quality Care, Health Education and Communication, Collaboration and Team
work
COMMUNITY HEALTH NURSING
HISTORY OF CHN
Date
1901 Act # 157 (Board of Health of the Philippines) ;
Act # 309 (Provincial and Municipal Boards of Health) were created.
1095 Board of Health was abolished; functions were transferred to the Bureau of
Health.
1912 Act # 2156 or Fajardo Act created the Sanitary Divisions, the forerunners of
present MHOs; male nurses performs the functions of doctors.
1919 Act # 2808 (Nurses Law was created)
- Carmen del Rosario, 1st Filipino Nurse supervisor under Bureau of Health.
October 22, 1922 Filipino Nurses Organization (Philippines Nurses Organization) was
organized.
1923 Zamboanga General Hospital School of Nursing and Baguio General Hospital
were established; other government schools of nursing were organized several years
after.
1928 1st Nursing convention was held
1940 Manila Health Department was created.
1941 Dr. Mariano Icasiano became the first ciy health officer; Office of Nursing was
created through the effort of Vicenta Ponce (Chief Nurse) and Rosario Ordiz (assistant
chief nurse)
December 8, 1941 Victims of World War II were treated by the nurses of Manila.
July 1942 Nursing Office was created; Dr. Eusebio Aguilar helped in the release of 31
Filipino Nurses in Bilibid Prison as Prisoners of War by the Japanese.
February 1946 Number of Nurses decreased from 556 308.
1948 First training center of the Bureau of Health was organized by the Pasay City
Health Department. Trinidad Gomez, Marcela Gabatin, Constancia Tuazon, Ms. Bugarin,
Ms. Ramos, and Zenaida Nisce composed the training staff.
1950 Rural Health Demonstration and Training Center was created.
1953 The first 81 Rural Health Units were organized.
1957 RA 1891 Ammended some sections of RA 1082 and created the eight categories
of Rural Health Unit causing an increase in the demand for the community health
personnel.
1958 1965 Division of Nursing was abolished (RA 977) and Reorganization
Act (EO 288)
1961 Annie Sand organized the National Nurses of DOH.
1967 Zenaida Nisce became the nursing program supervisor and consultant on the six
special diseases (TB, Leprosy, V.D., Cancer, Filariasis, and Mental Health Illness).
1975 Scope of responsibility of nurses and midwives became wider due to restructuring
of the health care delivery system.
1976 1986 The need for Rural Health Practice Program was implemented.
1990 1992 Local Government Code of 1991 (RA 7160)
1993 1998 Office of Nursing did not materialize in spite of persistent recommendation
of the officers, board members, and advisers of the National League of Nurses Inc.
January 1999 Nelia Hizon was positioned as the nursing adviser at the Office of Public
Health Services through Department Order # 29.
May 24, 1999 EO # 102, which redirects the functions and operations of DOH, was
signed by former President Joseph Estrada.
R.A 2382 Philippine Medical Act. This act defines the practice of medicine in the
country.
R.A 1082 Rural Health Act. It created the 1st 81 Rural Health Units.
- amended by R.A 1891; more physicians, dentists, nurses, midwives and
sanitary inspectors will live in the rural areas where they are assigned in order to raise
the health conditions of barrio people, hence help decrease the high incidence of
preventable diseases.
R.A 6425 Dangerous Drugs Act. It stipulates that the sale, administration, delivery,
distribution and transportation of prohibited drugs is punishable by law.
R.A 9165 The New Dangerous Draug Act of 2002.
P.D No. 651 requires that all Health Workers shall identify and encourage the
registration of all births within 30 days following delivery.
P.D No. 996 requires the compulsary immunization of all children below 8 years of age
against the 6 childhood immunizable diseases.
P.D No. 825 provides pernalty for improper disposal of garbage.
R.A 8749 Clean Air Act of 2000
P.D No. 856 Code of Sanitation. It provides for the control of all factors in mans
environment that affect health including the quality of water, food, milk, insects, animal
carriers, transmitters of disease, sanitary and recreation facilities, nilse, pollution and
control of nuisance.
R.A 6758 Standardizes the salary of government employees including the nursing
personnel.
R.A 6675 Generics Act of 1988 which promotes, requires and ensures the production
of an adequate supply, distribution, use and acceptance of drugs and medicines
identified by their generic name.
R.A 6713 Code of Conduct and Ethical Standards of Public Officials and Employees. It
is thepolicy of the state to promote high standards of ethics in public office. Public
officials and employeesshall at all times be accountable to the people and shall
discharges their duties with utmost responsibility, integrity, competence and loyalty, act
with patriotism and justice, lead modest lives uphold public interest over personal
interest.
R.A 7305 Magna Carta for Public Health Workers. This act aims: To promote and
improve the social and economic well-being of health workers, their living and working
conditions and terms of employment; to develop their skills and capabilities in order that
they will be more responsive and better equipped to deliver health projects and
programs; and to encouragethose with proper qualifications and excellent abilities to join
and remain in government service.
R.A 8423 Created the philippine Institute of Traditional and Alternative Health Care.
P.D No. 965 requires applicants for marriage license to receive instructions on family
planning and responsible parenthood.
P.D No. 79 defines, objectives, duties, and functions of POPCOM.
R.A 4073 advocates home treatment for lepsrosy.
Letter of Instruction No. 949 legal basis of PHC dated october 19, 1979.
-- promotes development of health programs on the community
level.
R.A 3573 requires reporing of all cases of communicable diseases and administration
of prophylaxis.
Misnistry Circular No. 2 of 1986 includes AIDS as notifiable disease.
R.A 7875 National Health Insurance Act
R.A 7432 Senior Citizens Act
R.A 7719 National Blood Services Act
R.A 8172 Salt Iodization Act ( ASIN LAW)
R.A 7277 Magna Carta for PWDS, provides their rehabilitation, self-development and
self-reliance and integration into the mainstream of society.
*A.O No. 2005 0014 National Policies on Infant and Young Child Feeding:
1. All newborns be breastfeed within 1 hour after birth.
2. Infants be exclusively breastfeed for 6 months.
3. Infants be given timely, adequate and safe complementary foods
4. Breastfeeding be continued up to 2 years and beyond.
I. Definition of Terms
Community derived from a latin word communicas which means a group of people.
- a group of people with common characteristics or interests living together within a
territory or geographical boundary.
- place where people under usual conditions are found.
COMPONENTS:
INDIVIDUAL PERCEPTIONS: Includes perceived susceptivility,seriousness and
threat. Seriousness of an illness.
MODIFYING FACTORS: Includes demographic variables, sociophysiologic
variables, structural variable, and cues to action. Susceptibility to an illness.
LIKELIHOOD TO ACTION: Depends on the perceived benefit versus the
perceived barriers. Benefits of taking actions.
Males age 40-49 seafarers ratio: 1: 5 anal sex- wont get pregnant, common in
rural
Vaginal: 1: 1000
PUBLIC HEALTH ( Dr. C.E. Winslow ) the science and art of preventing disease,
prolonging life, promoting health and efficiency through organized community effort for
the sanitation of the environment, control of communicable diseases, the education of
individuals in personal hygiene, the organization of medical and nursing services for
the early diagnosis and preventive treatment of diseases and the development of
social machinery to ensure everyone a standard of living adequate for the
maintenance of health, so organizing these benefits as to enable every citizen to
realize his birthright of birth and longevity.( Dr C.E Winslow ).
Art of Applying Science in the context of Politics so as to reduce Inequalities in Health
while ensuring the best health for the greatest number.
Aims:
1. health promotion
2. disease prevention
3. management of factors affecting health.
1. Virginia Henderson
- Assisting sick individuals to become healthy and healthy individuals achieve optimum
wellness
2. Dorothea Orem
- Providing assistance to clients to achieve self-care towards optimum wellness.
Early years- fetus- 12 years/ younger adults- 12-24 years
Orem- self care, autonomy----independent patient
3. Florence Nightingale
- Placing an individual in an environment. that will promote optimum capacity for self-
reparative process
- individual capable of self-repair and there is something to repair in an individual.
(Maglaya)
- The Utilization of the nursing process in the different levels of clientele individuals,
families, population groups and communities, concerned with the promotion of health,
prevention of disease and disability and rehabilitation.
(Jacobson)
- is a learned practice disciplined with the ultimate goal of contributing as individual and
incollaboration with others, to the promotion of clients optimum level of functioning
through teaching and delivery of care.
(Dr. Ruth B. Freeman)
- a service rendered by a professional nurse to IFCs population groups in health centers,
clinics schools, workplace for the promotion of health, prevention of illness, care of the
sick at home and rehabilitation.
- Technical nursing, interpersonal, analytical and organizational skills are applied to
problems of health as they affect the community.
-Unique blend of nursing & public health practice aimed at developing & enhancing
health capabilities of the people , service rendered by a professional nurse with the
comm., grps, families, and indiv at home, in H centers, in clinics, in school, in places of
work for the ff:
1. Promotion of health
2. Prevention of illness
3. Care of the sick at home and rehab - self-reliance
Concepts
1. The primary focus of community health nursing practice is on health promotion and
disease prevention.
Primary goal self reliance in health or enhanced capabilities.
Ultimate goal raise level of number of citizenry.
Philosophy of CHN Worth and dignity of man.
2. CHN practices to benefit the individual, family, special groups, and community
*CHN is integrated and comprehensive
3. Community Health Nurses are generalist in terms of their practice through life but the
whole community its full range of health problems and needs.
4. Community Health Nurses are generalist in terms of their practice through life
continuity in its full range of health problems and needs.
5. The nature of CHN practice requires that current knowledge derived from the
biological, social science, ecology, clinical nursing and community health organizations
be utilized.
6. Contact with the client and or family may continue over a long period of time which
includes all ages and all types of health care.
Levels of Health Care:
Primary Health Care: Management at the level of community
Secondary Health Care: Regional, District, Municipal, and Local Hospital
Tertiary Health Care: Sophisticated Medical Center Heart Center, KI
7. The dynamic process of assessing, planning, implementing and intervening provide
measurements of progress, evaluation and a continuum of the cycle until the termination
of nursing is implicit in the practice of Community Health Nursing.
Nursing Function:
Independent without supervision of MD
Collaborative in collaboration with other Health team (
interdisciplinary, intrasectoral )
Goal: To raise the level of citizenry by helping and families to cope with the
discontinuities in and threats to health in such a way as to maximize their potential for
high-level wellness. Nisce, et al
To elevate the level health of the multitude.
PHILOSOPHY OF CHN
*The philosophy of CHN is based on the worth and dignity of man.
1. Planner/ Programmer- identifies needs, priorities & problems if individual, family, &
comm.
- Formulates nursing component of H plans
In doctorless areas, she is responsible for the formulation of the municipal
health plan
Provides technical assistance to rural health midwives in health matters like
target setting.
2. Provider of Nursing care- provides direct nsg care to the sick, disabled in the homes,
clinics, schools,
or places of work
provide continuity of patient care
3. Manager/ Supervisor- formulates care plan for the:
4 Clientele:
a. Requisitions, allocates, distributes materials (meds & medical supplies &
records & reports equips
b. Interprets and implements programs, policies, memoranda, & circulars
c. Conducts regular supervisory visits & meetings to diff RHMs & gives feedbacks
on accomplishments
4. Community Organizer- motivates & enhance community participation in terms of
planning, org, implementing
and evaluating Health programs/ services.
5. Coordinator of Health Services- coordination with other health team & other govt org
(GOs & NGOs) to other
health programs as envt. sanitation health education, dental health & mental
health.
6. Trainer/ Health educator/ counselor- conducts training for RHMs, BHWs, hilots who
aim towards H promo & illness prevention through dissemination of correct info;
educating people
7. Researcher- coordinates with govt. & NGOs in the implementation of studies/
researches
participates in the conduct of surveys studies & researches on Nsg and H
related subjs.
8. Health Monitor----evaluating what deviates from normal
9. Manager ---under the nurse---midwives
10. Change Agent
11. Client Advocate
PUBLIC HEALTH
1. WINSLOW
- The science & art of preventing disease, prolonging life, promoting health &
efficiency through
organized community effort
To enable each citizen to realize his birth right of health & longevity.
Major concepts:
1. Health promotion
2. Peoples participation towards self-reliance
2. HANLON
- Most effective goal towards total development and life of the individual & his
society
3. PURDOM
- Applies holism in early years of life, young, adults, mid year & later
- Prioritizes the survival of human being
Concepts
1. Science and Art of Preventing diseases, prolonging life, promoting health and
efficiency through organized community effort for the:
a. sanitation of the environment.
b. control of communicable diseases.
c. the education of individuals in personal hygiene.
d. organization of medical and nursing services for early diagnosis and preventive
treatment of disease, and the development of social machinery to ensure everyone a
standard of living adequate for the maintenance of health, so organizing these benefits
as to enable every citizen to realize his birthright of health and longevity.
Determinants of Health
*Factors that can affect health
a. Income and social status - socioeconomic
b. Education - socioeconomic
c. Physical Environment - Environment
d. Employment and working conditions - socieconomic
e. Social support networks - socioeconomic
f. Culture, Customs and Traditions - Behavior
g. Genetics - Heredity
h. Personal Behavior and coping skills - Behavior
i. Health Services Health Care Delivery System
j. Gender Heredity
-ECOSYSTEM influence on OLOF ( Blum 1974 ).
PRINCIPLES
1. The need of the community is the basis of community health nursing.
2. The community health nurse must understand fully the objectives and policies of the
agency she represents.
3. The family is the unit of service.
4. CHN must be available to all regardless of race, creed and socioeconomic status.
5. The CHN works as a member of the health team
6. There must be provision for periodic evaluation of community health nursing service.
7. Opportunities for continuing staff education programs for nurses must be provided by
the community health nursing agency and the CHN as well.
8. The CHN makes use of available community health resources.
9. The CHN taps the already existing active organized groups in the community.
10. There must be provision for educative supervision in community health nursing.
11.There should be accurate recording and reporting in community health nursing.
12. Health teaching is the primary responsibility of the community health nurse.
STANDARDS IN CHN
I. Theory
Applies theoretical concepts as basisfor decisions in practice.
II. Data Collection
Gathering comprehensive, accurate data systematically.
III. Diagnosis
Analyzes collected data to determine the needs / health problems of Individual,
Family, Community.
IV. Planning
At each level of prevention, develops plans that specify nursing actions unique to
needs of clients.
V. Intervention
Guided by the plan, intervenes to promote, maintain or restore health, prevent illness
and institute rehabilitation.
VI. Evaluation
Evaluates responses of clients to interventions to note progress toward goal
achievement, revise data base, diagnose and plan.
VII. Quality Assurance and Professional Development
Participates in peer review and other means of evaluation to assure quality of nursing
practice.
Assumes professional development.
Contributes to development of others.
VIII. Interdisciplinary Collaboration
Collaborates with other members of the health team, professionals and community
representatives in assessing, planning, implementing and evaluating programs for
community health.
IX. Research
Indulges in research to contribute to theory and practice in community health nursing.
B. Levels of Care
LEVELS OF CARE/PREVENTION
a. The Three Levels of Helath Care Sevices
PRIMARY
-Is devolved to the cities and the municipalities. It is health care provided by center
physicians, public health nurses, rural health midwives, barangay health workers,
traditional healers and others at the barangay health stations and rural health units. The
primary health facility is usually the first contact between the community members and
the other levels of health facility.
- activites that prevent a problem before it occurs. Example: Immunization.
SECONDARY
-Secondary care is given by physicians with basic health training. This is usually given in
health facilities and district hospitals and out-patient departments of provincial hospitals.
This serves as a referral center for the primary health facilities. Secondary facilities are
capable of performing minor surgeries and perform some simple laboratory examinations.
- activities that provide early detection/diagnosis and treatment and Intervention.
Example: Breast self-examination, HIV screening, Operation timbang.
TERTIARY
-Is rendered by specialists in health facilities including medical centers as well as regional
and provincial hospitals, and specialized hospitals such as the Philippine Heart Center.
The tertiary health facility is the referral center for the secondary care facilities.
Complicated cases and intensive care requires tertiary care and all these can be
provided by the tertiary care facility.
- activities that correct a disease state and prevent it from further deteriorating.
Example: Teaching Insulin Administration in the home
b. Three Levels of Health Care Services and the Two Way Referral System
C. Types of Clientele
TYPES OF CLIENTELE
INDIVIDUAL
- People who visits the health center.
- People who receives health services.
e.g., Prenatal Supervision
Well Child Follow ups.
Morbidity Service
Teaching Client on Insulin Administration
Basic approaches in looking at the individual:
1. atomistic the basic constituents of an individual, use concepts of biology which in
turn refers to essentialism --- behavior --- psychological --- human behavior s dictated by
experience.
2. holistic suprasystems sociological in nature social constructionism nurture
behavior
SEX --- a biological concept (male / female)
--- a sociological concept --- gender --- musculinity or femininity --- based on
culture.
--- on sexual orientation: attracted to Opposite sex heterosexual
Same sex homosexual
Both bisexual
FAMILY
- 2 or more individuals who commit to live together for an extended period of time not
necessarily with marital affinity or blood relations.
- Considered as the basic unit of care.
a. Nuclear
b. Extended with lolos and lalas, titios and titas
c. Cohabiting live-in, Not married but with kids.
d. Dyad married but without kids.
MODELS:
Stages of Family Development by Evelyn Duvall
STAGE 1 The Beginning Family ( newly wed couples ).
TASK: Compliance with the PD 965 and acceptance of the new member of the family.
STAGE 2 The Early Child Bearing Family ( 0 30 months ).
TASK: Emphasize the importance of pregnancy and immunization and learn the concept
of parenting
STAGE 4 The Family with School Age Children ( 6 -12 years old).
TASK: Reinforce the concept of Responsible Parenthood.
STAGE 6 Launching Center ( 1st Child will get married upto the last child ).
TASK: Compliance with the PD 965 and acceptance of the new member of the Family.
STRUCTURAL FUNCTIONAL
Initial Data Base
a. Family Structure and Characteristics
Nuclear basic family
Extended in-law relations, or grandparents relations
*members of household in relation to head
*demographic data ( sex male or female, age, civil status )
Live in = married/ common law WIFE
Male Patriarchal Female Matriarchal
*types and structure of family
*dominant members in health
*general family relationship
Assessment: Family
-Initial data base
-1st level assessment
-2nd level assessment
c. Environmental Factors
*housing- number of rooms for sleeping
*kind of neighborhood
*social health facilities available
*comm. And transportatx facilities
*Health Deficits:
-Instances of failure in health maintenance ( disease, disability, developmental
lag )
3 TYPES:
a. Disease / Illness URTI, marasmus, scabies, edema
b. Disabilities blindness, polio, colorblindness, deafness
c. Developmental Problem like mental retardation, gigantism, hormonal, dwarfism
Problem Prioritization:
*Natur eof the Problem
Health Deficit
Health Threat
Forseeable Crisis
*Preventive Potential
High
Moderate
Low
*Modifiability
Easily modifiable
Partially modifiable
Not modifiable
*Salience
High
Moderate
Low
Family Service and Progress Record
COMMUNITY Patient
- Defined by geographic boundaries with certain identifiable characteristics, with common
values and interests.
POPULATION GROUPS-
-Aggregation of people who share common chaaracteristics, developmental stage or
common exposure to particular environmental factors thus resulting in common health
problems ( Clark, 1995: 5 ) e.g. children, elderly, women, workers, etc.
*SCHOOL AND HEALTH NURSING the application of nursing theories and principles
in the care of the school population.
Components:
School Health Services- maintain school clinic, screening all children- visual, hearing,
scoliosis
Environmental health- food sanitation, water supply, safe environment, safe toilet
The Philippine health care delivery system is composed of two sectors: (1) the public
sector, which largely financed through a tax-based budgeting system at both national
and local levels and where health care is generally given free at the point of service and
(2) the private sector (for profit and non-profit providers) which is largely market-
oriented and where health care is paid through user fees at the point of service.
The public sector consists of the national and local government agencies providing
health services. At the national level, the Department of Health (DOH) is mandated as
the lead agency in health. It has a regional field office in every region and maintains
specialty hospitals, regional hospitals and medical centers. It also maintains provincial
health teams made up of DOH representatives to the local health boards and personnel
involved in communicable disease control, specifically for malaria and schistosomiasis.
Other national government agencies providing health care services such as the
Philippine General Hospital are also part of this sector.
With the devolution of health services, the local health system is now run by Local
Government Units (LGUs). The provincial and district hospitals are under the provincial
government while the city/municipal government manages the health centers/rural health
units (RHUs) and barangay health stations (BHSs). In every province, city or municipality,
there is a local health board chaired by the local chief executive. Its function is mainly to
serve as advisory body to the local executive and the sanggunian or local legislative
council on health-related matters.
The private sector includes for-profit and non-profit health providers. Their involvement
in maintaining the peoples health is enormous. This includes providing health services in
clinics and hospitals, health insurance, manufacture of medicines, vaccines, medical
supplies, equipment, and other health and nutrition products, research and development,
human resource development and other health-related services.
DEPARTMENT OF HEALTH
-Lead agency in the Health Sector
-Sets the goals for the nations health status
-Establishes PARTNERSHIP
DOH MANDATE
1. Formulation
2. Support
3. Issuance
4. Promulgation
5. Development
Roles of DOH:
1. Leadership in Health
*Serve as the national policy and regulatory institution.
*Provide leadership in the formulation, monitoring and evaluation of the national health
policies, plans and programs.
*Serve as advocate in the adoption of health policies, plans and programs
2. Enabler and Capacity builder
*Innovate new strategies in health.
*Exercise oversight functions and monitoring and evaluation of national health plans,
program and policies.
*Ensure the highest achievable standards of quality health care, promotion and
protection
3. Administrator of specific services
*Manage selected national health facilities and hospitals with modern and advanced
facilities.
*Administer direct services for emergent health concerns that require new complicated
technologies.
***VISION:
Old: Health for all Filipinos
New: The Leader of health for all in the Philippines
New: The DOH is the leader, staunch advocate and model in promoting Health for all in
the Philippines.
New: A global leader for attaining better health outcomes, competetive and responsive
health care system, and equitable health financing by 2030.
***MISSION:
-Old: Ensure accessability and quality of health care services to improve the quality of life
of all Filipinos, especially the poor.
-New:To guarantee equitable, sustainable and quality health for all Filipinos, especially
the poor, and to lead the quest for excellence in health.
Important CONCEPT!!!
In the community setting, the marginalized refers to...
D
O
P
E
A
S
PHILOSOPHY OF DOH:
-Quality is above Quantity!
PRINCIPLES OF DOH
P Performance of health sector must be enhanced.
U Universal Access to basic health services.
S Shifting from infectious to degenerative diseases must be managed.
H Health, and nutrition of vulnerable group must be prioritized.
***STRATEGIES OF DOH
SAID!!!
S support the local health system and front line workers.
A assurance of health care for all.
I increase investment of PHC.
D development of national standards, and objective for health.
Roadmap for All Stakeholders in Health: National Objectives for Health 2005 2010.
National Objective for Health: sets the target and the critical indicators, current
strategies based on field experience, and laying down new avenues for improved
interventions.
Major Helath Plans towards Health in the Hands of the People in the year 2020
A Healthy BARRIO should be:
a. Residents actively participate in attaining good health; they are PARTNERS in health
care.
b. Highlight Project: BOTIKA SA PASO CAMPAIGN
c. Goal: to maintain herbal plants in pots for family use
A Healthy CITY should be:
a. The physical environment in the workplace, streets, and public places promote
health, safety, order and cleanliness through structural manpower support
b. Health- Related Strategies: Construction of well-maintained, income generating
public toilets; designation of a pook-sakayan, pook-babaan
A Healthy EATING PLACE should be:
a. Eating place where:
- safe and properly prepared, stored and transferred foods
- nutritious foods and drinks are served.
b. Complies with the following sanitation standards:
- safe, environment-friendly
- with clean restrooms
- food handlers are medically fit
A Healthy MARKET should be:
a. Adequate water supply
b. Proper drainage
c. Well-maintained toilet facilities
d. Proper garbage and waste disposal
e. Cleanliness maintained
f. Affordable quality foods
A Healthy HOSPITAL should be:
a. A Center of Wellness
b. Promotes Preventive care
c. Patient-centered
A Healthy STREET should be:
a. Well-maintained roads and public waiting areas
b. Clean and obstruction free sidewalks
c. With minimal traffic problems
d. With adequate strict law enforcement
e. Project: Pook Tawiran
f. Goal: to promote and reorient people especially erring pedestrians on the use of
pedestrian crossings
GOALS AND OBJECTIVES OF DOH
GREEPPP!!!
G general health status of Filipino must improve
R reduce morbidity, mortality and disability to different diseases
E eradicate poliomyelitis
E eliminate certain endemic disease
P promote the health and nutrition of the family
P promote healthy lifestyle
P promote environmental sanitation
E. PHC as a Strategy
PHC as a Strategy
*September 6 12, 1978 First International Conference on PHC in Alma Ata, Russia
( USSR ) the Alma Ata Declaration stated that PHC was the key to attain the health for
all goal.
*October 19, 1979 Letter of Instruction ( LOI 949 ), the legal basis of PHC was signed
by President Ferdinand E. Marcos, which adopted PHC as an approach toward the
design, development and implementation of programs focusing on health development at
community level.
LOI 949 signed by President Marcos with an underlying theme: Health in the hands of
the People by 2020.
An improved state of health and quality of life for all people attained through SELF-
RELIANCE.
Concept of PHC
KEY STRATEGY TO ACHIEVE THE GOAL:
- characterized by partnership and empowerment of the people that shall permeate as
the core strategy in the effective provision of essential health service that are community
based, accessible, acceptable and sustainable at a cost, which the community and the
government can afford.
MISSION:
*To strengthen the health care system by increasing opportunities and supporting the
conditions wherein people will manage their own health care.
4. SELF RELIANCE
5. Partnership between the community and the health agencies in the provision of
quality of life = Providing linkages between the government and the non government
organization and peoples organization.
HEALTH
- is not merely the absence of disease. Neither it is only a state of physical and mental
well being.
- Health being a soical phenomenon recognizes the interplay of political, socio cultural
and economic factors as its determinant.
- Good Health therefore, is manifested by the progressive improvements in the living
conditions and quality of life enjoyed by the community residents (PCF, DEVELOPMENT
is the quest for an improved quality of life for all.
-Development is mulit dimentional. It has a political, social, cultural, institutional and
environmental dimensions ( Gonzales 1994 ). Therefore, it is measured by the ability of
people to satisfy their basic needs.
7. SOCIAL MOBILIZATION =
- It enhances people participation or governance, support system provided by the
Government, networking and developing secondary leaders.
8. DECENTRALIZATION
*PHC as a service delivery policy of the DOH permeates all strategies and thrusts of
government health programs from the national to the local and community levels
Dimension Commercialized Health Primary Health Care
Care
Goal Absence of disease for Prevention of disease
the individual Socio-economic
development
Focus of Care Sick Sick and well individuals
Setting for Hospital-based Satellite Health Centers
Services Urban-Centered Community Health
Centers
Accessible only to a few Rural-Based
people Accessible to all
People Passive recipients of Active participants in
health care health care
Structure Health is isolated from Inter- and intra- sectoral
other sectors of society linkaging allows health to
be integrated with over-all
socio-economic
development efforts
*AC 196 A: Ampalaya was deleted in 10 herbal plants advised by DOH in October 9,
2003
Reminders on the Use of Herbal Medicine:
1. Avoid the use of insecticides
2. Use a clay pot and remove cover while boiling at low heat.
3. Use only the part being advocated
4. follow accurate dose of suggested preparation.
5. Use only one kind of herbal plant for each type of symptom or sickness.
6. Stop giving the herbal medication in cases of untoward reactions.
7. If signs and symptoms are not relieved after 2-3 doses, consult a doctor.
Policies to abide:
1. Know indications
2. Know parts of plants with therapeutic value: roots, fruits, leaves
3. Know official procedure/preparation
Procedures/Preparations:
a. Decoction
Gather leaves & wash thoroughly, place in a container the washed leaves &
add water
Let it boil without cover to vaporize/steam to release toxic substance &
undesirable taste
Use extracts for washing
b. Poultice
Done by pounding or chewing leaves used by herbolaryo
Example: Akapulko leaves-when pounded, it releases extracts coming out
from the leaves contains enzyme (serves as anti-inflammatory) then apply
on affected skin or spewed it over skin
For treatment of skin diseases
c. Infusion
To prepare a tea (use lipton bag), keep standing for 15 minutes in a cup of
warm water where a brown solution is collected, pectin which serves as an
adsorbent and astringent
Used for diarrhea and for pneumonia so PHN discourages to buy
commercially prepared cough syrup expectorant: Nature of Cough
1) Dry mucolytic liquefy mucus
Example: Carbocisteine, Guafenesin
2) Productive expectorant irritants to the mucus gland
Example: Bromhexine (Bisolvon)
3) Non stop coughing antitussive
Example: Dextromethorpan (Robitussin) contains codeine
Robitussin AC contains atropine & codeine
d. Juice/Syrup
To prepare a papaya juice, use ripe papaya & mechanically mashed then
put inside a blender & add water
To produce it into a syrup, add sugar then heat to dissolve sugar & mix it
For problems of constipation
Example: papaya, mango & caimito
e. Cream/Ointment-for topical use
Cream is water based & used for wet skin lesions
Ointment is oil based & used for dry lesions
Example: Akapulko Leaves
start with poultice (pound leaves) to turn it semi-solid
add flour to keep preparation pasty & make it adhere to skin lesions
to make it into an ointment: add oil (mineral, baby or any oil-serves as
moisturizer) to the prepared cream to keep it lubricated while being
massage on the affected area
FAMILY Basic unit of society, a primary entity of health care or institution responsible
for the physical, emotional, and social support of its members.
Two Types:
- Family of Orientation
- Family of Procriation
STEPS:
1. RELATING
- Establishing a working relationship. Results in positive outcomes such as good quality
of data, partnership in addressing identified health need and problems, and satisfaction
of the nurse and the client.
2. ASSESSMENT
- Data Collection, Data Analysis and Data Interpretation and Problem definition or
Nursing Diagnosis.
TWO TYPES OF ASSESSMENT
a. First Level Assessment Data on status / conditions of family household
members.
b. Second Level Assessment Data on family assumption of health tasks on each
problem identified in the First Level Assessment.
3. PLANNING
- Determination of how to assist client in resolving concerns related to restoration.
Maintenance or promotion of health.
- Establishment of priorities, set goals / objectives, selects strategies, describe rationale.
4. IMPLEMENTATION
- The carring out of plan of care by client and nurse, make ongoing assessment,
update / revise plan, document responses.
5. EVALUATION
- A systematic, continuous process of comparing the clients response with written goal
and objective.
-Determines progress and evaluate the implemented intervention as to:
1. Effectiveness
2. Efficiency
3. Adequacy
4. Acceptability
5. Appropriateness
I. NURSING ASSESSMENT
-Involves a set of actions by which the nurse measures the status of the family as a
client, their ability to maintain wellness, prevent and control or resolve problems in order
to achieve health and well being among its members.
2. Data Analysis
Steps:
1. Sorting of data for broad categories (such as those related with health status or
practices about home and environment).
2. Clustering of related cues to determine relationship among data.
3. Distinguishing relevant from irrelevant data. This will help in deciding what
information is pertinent to the situation at hand and what information is
immaterial.
4. Identifying patterns such as physiologic function, developmental,
nutritional/dietary, coping/adaptation or communication patterns.
5. Compare patterns with norms or standards of health, family functioning and
assumption of health tasks.
6. Interpreting results of comparisons to determine signs and symptoms or cues of
specific wellness state/s, health deficit/s, health threat/s, foreseeable crises/stress
point/s and their underlying causes or associated factors.
7. Making conclusions about the reasons for the existence of the health condition or
problem, or risk for non-maintenance of wellness state/s which can be attributed
to non-performance of family tasks.
*Family Nursing Problem - Stated as an inability to perform specific health task and the
reasons / etiology) why the family cannot perform such task.
2. Second Level of Assessment defines the nature or type of nursing problems that
the family encounters in performing health.
II. Inability to make decisions with respect to taking appropriate health action due
to:
A. Failure to comprehend the nature/ magnitude of the problem / condition
B. Low salience of the problem / condition
C. Feeling of confusion, helplessness and / or resignation brought by perceived
magnitudes / severity of the situation or problem, i.e., failure to break down
problems into manageable units of attacks
D. Lack of / or inadequate knowledge / insight as to alternative courses of action
to take
E. Inability to decide which action to take among the list of alternatives
F. Conflicting opinions among family members / significant others regarding
action to take
G. Lack of / or inadequate knowledge of community resources for care
H. Fear of consequence of action, specially:
social consequences
economic consequences
physical / psychological consequences
I. Negative attitude towards the health problem By negative attitude is meant
one that interferes with rational decision making
J. Inaccessibility of appropriate resources for care, specifically:
1. physical inaccessibility
2. cost constraints or economic / financial inaccessibility
K. Lack of trust / confidence in the health personnel / agency
L. Others, specify______________
II. PLANNING
- The step in the process which answers the following questions:
*What is to be done?
*How is to be done?
*When it is to be done?
-It is actually the phase wherein the health care provider formulates a care plan.
4. Salience - Refers to the family's perception and evaluation of the problem in terms
of seriousness and urgency of attention needed or family readiness.
Scoring
1. Decide a score for each of the criteria
2. divide the score by the highest possible & multiply by the weight
Score x weight
Highest score
3. Sum up the score of all criteria. The highest score is 5 equivalent to the total
weight.
CRITERIA Weight
1. Nature of the problems Presented 1
Scale:
-Health deficit / Wellness 3
-Health threat 2
-Foreseeable crisis 1
2. Modifiability of the problem 2
Scale:
-Easily modifiable 2
-Partially modifiable 1
-Not modifiable 0
3. Preventive potential 1
Scale:
-High 3
-Moderate 2
-Low 1
4. Salience 1
Salience:
-A condition / problem needing Immediate 2
attention
*A condition / problem not needing 1
Immediate attention
*Not perceived as a problem or condition 0
needing change.
Goal
* It is a general statement of the condition or state to be brought about by specific
courses of action.
Objective
Refers to a more specific statement of desired outcome of care.
They specify the criteria by which the degree of effectiveness of care is to be
measured.
Types of Objective
1. Short term or Immediate Objective
Formulated for problem situation which require immediate attention & results can
be observed in a relatively short period of time.
They are accomplished with few HCP-family contacts & relatively less resources.
2. Medium or Intermediate objective
Objectives which is not immediately achieved & is required to attain the long
ones.
3. Long Term or Ultimate Objective
This requires several HCP-family contacts & an investment of more resources.
Typology of Interventions
1. Supplemental - the HCP is the direct provider of care.
2. Facilitative - HCP removes barriers to needed services.
3. Developmental - improves clients capacity.
III. Implementation
Actual doing of interventions to solve health problems.
IV. Evaluation
Determination whether goals / objectives are met.
Determination whether nursing care rendered to the family are effective.
Determines the resolution of the problem or the need to reassess, and re-plan
and re-implement nursing interventions.
According to Alfaro-LeFevre:
Types of Evaluation:
On-going Evaluation analysis during the implementation of the activity, its
relevance, efficiency and effectiveness.
Terminal Evaluation undertaken 6-12 months after the care was completed.
Steps in Evaluation:
1. Decide what to Evaluate.
Determine relevance, progress, effectiveness, impact and efficiency
2. Design the Evaluation Plan
Quantitative a quantifiable means of evaluation which can be done
through numerical counting of the evaluation source.
Qualitative descriptive transcription of the outcome conducted through
interview to acquire an in-depth understanding of the outcome.
3. Collect Relevant Data that will support the outcome
4. Analyze Data - What does the data mean?
5. Make Decisions
If interventions are effective, interventions done can be applied to other
client / group with the similar circumstances
If ineffective, give recommendations
6. Report / Give Feedbacks
Dimensions of Evaluation
1. Effectiveness focused on the attainment of the objectives.
2. Efficiency related to cost whether in terms on money, effort or materials.
3. Appropriateness refer its ability to solve or correct the existing problem, a
question which involves professional judgment.
4. Adequacy pertains to its comprehensiveness.
Thermometer
Tape measure
Ruler
BP apparatus
Weighing scale
Checklist
Key Guide Questionnaires
Return Demonstrations
Methods of Evaluation
1. Direct observation
2. Records review
3. Review of questionnaire
4. Simulation exercises
1.1 Family Based Nursing Services (Family Health Nursing Process)
Nursing Assessment of Family:
First Level Assessment:
1. Family structure, characteristics and dynamics
2. Socio-economic and cultural characteristics
3. Home and environment
4. Health status of each member
5. Values and practices on health promotion/maintenance
and disease prevention
Second Level Assessment data include those that specify or describe the
familys realities, perceptions about and attitudes related to the assumption or
performance of family health tasks on each health condition or problem
identified during the first level assessment.
Developing the Nursing Care Plan
Steps in developing a family care plan:
1. The prioritized condition/s or problems
2. The goals and objectives of nursing care
3. The plan of interventions
4. The plan for evaluating care
Implementing the Nursing Care Plan
During this phase the nurse encounters the realities in family nursing practice
which can motivate her to try out creative innovations or overwhelm her to
frustration or inaction. As the nurse practitioner works with clients she
experiences varying degrees of demands on her resources. A dynamic attitude
on personal and professional development is, therefore, necessary if she has
to face up to challenges of nursing practice.
Evaluation of Family Health Services.
2. Planning
- purpose is to act on determined needs of the community people.
3. Implementation
- purpose is to achieve the optimum level of health of the community people.
4. Evaluation-
- to determine the effectiveness of health care programs.
3 elements : structural , process & measurable outcome or objective
NURSING PROCEDURES
Clinic visit
- patient visits the Health center to avail of the services there to offered by the facility
primarily for consultation on matters that ailed them physically.
-Process of checking the clients health condition in a medical clinic.
PURPOSE: (C.U.R.E)
-Consult about signs and symptoms of illness.
-Utilize service of a health agency.
-Render some treatment procedures.
-Evaluate through some diagnostic procedures
III. Triaging
1. Manage program-based cases (like the IMCI)
2. Refer all non-program based cases to the physician
3. Provide first aid treatment to emergency cases and refer to the next level when
necessary
VII. Prescription/dispensing
1. Give proper instructions on drug intake
Home visit
- family nurse contact which allows the health worker to assess the home and family
situations in order to provide the necessary nursing care and health related activities.
- a professional face to face contact made by the nurse with a patient or the family to
provide necessary health care activities and to further attain the objectives of the
agency.
-PRIORITY during HOME VISITS: Newborn (First), Post-Partum, Pregnant Mother,
Morbid Individual (Last).
Bag Technique: tool by which the nurse, during her visit will enable her to perform a
nursing procedure with ease and deftness, to save time and effort
- a tool making of the public health bag through which the nurse during the home visit can
perform nursing procedures with ease and deftness saving time and effort with the end in
view of rendering effective nursing care.
*Public Health Bag: an essential and indispensable equipment of a public health nurse
which she has to carry along during her home visits.
SOLUTION:
1. Benedicts Solution For sugar detection
2. Acetic Acid For Albumin Detection
3. Zephiram Solution Soaking Solution
4. Alcohol, Betadine
5. Ammonia
-Placed waste paper bag outside of work area to prevent contamination of clean area.
-RATIONALE IN THE USE OF PHN BAG :
*Technique during home visit
- It helps render effective nursing care.
Intravenous Therapy
- Insertion of a needle or catheter into a vein to provide medication and fluids based on
physicians written prescription
- Can be done only by nurses accredited by ANSAP(Association of Nursing Service
Administration of the Philippine.)
- INDICATIONS:
*Maintenance /Correction of dehydration in patient unable to tolerate adequate volume of
oral fluid medications
*Parenteral Nutrition
*Administration of Drugs
*Blood Transfusion
- CONTRAINDICATIONS:
*Administration of irritant fluids / drugs through peripheral access (e.g., Sodium Chloride,
Hypertonic Potassium Chloride).
Specimen Collection
-URINE Sterile Bottle, Midstream Collection
-FECES Clean Container, Small amount of feces only.
-SPUTUM NPO midnight first collection early AM then submit at the health center
immediately, then second collection following day early in the AM then submit at the
health center then collect the third sputum; instruct the patient to take a deep breath four
times then cough out.
PLANNER / PROGRAMMER
1. Identifies needs, priorities, and problems of individuals, families, and communities.
2. Formulates municipal health plan in the absence of medical doctor
3. Interprets and implements nursing plan, program policies, memoranda, and circular for
the concerned staff personnel.
4. Provides technical assistance to rural health midwives in health matters.
MANAGER / SUPERVISOR
1. Formulates individual, family, group, and community centered plan.
2. Interprets and implements programs, policies, memoranda, and circulars.
3. Organizes work force, resources, equipment, and supplies at local level.
4. Provides technical and administrative support to Rural Health Midwives (RHM)
5. Conducts regular supervisory visits and meetings to different RHMs and gives
feedback on accomplishments.
COMMUNITY ORGANIZER
1. Motivates and enhances community participation in terms of planning, organizing,
implementing, and evaluating health services
2. Initiates and participates in community development activities.
COORDINATOR OF SERVICES
1. Coordinates with individuals, families, and groups for health related services provided
by various members of the health team.
2. Coordinates nursing program with other health programs like environmental sanitation,
health education, dental health, and mental health.
HEALTH MONITOR
1. Detects deviation from health of individuals, families, groups, and communities through
contracts / visits with them.
ROLE MODEL
1. Provides good example of healthful living to the members of the community.
CHANGE AGENT
1. Motivates changes in health behavior in individuals, families, groups, and communities
that also include lifestyle in order to promote and maintain health.
RESEARCHER
1. Participates in the conduct of survey studies and researches on nursing and health
related subjects.
2. Coordinates with government and non government organization in the
implementation of studies / research.
CHN NOTES:
1. Primary Goal in CHN Self-reliance in health
2. Ultimate Goal in CHN Raise the level of health of the citizenry
3. Unit of care - Family
4. Levels of Clientele Individual, Family, Special Population & Community
5. Primary Focus Health Promotion & Disease Prevention
6. Philosophy Of CHN Uphold the worth & dignity of man
7. Theoretical Bases of CHN Practice Theories & Principles of Nursing & Public Health
8. CHN as : People-oriented, comprehensive & integrated, focus on health
I. Community Organizing
COMMUNITY ORGANIZING
Maglaya DOH
Preparatory Phase Community Analysis
Organizational Phase Design and Initiation
Education and training Implementation
Collaboration Phase Program Maintenance Consolidation
Phase Out Dissemination Reassessment
5 components
Demographic, social and economic profile of the community
derived from secondary data
Health risk profile
Health/wellness outcome profile
Survey of current health promotion programs
Studies conducted in certain target groups
Steps in community analysis
Define the community - Determine the geographic boundaries of the
target community. This is usually done in consultation with representatives of
the various sectors.
Collect data As earlier mentioned, several types of data have to
be collected and analyzed.
Assess community capacity This entails and evaluation of the
driving forces which may facilitate or impede the advocated
change. Current programs have to be assessed including the
potential of the various types of leaders/influential, organization
and programs.
Assess community barriers Are there features of the new
program which run counter to existing customs and traditions? Is
the community resilient to change?
Assess readiness for change _ Data gathered will help in the
assessment of community interest, their perception on the
importance of the problem.
Synthesis of data and set priorities This will provide a
community profile of the needs and resources, and will become
the basis for designing prospective community interventions for
health promotion.
3. Implementation
Implementation put design phase into action. To do so, the following
must be done:
Generate broad citizen participation - There are several ways to
generate citizen participation. One of them is organizing task
force, who, with appropriate guidance can provide the necessary
support.
Develop a sequential work plan - Activities should be planned
sequentially. Oftentimes, plan has to be modified as events
unfold. Community members may have to constantly monitor
implementation steps.
Use comprehensive integrated strategies - . Generally the
program utilize more than one strategies that must complement
each other.
Integrate community values into the programs, materials and
messages. The community language, values and norms have to
be incorporated into the program.
5. Dissemination reassessment
Continuous assessment is part of the monitoring aspect in the
management of the program. Formative evaluation is done to provide
timely modification of strategies and activities. However, before any
programs reach its final step, evaluation is done for future direction.
Update the community analysis - Is there a change in leadership,
resources and participation? This may necessitate reorganization
and new collaboration with other organizations.
Assess effectiveness of interventions/programs - Quantitative
and qualitative methods of evaluation can be used to determine
participation, support and behavior change level of decision-
making and other factors deemed important to the program
Chart future directories and modifications - This may mean
revision of goals and objectives and development of new
strategies. Revitalization of collaboration and networking may be
vital in support of new ventures.
Summarize and disseminate results - . Some organizations die
because of the lack of visibility. Thus, a dissemination plan
maybe helpful in diffusion of information to further boost support
to the organizations endeavor.
Contents:
1. Introduction
1.1 Rationale accurate, valid, timely and relevant information on the
community profile and health problems are essential so that resources can be
maximized
1.2 Purpose to analyze the data in order to develop responsive
intervention strategies that address the root cause of the problem
1.3 Statement of Objective what are to be accomplished to attain the
study
1.4 Methodology and tool used a description of the adoption,
construction and administration of instruments
1.5 Limitation of the study state any limitations that exist in the
reference or given population or area of assignment
3. Analysis of Data
3.1 Identification of health problems
3.2 Prioritized problems identified
5. Conclusion
6. Recommendation
Community Diagnosis
1. Preparation of Community Diagnosis
a. Identify barangay to survey or required by the health center
b. Ocular survey
c. Community assembly
2. Conduct of survey proper using the format/survey form
a. Random sampling or saturation
b. Guidelines in filling survey form
c. Data collection techniques
3. Make graph or chart of each data gathered
4. Data analysis and interpretation
5. Preparation of action plan /project plan
HRDP CO-PAR
COMMUNITY ORGANIZING
A continuous process of awareness building, organizing and mobilizing community
members towards community development.
FAMILY HEALTH
Aims to:
1. Improve the survival, health and well-being of mothers and the unborn through a
package of services for the pre-pregnancy, prenatal, natal and postnatal packages.
2. Reduce morbidity and mortality rates for children 0-9 years.
3. Reduce mortality from preventable causes among adolescents and young people.
4. Reduce mortality and morbidity among Filipino adults and improve their quality of life.
5. Reduce morbidity and mortality of older persons and improve their quality of life.
The Maternal Health Program
Strategic thrusts for 2005-2010
a. Antental Registration
Prenatal Visits Period of Pregnancy
st
1 visit As early as possible before 4 months or during the 1st
trimester.
nd
2 visit During the 2nd trimester.
3rd visit During the 3rd trimester.
Every 2 weeks After 8th month until delivery.
c. Micronutrients Supplementation
Vit A: 10,000 IU 2x a week starting on 4th month of pregnancy
Iron: 600mg/400ug tablet daily
Important Concept!!!
COUPLE Decision maker
DOH Regulator
Community Health Nurse Facilitator
Important Concept!!!
High risk Pregnancies
-Too early
-Too late
-Too Frequent
-Too many
3. Condom
- 97% effective
- Mother is most responsible in inserting the condom.
2. Vasectomy
- 99% effective
- Vas deferens is cut
- Does not give immediate sterility
- There is a waiting time of six (6) months
- Sperm is still stored
- After six months, patient can engage in unprotected coitus.
- Not Popular among Filipinos
Nursing Alert!!!
Methods that are not part of Natural Family Planning: (not accepted by the DOH)
- Withdrawal
- Calendar Method
To Mother:
Reduces womans risk of excessive blood loss after birth
Provides natural methods of delaying pregnancies
Reduces the risk of ovarian and breast cancers and osteoporosis
Newborn Screening??????
DPT:
HepB 5 ml IM destroyed by freezing
TT
SIDE-EFFECTS OF BCG:
c.
AT BIRTH 1 months 2 3 months 9-12 Indolen
months months t
1st BCG DPT1 DPT2 DPT3 MEASLES ulcerati
OPV1 OPV1 OPV3 on-
HEPB 1 HEPB 2 HEPB 3 ulcer
after 12 weeks Treatment: Powedered
INH
d. Glandular enlargement- abscess (2-3 weeks abscess will leave scar 12 weeks after)
SIDE-EFFECTS OF DPT:
* Even if the interval exceeded that of the expected interval, continue to give the doses
of the vaccine.
* Immunization can still be given until the child reaches 6 y/o
* If there has been a reported epidemic of measles, measles vaccine can be given as
early as six months
* BCG booster dose must be given to school entrants regardless of presence of BCG
scar.
* There is no contraindication to immunization, EXCEPT when the child had convulsions
upon giving the 1st dose of DPT.
* MALNUTRITION is not a contraindication, but RATHER AN INDICATION for
immunization since common childhood disease are often severe to malnourished
children.
*COLD CHAIN
A system used to maintain the potency of a vaccine from that of manufacturer to the
time it is given to child or pregnant woman.
Principles:
It is a MUST to mark ampules/vials with an X mark each time they are carried
to the field, because if a VACCINE IS NOT USED on the 3 rd trip, it must
already BE DISCARDED.
II. Transport
III. Handling
TARGET SETTING:
Goal: By 2010, to reduce the infant and under five mortality rate at least one third, in
pursuit of the goal of reducing it by two thirds by 2015.
AIM: To reduce death, illness and disability, and to promote improved growth and
development among children under 5 years of age.
IMCI includes both prventive and curative elements that are implemented by
families and communities as well as by health facilities.
Objective: Aims to reduce death, illness and disability, and to promote improved growth
and development among children under five years old.
*To reduce SSIGNIFICANTLY global mortality and morbidity associated with
the major causes of disease in children.
*To contribute to healthy gorth and development of children.
***For many sick children a single diagnosis may not be apparent or appropriate.
Presenting Complaint:
*Cough and / or fast breathing
*Lethargy / Unconsciousness
*Measles rash
*Very sick young infant
Micronutrient Supplementation
Dental health Early Child Development
Child Health Injuries
Its main goal is to reduce morbidity and mortality rates for children 0-9 years
with the strategies necessary for program implementation.
2005 It was estimated that 35 million deaths would have occurred due to these
diseases, contributing 60% of deaths worldwide. As well as a high death toll, chronic
diseases also caused disability, often for decades of a persons life. The most widely
used summary measure of the burden of disease is the disability adjusted life year or
DAILY, which combines the number of years of healthy life lost to premature death
with time spent in less than full health. One DAILY can be thought of as one lost
healthy year of life. The projected burden of disease of these diseases is
approximately half or 48% of the global burden of disease.
2020 The diseases are expected to account for 73% of deaths and 60% of the disease
burden.
2002 Life expectancy of Filipinos has gone up to 69.6 years.
- MORTALITY statistics showed that 7 out of 10 leading causes of deaths
in the country are diseases which are lifestyle related: diseases of the
heart and the vascular system, cancers, chronic obstructive pulmonary
diseases, accidents, diabetes, kidney problem.
- MORBIDITY statistics also showed that hypertension and diseases of
the heart are among the top 10 leading causes of illnesses in the
country.
2003 The result of the National Nutrition and Health Survey conducted that recently
90% of Filipinos has one or more risk factors associated with chronic, non-communicable
diseases.
HEALTHY LIFESTYLE defined as a way of life that promotes and protects health and
well-being. This would include practices that promotes healthy such as healthy diet and
nutrition, regular and adequate physical activity and leisure, avoidance of substances that
can be abused such as tobacco, alcohol and other addicting substances, adequate
stress management and relaxation; and practices that offer protection from health risks
such as safe sex and immunization.
GOAL:
Reduce the toll of morbidity, disability and premature deaths due to chronic, non-
communicable lifestyle related disease.
OBJECTIVES:
1. Analyze the social, economic, political and behavioral determinants of NCD that will
serve as bases for:
a. Developing policy guidelines;
b. Setting legislative and political directions, and
c. Providing financial measures to support NCD prevention and control.
3. Strengthen health care for people with NCD through health sector reforms and cost
effective interventions. In order to contribute health status individuals and respond to the
communitys basic health care needs, there must be enhance capability to take action to
address these major NCD risk factors.
To achieve significant reduction in morbidity and mortality from major NCDs, the
following approaches should characterize the program:
1. Comprehensive Approach Focused on Primary Prevention
2. Community Based Approach
3. Integrated Approach
Health Advocate
Public Health Nursing promote active community participation in NCD prevention and
control through advocacy work. As a health advocate, the PHN helps the people toward
optimal degree of independence in decision making and in asserting their right to their
right to a safer and better community. This involves:
1. Informing the people about the rightness of the cause. It is important to convey the
problem, show it affects people in the community and describe possible actions to take.
2. Thoroughly discussing with the people the nature of the alternatives, their content and
consequences. In this manner, needs demands of the people are amplified and
eventually become the framework for decision making.
3. Supporting peoples right to make a choice and to act on the choice. The people must
be assured that they have the right responsibility to make decisions and that they do not
to change their decisions because of others objections.
4. Influencing public opinion. The advocate affirms the decision made by the people by
getting powerful individuals or groups to listen, support and eventually, make substantial
changes to solve the problem.
Health Educator
Health Education is an essential tool to achieve community health. In non-communicable
disease prevention and control, health education focuses on establishing or inducing
changes in personal and group attitudes and behavior that promote healthier living.
PHNs, as well as educators and media personel, should conduct healthier education in a
variety of settings.
Community Organizer
As an organizer, the ultimate goal of the PHN is community health development
and empowerment of the people. This is achieve by:
*Raising the level of awareness of the community regarding non communicable
diseases, its causes, prevention and control;
*Organizing and mobilizing the community in taking action for the reduction of risk
factors;
*Influencing executive and legislative bodies to create and enforce policies that favor a
healthy environment.
Healthy Trainer
The PHN provides technical assistance in the assessment of the skills of auxiliary
health workers in NCD prevention and control; teaching and supervision on clinical
management of non communicable diseases and other community based services
and recording, reporting and utilization of health information related to non
communicable diseases.
Researcher
Research is an integral part of a primary health care approach to non
communicable disease prevention and control program. It is inextricably related to
community health practices since it provides the theoretical bases for developing
appropriate and responsive intervention programs and strategies.
ETIOLOGY / CAUSE
*In terms of etiology, hypertension is classified into primary and secondary hypertension.
Primary hypertension has no definite cause. It is also called essential hypertension.
Secondary hypertension is usually the result of some other primary diseases leading to
hypertension such as renal disease. For the rest of these session, we will be focusing on
primary hypertension, which is more common.
*Although exact cause is unknown, primary hypertension is attributed to atherosclerosis.
RISK FACTORS
*There is no single cause for primary hypertension but several risk factors have been
implicated in its development.
*Risk factors include family health history, advancing age, race and high salt intake.
*Other lifestyle factors interact with these risk and contribute to the development of
hypertension such as obesity, excess alcohol consumption, intake of potassium (diet high
in sodium is generally low in potassium; increasing potassium in diet increase elimination
of sodium), calcium, and magnesium, stress, and use of contraceptive drugs.
*FAMILY HISTORY
-People with a positive family history of hypertension are twice at risk than those with no
history.
*AGE
-Older person are at greater risk for hypertension than younger persons.
-The aging processes that increase BP include stiffening of the arteries, decreased
baroreceptor sensitivity, increase peripheral resistance and decreased renal blood flow.
-For years, systolic hypertension common in older persons was considered benign and,
therefore, not treated. However, the Framingham study showed that there was two to five
times increased in death from CVD associated with isolated systolic hypertension.
*HIGH SALTH INTAKE
-Excessive salt intake does not cause hypertension in all people, nor does reducing salt
intake, reduce BP in all hypertensives. Some people are more susceptible than others to
effects of increased salt intake.
*OBESITY
-Risk for hypertension is two times greater among overweight / obese persons compared
to people of normal weight, and three times more than that of underweight persons.
-Fat distribution is more important risk factor than actual weight as measured by waist
to hip ratio.
-The exact mechanism of how obesity contributes to the development of hypertension is
unknown. Whatever the cause, weight loss is effective in reducing BP in obese
hypertensive patients.
-Weight loss or sodium restriction in hypertensives, controlled for 5 years, more than
doubled the success of withdrawal of drug therapy.
*EXCESSIVE ALCOHOL INTAKE
-As much as 10% of hypertension cases could be related to alcohol consumption.
Regular consumption of 3 or more drinks per day increased risk of hypertension. Systolic
pressures were more markedly affected than diastolic pressure.
SMOKING/TOBACCO USE
-Risk of death from CAD is 70-200 times greater for men who smoke one or more packs
of cigarettes per day compared to those who do not smoke. This risk is most seen in
young people, particular those younger than 50 years old.
KEY AREAS FOR PREVENTION OF CAD
Promote regular physical activity and exercise; exercise increases HDL, prevent
obesity and improves optimum functioning of the heart.
Encourage proper nutrition particularly by limiting intake of saturated fats that
increased LDL, limiting salt intake and increasing intake of dietary fiber by eating more
vegetables, fruits, unrefined cereals and wheat breads.
Maintain body weight and prevent obesity through proper nutrition and physical
activity/ exercise.
Advise smoking cessation for active smokers and prevent exposures to second-hand
smoke by family members, friends and co-workers of active smokers. In general,
promote a smoke- free environment through advocacy and community mobilization.
Early diagnosis, from prompt treatment and control of diabetes and hypertension;
these diseases are risk factors and contribute to the development of coronary artery
disease.
B. Cancer
-cancer is not a single disease.
-cancer develops when cell in a part of the body begin to grow out of control.
-they compete with normal cells for the blood supply and nutrients that normal cells need
thus causing weight loss.
-cancer cells often travels to the other part of the body where they begin to grow and
replace normal tissue. This process is called metastasis. It occurs as the cancer cells get
into the bloodstream or lymph vessels of our body.
-the immune system seems to play a role in the development and spread of cancer.
When the immune system is intact, isolated cancer cells will usually be detected and
removed from the body. When the immune system is impaired as in people with
immunodeficiency diseases, people with organ transplant who are receiving
immunosuppressant drugs, or in AIDS, there is usually an increase in cancer incidence.
CAUSES OF CANCER
-Normal cells transform into cancer cells because of damage to DNA. People can inherit
damage DNA which account for inherited cancers. Many times though, a persons DNA
becomes damaged by exposure to something toxic in the environment such as
chemicals, radiation or viruses.
Carcinogens
*a carcinogen is an agent capable of causing cancer. This maybe a chemical, an
environmental agent, radiation and viruses.
*Effect of carcinogenic agents usually depend on the dose or amount of exposure; the
larger the dose or the longer the exposure, the greater the risk of cancer.
*Many cancers are associated with lifestyle risk factors such as smoking, dietary factors
and alcohol consumption.
Chemicals and Environmental Agents
*Polycyclic hydrocarbons are chemicals found in cigarette smoke, industrial agent, or
in food such as smoke foods. Polycyclic hydrocarbons produced from animal fat in the
process of broiling meats and are present in smoked meats and fish.
*Aflatoxin is found in peanuts and peanut butter.
*Other includes benzopyrene, nitrosamines, and a lot more.
Benzopyrene
*Produced when meat and fish are charcoal broiled or smoked (e.g tinapa or smoked
fish). Avoid eating burned food and eat smoked foods in moderation.
*Also produced when food is fried in fat that has been reused repeatedly. Avoid reusing
cooking oil.
Nitrosamines
*These are powerful carcinogens use as preservatives in food like tocino, longganisa,
bacon and hotdog.
*Formation of nitrosamines may be inhibited by the presence of antioxidants such as Vit.
c in the stomach. Limit eating preserved food and eat more vegetables and fruits that are
rich in dietary fiber.
Radiation
*Radiation can also cause cancer including ultraviolet rays from sunlight, x-rays,
radioactive chemicals and other forms of radiation.
Viruses
* a virus can enter a host cell and cause cancer. This is found in cervical cancer(human
papilloma virus), liver cancer( hepatitis B virus), certain leukemias, lymphoma an
nasopharyngeal cancer( epstain barr virus).
ETIOLOGY / CAUSES
*Specific cause depends in the type of diabetes, however it is easier to think of diabetes
as an interaction between two factors: Genetic Predisposition (diabetogenic genes) and
Environment / Lifestyle (obesity, poor nutrition, lack of exercise).
TYPES OF DIABETES
Type 1 Diabetes is insulin dependent diabetes mellitus (IDDM) and Type 2 is
noninsulin dependent diabetes mellitus (NIDDM) Gestational Diabetes is diabetes
that develops during pregnancy. It may develop into full blown diabetes.
NIDDM is more common, occurring in about 90 95% of all persons with diabetes. It is
also more preventable because it is associated with obesity and diet.
Type 1 DM
*Characterized by absolute lack of insulin due to damaged pancreas, prone to develop
ketosis, and dependent on insulin injections.
*Genetic, environment, or may be acquired due to viruses (e.g. mumps, congenital
rubella) and chemical toxins (e.g. Nitrosamines).
Type 2 DM
*Characterized by fasting hyperglycemia despite availability of insulin.
*Possible causes include impaired insulin secretion, peripheral insulin resistance and
increased hepatic glucose production.
*Usually occurs in older and overweight persons (about 80%).
Complications
*Acute complications include diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic
nonketotic coma (HHNK) and hypoglycemia especially in type 1 diabetic.
*Chronic complications cause most of the disability associated with disease. These
include chronic renal disease (nephropathy), blindness (retinopathy) coronary artery
disease and stroke, neuropathy and foot ulcers.
DIAGNOSIS
*A diagnosis of COPD should be considered in any patient who has symptoms of cough,
sputum production, or dyspnea, and / or a history of exposure to risk factors for the
disease. The diagnosis is confirmed by spirometry.
COMPLICATIONS
-Respiratory failure In advanced COPD, peripheral airways obstruction, parenchymal
destruction, and pulmonary vascular abnormalities reduce the lungs capacity for gas
exchange, producing hypoxemia and, later on, hypercapnea.
-Cardiovascular disease Pulmonary hypertension, which develops late in the course
of severe COPD), is the major cardiovascular complication of COPD), and is associated
with the development of cor pulmonale and a poor prognosis.
E. Bronchial Asthma
Asthma is a chronic disease. It is an inflammatory disorder of the airways in which many
cells and cellular elements play a role. Chronic inflammation causes an associated
increase in airway hyper responsiveness that leads to recurrent episodes of wheezing,
breathlessness, chest tightness and coughing, particularly at night or in the early
morning.
These episodes are usually associated with widespread but variable airflow obstruction
that is often reversible either spontaneously or with treatment.
Asthma triggers
Triggers are risk factors for asthma exacerbations. These cannot cause asthma to
develop initially, but can exacerbate established asthma. They induce inflammation and /
or provoke acute bronchoconstriction. It involves further exposure to causal factors
(allergens and occupational agents) that have already sensitized the airways of the
person with asthma.
Other form of triggers are irritant gases and smoke, house dust mite found in pillows,
mattresses, carpets; respiratory infection, inhaled allergens, weather changes, cold air,
exercise, certain foods, additives and drugs.
*Eat at least 2 serving of fruit per day, 1 serving is a vitamin C rich fruit. One
serving of fruit depends on type of fruit.
C. Overweight/Obesity
* Body fat can best be assessed using Body Mass Index (BMI) and waist
circumference. BMI correlates closely with total body fat in relation to height
and weight. However, this does not compensable for frame size, does not
indicate fat distribution, and cannot be adjusted for age.
Body Mass Index (BMI) BMI is calculated using the following formula:
BMI = Weight in kgs / Height in meters.
GUIDELINE
Based on Asia Pacific Obesity Guidelines:
BMI Interpretation
<18.5 Underweight
18.6 22.9 Healthy weight
>23.0 Overweight
23.0 24.9 At risk
25.0 29.9 Obese 1
>30.0 Obese 2
Waist Hip Ratio (WHR) Another useful measures of obesity is the waist
to hip ration by dividing the waist circumference at the narrowest point by
the hip circumference at the widest point.
WHR = Waist circumference (cm) / Hip circumference (cm)
WHR Interpretation:
*Less than 1.0 (men); less than 0.85 (women) = normal WHR
*Equal to or greater than 1.0 (men) and 0.85 (women) = android or
central obesity.
D. Physical Inactivity/Sedentary Lifestyle
*Assessment of physical activity includes on type of work, means of
transportation and leisure time activities like sports and formal exercise.
Minimum Recommended amount of physical activity needed to achieve
health benefit:
Regular Physical Activity: Minimum 30 minutes per day most days of the
week preferably daily.
If moderate intensity: 5 or more days of the week.
If vigorous intensity: 3 or more days of the week.
Guideline:
At least 30 minutes of cumulative physical activity moderate in intensity for
most days of the week.
E. Excessive Alcohol Drinking
*Assess habitual alcohol intake and risky behavior, such as driving or
operating machinery while intoxicated.
2. SELF AWARENESS
-it means knowing ones self, getting in touch with ones feelings, or being open to
experiences. It increases sensitivity to the inner self and relationship with the world
around.
4. SIESTA
-it means taking a nap, short rest, a break or recharging of battery in order to
improve productivity. It helps relax the mind and body muscles. It had been proven
thru a study that siesta invigorates ones body. Performance of an individual
scored high when siesta is observed with a 15 30 minutes nap. It relieves stress
tension and one wakes up invigorated and set for the next activity.
5. STRETCHING
-are simple movements performed at a rhythmical and slow pace executed at the
start of a demanding activity loosen muscles, lubricate joints, and increase bodys
oxygen supply. It requires no special equipment, no special clothes, and no
special skills and can be done anywhere and anytime.
6. SENSATION TECHNIQUE
-The sense of touch is a powerful and highly sensitive forms of communication. It
is a natural reaction to reach out and touch whether to feel the shape or texture of
something or to respond to another person, perhaps by comforting them. Massage
helps to soothe away stress, unknotting tensed and aching muscles, relieving
headaches and helping sleep problems. But massage is also invigorating; it
improves the functioning of many of the bodys systems, promotes healing and
tones muscles, leaving with a feeling of renewed energy.
7. SPORTS
-Engaging in sports and in physical activities like these have been known to
relieve stress. It also gives the body the exercise it badly needs.
8. SOCIALS
-a man is a social being who exist in relationships with his physical environment and
in relationship with people and society.
Socialization plays a very important role in the development of intrapersonal
relationships. Through socialization life becomes meaningful, happy and worthy.
On the contrary without socialization life will be boring and empty.
10. SPEAK TO ME
-the world is designed as a mutual support system in which all things relate to
each other. Communication is the means by which people make their needs
known. It is the way they obtain understanding, reinforcement and assistance from
others. Communication is aimed at a goal, so it must remain open until the goal is
reached. Interpersonal conflicts generally are resolved most effectively by open
communications that accept the feelings of the persons involved and leas to better
resolution of problems. Talking to someone when feeling overwhelmed or unable
to deal with stress or feeling helpless is often the best way of coping with stress.
12. SMILE
- It has been observed that people who always smile are healthy people. Smile is
an expression of pleasure. It has been found out through research that it relieves
all kinds of stresses, physical, or mental. It is also considered one of the
ingredients or factors that motivates and encourages people to work harder and
improve their level of performance in anything they do.
3. Childhood Blindness
The prevalence of blindness among children (up to age 19) is 0.06% while the
prevalence of visual impairment in the same age group is 0.43%.
Screening of children for any sign of visual impairment can be done by pediatricians,
school clinics and health workers.
TWO TYPES
INFECTIOUS DISEASE
*Not easily transmitted by ordinary contact but require a direct inoculation through a
break in the previously intact skin or mucous membrane
CONTAGIOUS DISEASE
*Easily transmitted from one person to another through direct or indirect means
TERMINOLOGIES
DISINFECTION destruction of pathogenic microorganism outside the body by
directly applying physical or chemical means
Concurrent method of disinfection done immediately after the infected
individual discharges infectious material/secretions. This method of
disinfection is when the patient is still the source of infection
Terminal applied when the patient is no longer the source of infection.
Disinfectant -chemical used on non living objects
Antiseptic chemical used on living things.
Bactericidal kills microorganism
Sterilization complete destruction of all microorganism
General Principles
Pathogens move through spaces or air current
Pathogens are transferred from one surface to another whenever objects touch
Hand washing removes microorganism
Pathogens are released into the air on droplet nuclei when person speaks,
breaths, sneezes
Pathogens are transferred by virtue of gravity
Pathogens move slowly on dry surface but very quickly through moisture
INFECTION
invasion and multiplication of microorganisms on the tissues of the host resulting
to signs and symptoms as well as immunologic response
injures the patient either by:
o competing with the hosts metabolism
o cellular damage produced by the microbes intracellular multiplication
Factors of severity of infection
o disease producing ability
o the number of invading microorganism
o The strength of the hosts defence and some other factors.
Epidemiological triad:
o Agent
o Host
o Environment
Causes of INFECTION
Some bacteria develop resistance to antibiotics
Some microbes have so many strains that a single vaccine cant protect against all
of them ex. Influenza
Most viruses resist antiviral drugs
Opportunistic organisms can cause infection in immunocompromised patients
Most people have not received vaccinations
Increased air travel can cause the spread of virulent microorganism to heavily
populated area in hours
Use of immunosupressive drugs and invasive procedures increase the risk of
infection
Problems with the bodys lines of defense
RISK FACTORS
Age, sex, and genes
Nutritional status, fitness, environmental factors
General condition, emotional and mental state
Immune system
Underlying disease ( diabetes mellitus, leukemia, transplant)
Treatment with certain antimicrobials (prone to fungal infection), steroids,
immunosuppresive drugs etc.
Mode of Transmission
Contact transmission
Direct contact - person to person
Indirect - thru contaminated object
o Droplet spread - contact with respiratory secretions thru cough, sneezing,
talking. Microbes can travel up to 3 feet.
Airborne Transmission
Vector Borne Transmission
Vehicle Borne Transmission
Control Measures
Masking Wear mask if needed. Patient with infectious respiratory diseases
should wear mask.
Handwashing Practice it with soap and water.
Gloving Wear gloves for all direct contact with patients. Change gloves and
wash hands every after each patient.
Gowning - Wear gown during procedures which are likely to generate splashes of
blood or sprays of blood and body fluids, secretions or excretions.
Eye protection (goggles) wear it to prevent splashes.
Environmental disinfection Clean surfaces with disnfectant 70% alcohol,diluted
bleach)
Ex. Normal clean clean the room post discharge, final clean- MRSA and
infectious pts.
ISOLATION PRECAUTIONS
Separation of patients with communicable diseases from others so as to reduce or
prevent transmission of infectious agents.
7 Categories Recommended in isolation
Strict isolation prevent spread of infection from patient to patient/staff.-
handwashing, infectous materials must be discarded, use of single room, use of
mask, gloves and gowns and (-) pressure if possible
Contact isolation prevent spread by close or direct contact
Respiratory isolation prevent transmission thru air.
TB isolation for (+) TB or CXR suggesting active PTB.
Enteric Isolation direct contact with feces
Drainage/secretion precaution- prevents infection thru contact with materials or
drainage from infected person.
Universal Precaution for handling blood and body fluids. (Bloods, pleural fluid,
peritoneal fluid etc.)
PREVENTION
Health Education educate the family about
Immunization
MOT
Environmental sanitation breeding places of mosquito, disposal of feces
Importance of seeking medical advice for any health problem
Preventing contamination of food and water.
Environmental Sanitation
o Water Supply Sanitation Program DOH thru EHS (Environmental Health
Services)
o Policies on Food Sanitation Program
o Policies on Hospital Waste Management
The Community Health Nurse is in the best position to do health education such
as
o > development of materials for environmental sanitation
o > providing group counselling, holding community assemblies and conferences.
o > create programs for sanitation
o > be a role model
Immunization introduction of specific antibody to produce immunity to certain disease.
o Natural passive (from placenta), active (thru immunization & recovery from
diseases)
o Artificial passive (antitoxins), active (vaccine, toxoid)
Maintain vaccine potency by preventing:
o Heat and sunlight
o Freezing
Antiseptic/ disinfectants/ detergents lessen the potency of vaccine. Use water only
when cleaning fridge/ref.
COLD CHAIN SYSTEM maintenance of correct temperature of vaccines,
starting from the manufacturer, to regional store, to district hospital, to the health center
to the immunizing staff and to the client.
Classification
1. Inactive asymptomatic, sputum is (-), no cavity on chest X ray
2. Active (+) CXR, S/S are present, sputum (+) smear
Classification 0-5
A. Minimal slight lesion confined to small part of the lung
B. Moderately advanced one or both lungs are involved, volume affected should not
extend to one lobe, cavity not more than 4 cm.
C. Far advance more extensive than B
MANIFESTATIONS
Primary Complex: TB in children: non contagious, children swallow phlegm, fever,
cough, anorexia, weight loss, easy fatigability
Adult TB
o afternoon rise in temperature
o night sweats
o weight loss
o cough dry to productive
o Hemoptysis
o sputum AFB (+)
Milliary TB - very ill, with exogenous TB like Potts disease
Primary Infection
o Asymptomatic
o No manifestations even at CXR, Sputum AFB
Primary Complex
o Minimal manifestations
o Lymphadenopathy
DX
Tuberculin testing
CXR
Sputum AFB
Prevention
BCG
Avoid overcrowding
Improve nutritional status
TX
DOTS
6 months of RIPE
Respiratory isolation,
Take medicines religiously prevent resistance
Stop smoking
Plenty of rest
Nutritious and balance meals, increase CHON, Vit. A, C
MENINGITIS
Inflammation of the meninges usually some combination of headache, fever,
stiff neck, and delirium
Meningococcemia: cerebrospinal fever
o Etiologic agent: Neisseria meningitidis
o Incubation: 2-10 days
o MOT: droplet
Acute meningococcemia - with or without meningitis
o Waterhouse Friederichsen Syndrome
Diagnostic exams:
o Lumbar tap, CSF - high WBC and CHON, low glucose
Manifestations:
o Sudden onset of fever x 24h
o Petechiae, Purpuric rashes
o Meningeal irritation
Stiff neck
Opisthotonus
Kernigs sign
Brudzinski sign
o ALOC (Altered level of consciousness)
o S/S of Increase ICP
Nursing Mgt:
Administer prophylactic antibiotics: Rifampicin - drug of choice
Aquaeous Pen
Mannitol
Dexamethasone
Priority: AIRWAY, SAFETY
Maintain seizure precaution
Respiratory precaution
Handwashing
Suction secretions
DIPTHERIA
Acute contagious disease characterized by generalized toxemia coming from localized
inflammatory process
Etiologic agent: Corynebacterium Diptheria (Klebs loffer bacillus)
Incubation period: 2-5 days
Period of communicability: variable, ave:2-4 weeks
MOT Droplet, direct or intimate contact, fomites, discharge from nose, skin, eyes
Manifestation
PSEUDOMEMBRANE - grayish white, smooth, leathery and spider web like
structure that bleeds when detached
Types of Respiratory Diptheria
NASAL
o serous to serosanginous purulent discharge
o Pseudomebrane on septum
o Dryness/ excoriation on the upper lip and nares
PHARYNGEAL
o pharyngeal pseudomembrane
o bull neck ( cervical adenitis)
o Difficulty swallowing
LARYNGEAL
o Sorethroat, pseudomembrane
o Barking, dry metallic cough
Complications
o Due to TOXEMIA
Toxic endocarditis
Neuritis
Toxic nephritis
o Due to Intercurrent Infection
Bronchopneumonia
Respiratory failure
DX
Nose and throat swabs - culture of specimen form beneath membrane
Virulence test
SHICKs TEST: test for susceptibility to diptheria
MOLONEYs TEST: test for hypersensitivity to diphtheria
MANAGEMENT
1. Penicillin, Erythromycin
2. Diptheria Antitoxin after skin test if (+), fractional dose
3. Supportive
O2, if laryngeal obstruction tracheostomy
CBR for 2 weeks
Increase fluids, adequate nutrition- soft food, rich in Vit C
Ice collar
4. Isolation till 3 NEGATIVE cultures
Prevention
DPT
Manifestation
o rapid cough 5-10x in one inspiration ending a high pitched whoop.
Catarrhal slight fever in PM, colds, watery nasal discharge, teary eyes,
nocturnal coughing, 1-2 weeks
Paroxysmal Spasmodic stage; 5-10 successive forceful coughing ending
with inspiratory whoop, involuntary micturition and defecation, choking spells,
cyanosis
Convalescent 4th- 6th week; diminish in severity, frequency
Complications:
Otitis media
Acute bronchopneumonia
Atelectasis or emphysema
Rectal prolapse, umbilical hernia
Convulsions (brain damage - asphyxia, hemorrhage)
Dx:
Elevated WBC
Nasopharyngeal swab
Nursing Management
Prevention:
o DPT
Parenteral fluids
Erythromycin - drug of choice
Prone position during attack
Abdominal binder
Adequate ventilation, avoid dust, smoke
Isolation
Gentle aspiration of secretions
MEASLES
Acute viral disease with prodromal fever, conjunctivitis, coryza, cough and
Kopliks spots
AKA: Rubeola, 7-day measles
Etiologic agent: Morbilli Paramyxoviridae virus
Incubation period: 10-12 days
Period of communicability: 3 days before and 5 days after the appearance of
rashes. Most communicable during the height of rash.
MOT: Airborne
Sources of infection secretions from eyes, nose and throat
Manifestations
1.Pre eruptive stage / Prodromal (10-11 days)
o Coryza, Cough, Conjunctivitis
o Kopliks Spots, whitish spot at the inner cheek
o Fever, photophobia
2. Eruptive stage
o Maculopapular rashes
o Rash is fully developed by 2nd day
o High grade fever on and off
o Anorexia, throat is sore
3. Convalescence (7-10 days)
o Desquamation of the skin
Diagnostics
Nose and throat swab
Treatment
1. Antiviral drugs- Isoprenosine
2. Antibiotics if with complications
3. Supportive O2, IVF
Complications bronchopneumonia, otitis media, encephalitis
Nursing Management
Preventive measles vaccine at 9 months, MMR 15 months and then 11-
12; defer if with fever, illness
Isolation - contact/respiratory
TSB , Skin care daily cleansing wash
Oral and nasal care
Plenty of fluids
Avoid direct glare of the sun- due to photophobia
GERMAN MEASLES
Mild viral illness caused by rubella virus.
AKA: Rubella; 3-Day Measles
Incubation period from exposure to rash 14 -21d
Period of communicability one week before and and 4 days after onset of
rashes. Worst when rash is at its peak.
MOT: Droplet, nasal ceretions, transplacental in congenital
Manifestations
1. Prodromal low grade fever, headache , malaise, colds, lymph node
involvement on 3rd to 5th day
2. Eruptive FORSCHEIMERS SPOTS: pinkish rash on soft palate, rash on face,
spreading to the neck, arms and trunk
o lasts1-5 days with no pigmentation or desquamation
o muscle pain
Treatment
o symptomatic treatment
Complications
1. Encephalitis, neuritis
2. Rubella syndrome microcephaly, mental retardation, deaf mutism, congenital
heart disease
Nursing Management
1. Isolation. Bed rest
2. Room darkened photophobia
3. Encourage fluid
4. Like measles tx
PREVENTION;
MMR, Pregnant women should avoid exposure to rubella patients
Administration of Immune serum globulin one week after exposure to rubella.
CHICKEN POX
Acute and highly contagious viral disease characterized by vesicular eruptions on the
skin
Infectious agent Herpes zoster virus or Varicella zoster
Incubation period 10 -21 days
Period of communicability: 1 day before eruption up to 5 days after the appearance
of the last crop
MOT: airborne, direct, indirect
o Direct contact thru shedding vesicles,
o Indirect thru linens or fomites
Manifestations
Pre eruptive: Mild fever and malaise
Eruptive: rash starts from trunk
Lesions - red papules then becomes milky and pus like within 4 days,
Pruritis
NURSING MANAGEMENT
Strict isolation until all vesicles scabs disappear
Hygiene of patient
Cut finger nails short
Baking soda - pruritus
PREVENTION: Live attenuated varicella vaccine
VZIG - effective if given 96h post exposure
Herpes Zoster
Acute inflammatory disease known to be caused by herpes virus varicellae or VZ virus
Infection of the sensory nerve charac by extremely painful infection along the sensory
nerve pathway
Occurs as reinfection of VZ virus
MOT
o Direct
o Indirect airborne
Incubation: 1-2 weeks
Diagnostic procedure
o Hx of chickenpox
o Pain and burning sensation over lesions of vesicles along nerve pathway
o Smear of vesicle fluid- giant cells
o Viral cultures of vesicle fluid
o Electron microscopy
o Giemsa-stained scraping multinucleate giant epithelial cells
S/S
o Burning, itching, pain then erythematous patches followed by crops of
vesicles
o Eruptions are unilateral
o Lesions may last 1-2 weeks
o Fever, regional lymphadenopathy
o Paralysis of cranial nerve, vesicles at external auditory canal
o Paralytic ileus, bladder paralysis, encephalitis
Complications
o Opthalmia herpes blindness because of damage of gasserian ganglion
o Geniculate herpes deafness because of infection of 7th CN (AKA: Ramsay
Hunt Syndrome)
Nursing Intervention
o Compress of NSS or alluminum acetate over lesions
o Analgesics, sedatives weeks to mos
o Steroids
o Keep blister covered with sterile powder esp after break
o Prevent bacterial invasion
o Encourage proper disposal of secretions and usage of gown and mask
MUMPS
Acute viral disease manifested by swelling of one or both of the parotid glands,
with occasional involvement of other glandular structures,particularly testes in
male.
Etiologic agent filterable virus of paramyxovirus group usually found in saliva of
infected person.
AKA: Epidemic/ infectious parotitis
Incubation period: 14 -25 days.
Period of communicability 6d before and 9d post onset of parotid gland swelling.
o 48 hrs immediately preceding the onset of swelling is the highest
communicability.
MOT: direct, indirect - droplet, airborne
CLINICAL MANIFESTATIONS
1. Sudden headache, earache, loss of appetite
2. Swelling of the parotid gland
3. Pain is related to extent of the swelling of the gland which reaches its peak in 2 days
and continues for 7-10 days.
4. Fever may reach 40 C during acute stage,
5. One gland may be affected first and 2 days later the other side is involved
COMPLICATIONS
1. Orchitis testes are swollen and tender to palpation.
2. Oophoritis- pain and tendeness of the abdomen
3. Mastitis
4. Deafness may happen
5. Meningo-encephalitis -possible
DIAGNOSTIC PROCEDURES
1. Viral culture
2. WBC Count
TREATMENT MODALITIES
1. Antiviral drugs
2. NSAIDS - Acetaminophen
Nursing Interventions
o Symptomatic
o Application of warm/ cold compress
o Oral care, warm salt water gargle
o Diet semi solid, soft food easy to chew
Acid foods/fluids fruit juices may increase discomfort
TYPHOID FEVER
Infection of the GIT affecting the lymphoid tissues(ulceration of Peyers patches)
of the small intestine
Etiologic Agent: Salmonella typhosa and typhi, Typhoid bacillus
Incubation period: 1-2 weeks
Period of communicability: as long as the patient is excreting the
microorganism,
MOT: fecal-oral route, contaminated water, milk or other food
Sources of Infection
o A person who recovered from the disease can be potential carrier.
o Ingestion of shellfish taken from waters contaminated by sewage disposal
o Stool and vomitus of infected person are sources of infection.
CLINICAL MANIFESTATIONS
ONSET
Ladderlike fever
Nausea, vomiting and diarrhea
RR is fast, skin is dry and hot, abdomen is distended
Head-ache, aching all over the body
Worsening of symptoms on the 4th and 5th day
Rose spots
TYPHOID STATE
Tongue protrudes- dry and brown
sordes
(coma vigil)
(subsultus tendinus)
(Carphologia)
Always slip down to the foot part of the bed,
Severe case - delirum sets in often ending in death
Complications
o Hemorrhage, Peritonitis, Pneumonia, Heart failure, Sepsis
DIAGNOSTIC PROCEDURES
1. WBC elevated
2. Blood Culture (+) S. typhosa
3. Stool Culture (+)
4. Widal test blood serum agglutination test
O antigen active typhoid
H antigen- previously infected or vaccinated
Vi antigen - carrier
TREATMENT
1. Chloramphenicol drug of choice
2.Paracetamol
NURSING MANAGEMENT
1. Restore FE balance
2. Bedrest
3. Enteric precaution
4. Prevent falls/ safety prec
5. Oral/personal hygiene
6. WOF intestinal bleeding-bloody stool, sweating, pallor
7. NPO, BT
CHOLERA
An acute bacterial disease of the GIT characterized by profuse diarrhea,
vomiting, loss of fluid.
Etiologic agent: Vibrio cholerae, V. comma
Pathognomonic sign: rice watery stool
Incubation period: 2-3 days
Period of Communicability: entire illness, 7-14d
MOT: fecal oral route
Clinical manifestations
o Acute, profuse, watery diarrhea.
o Initial stool is brown and contains fecal material becomes rice water
o Nausea/ Vomiting
Signs and symptoms of Dehydration
o poor tissue turgor, eyes are sunken
o Pulse is low or difficult to obtain, BP is low and later unobtainable.
o RR rapid and deep
o Cyanosis later
o Voice becomes hoarse speaks in whisper
Oliguria or anuria
Conscious, later drowsy
Deep shock
Death may occur as short as four hours after onset.
Usually first or 2nd day if not treated.
Principal deficits
1. Severe dehydration - circulatory collapse
2. Metabolic acidosis loss of large volume of bicarbonate rich stool. RR rapid and
deep
3. Hypokalemia massive loss of K. abdominal distention paralytic ileus
DIAGNOSTIC EXAMS
Fecal microscopy
1. Rectal swab
2. Stool exam
Treatment
1. IVF- rapid replacement
2. Oral rehydration
3. Strict I and O
4. Antibiotics Tetracycline, Cotrimoxazole.
NURSING MANAGEMENT
1. Medical Asepsis
2. Enteric precaution
3. VS monitoring
4. Intake and Output
5. Good personal hygiene
6. Proper excreta disposal
7. Concurrent disinfection.
8. Environmental sanitation
PREVENTION
1. Protection of food and water supply from fecal contamination.
2. Water should be boiled/ chlorinated.
3. Milk should be pasteurized.
4. Sanitary disposal of human excreta
5. Environmental sanitation.
DYSENTERY
Acute bacterial infection of the intestine characterized by diarrhea and fever
Etiologic Agent: Shigella group
o Shigella flesneri - commmon in the Philippines
o Shigella boydii, S. connei,
o S. dysenteria most infectious, habitat exclusively in man, they develop
resistance to antibiotics
Incubation period 7 hrs. to 7 days
Period of communicability during acute infection until the feces are (-)
MOT fecal-oral route, contaminated water/ milk/ food.
Clinical manifestations
Fever esp. in children
Nausea, vomiting and headache
Anorexia, body weakness
Cramping abdominal pain (colicky)
Diarrhea bloody and mucoid
Tenesmus
Weight loss
DIAGNOSTICS
Fecalysis
Rectal Swab/culture
Bloods WBC elevated
Blood culture
TREATMENT
Antibiotics- Ampicillin, Cotrimoxazole, Tetracycline
IVF
Anti diarrheal are Contraindicated
NURSING MANAGEMENT
1. Maintain fluid and electrolyte balance
2. Restrict food until nausea and vomiting subsides.
3. Enteric precaution
4. Excreta must be disposed properly.
5. Prevention- food preparation, safe washing facilities, fly control.
POLIOMYELITIS
An acute infectious disease caused by any of the 3 types of poliomyelitis virus which
affects mainly the anterior born cells of the spinal cord and the medulla, cerebellum
and the midbrain
AKA: Acute anterior poliomyelitis, heinmedin disease, infantile paralysis
Etiologic Agent: Poliovirus (Legio Debilitans)
3 Types of Poliovirus
Type I - most paralytogenic, most frequent
Type II - next most frequent
Type III - least frequent associated with paralytic disease
3 Strains
o Brunhilde
o Laasing
o Leon
MOT: Fecal-Oral
Incubation period: 7-14 days ave (3-21 days)
Period of communicability:
o 7-16 days before and few days after onset of s/s
Signs and Symptoms:
o Febrile episodes with varying degrees of muscle weakness
o Occasionally progressive Flaccid Paralysis
3 Types of Paralysis
Spinal Paralytic
o Flaccid paralysis
o Autonomic involvement
o Respiratory difficulty
Bulbar Form
o Rapid & serious
o Vagus and glossopharyngeal nerves affected
o Cardiac and respiratory reflexes altered
o Pulmo edema
o Hypertension, impaired temp regulation
o Encephalitic s/s
Bulbospinal
o Combination
Minor Polio
o Inapparent / subclinical
o Abortive: recover within 72 hours; flulike; backache; vomiting
Major Polio
o Paralytic: asymmetrical weakness, paresthesia, urinary retention,
constipation
o Non paralytic: slight involvement of the CNS; stiffness and rigidity of
the spine, spasms of hamstring muscles, with paresis
o Tripod position: extend his arms behind him for support when upright
o Hoynes sign: head falls back when he is in supine position with the
shoulder elevated
o Meningeal irritation: (+) Brudzinski, Kernigs sign
Diagnostic tests:
Throat swab, stool exam, LP
Nursing Interventions:
Supportive, Preventive Salk and Sabin Vaccine
NO morphine
Moist heat application for spasms
AIRWAY: tracheotomy
Footboard to prevent foot drop
Fluids, NTN, Bedrest
Enteric and strict precautions
HEPATITIS A
Inflammation of the liver caused by hepatitis A virus
AKA: infectious hepatitis
Incubation period: 2-6weeks
MOT: oral-fecal/ enteric transmission
Diagnostic test: liver function (SGOT/SGPT)
Clinical manifestations
Prodromal/ pre icteric
S/S of URTI
Weight loss
Anorexia
RUQ pain
Malaise
Icteric
Jaundice
Acholic stool
Bile-colored urine
Diagnostic tests: HaV Ag, Ab, SGOT, SGPT
Nursing Interventions:
o Provide rest periods
o Increase CHO, mod Fat, low CHON
o Intake of vits/minerals
o Proper food preparation/handling
o Handwashing to prevent transmission
AMOEBIASIS
Involves the colon in general but may involve the liver or lungs as well
Etiologic agent: Entamoeba histolytica
Incubation: 3-4 weeks
Period of communicability: duration of illness
MOT: fecal oral route
Indirect - Ingestion of food contaminated with E.Histolytica cysts, polluted water
supply, exposure to flies, unhygienic food handlers.
Direct contact sexual, oral, or anal, proctogenital
Clinical manifestations
Intermittent fever
Nausea, vomiting, weakness
Later : anorexia, weight loss, jaundice
Diarrhea watery and foul smelling stool often containing blood streaked mucus.
Colic and abdominal distention
Intestinal perforation bleeding
DIAGNOSTIC EXAM
Stool Exam ( cyst, amoeba+++)
WBC elevated
TREATMENT
o Amoebacides Metronidazole(Flagyl) 800mg TID X 7days
o Bismuth gylcoarsenilate combined with Chloroquine
o Antibiotic Ampicillin, Tetracycline, Chloramphenicol
o Fluid replacement IVF, oral
NUSING MANAGEMENT
Enteric precaution
Health education- boil drinking water (20-30 mins), Use mineral water.
Cover leftover food.
Avoid washing food from open drum/pail.
Wash hands after defecating and before eating.
Observe good food preparations.
Fly control
ASCARIASIS
Helminthic infection of the small intestine caused by ASCARIS LUMBRECOIDES
MOT: fecal-oral
Incubation period: 4-8 weeks
Communicability: as long as mature fertilized female worms live in intestine
Treatment:
o Pyrantel Pamoate
o Piperazine Citrate
o Mebendazole, Tetramizole
o Dicyclomine Hcl, NSAIDS for abdominal pain
o For intestinal obstruction
Decompression
Fluid and electrolyte therapy
If persistent, laparotomy
o Follow-up stool exam 1-2 weeks after treatment
Nursing Intervention:
o Isolation- not needed
o Enteric precaution
o Handwashing
o Proper nutrition
o Maintenance of hydration / fluid balance / boil of water
o Improve personal hygiene
o Proper food prep/handling
o Administer meds (NSAIDS, MEBENDAZOLE).
TETANUS
An acute, often fatal, disease characterized by generalized rigidity and convulsive
spasms of skeletal muscles caused by the endotoxin released by C. Tetani
AKA: Lockjaw
Sources:
o Animal and human feces
o Soil and dust
o Plaster, unsterile sutures, rusty scissors, nails and pins
MOT:
o Direct or indirect contact to wounds
o Traumatic wounds and burns
o Umbilical stump of the newborn
o Dirty and rusty hair pins
o GIT- port of entry rare
o Circumcision/ ear pearcing
Complications:
o Laryngospasm
Hypostatic pneumonia
Hypoxia
Atelectasis
o Trauma
Fractures
o Septicemia
Nosocomial infections
o Death
Diagnostic procedure:
entirely clinical
CSF normal
WBC - normal or slight elevation
Treatment:
Wounds should be cleaned
Necrotic tissue and foreign material should be removed
Tetanic spasms - supportive therapy and maintenance of an adequate airway
Tetanus immune globulin (TIG)
o help remove unbound tetanus toxin
o cannot affect toxin bound to nerve endings
o single intramuscular dose of 3,000 to 5,000 units
o Contains tetanus antitoxin.
Oxygen
NGT feeding
Tracheostomy
Adequate fluid, electrolyte, caloric intake
During convalescence
o Determine vertebral injury
o Attend to residual pulmonary disability
o Physiotherapy
o Tetanus Toxoid
Nursing Interventions:
Prevention
DPT
o Adverse Reactions
o Local reactions (erythema, induration)
o Fever and systemic symptoms not common
o Exagerated local reactions
Nursing interventions:
Prevention of CV and respiratory complications
o Adequate airway
o ICU ET- MV
Provide cardiac monitoring
KVO
Wound care (TIG, Debridement, TT)
Administer antibiotics as ordered
o Penicillin
Care during tetanic spasm/ convulsion
o Administer Diazepam muscle rigidity/spasm
o Administer neuromuscular blocking agents (metocurin iodide) relax
spasms and prevent seizure
Keep on seizure precaution
Parenteral nutrition
Avoid complications of immobility (contractures, pressure sores)
WOF urinary retention, fractures
RABIES
A viral zoonotic neuroinvasive disease that causes acute encephalitis
Etiologic agent: Rhabdovirus
AKA: Hydrophobia, Lyssa
Negri bodies in the infected neurons pathognomonic
Incubation period: 4-8 weeks; 10d-1yr
Period of communicability: 3-5 days before the onset of s/s until the entire
course of disease
MOT: contamination of a bite of infected animals
Diagnostic procedures
O History of exposure
O PE/ assessment of s/s
O Microscopic examination of Negri bodies using Sellers May-Grunwald and
Mann Strains
O Fluorescent Rabies Antibody technique / Direct Immunofluorescent test.
Clinical Manifestations
Prodromal Phase / Stage of Invasion
Fever, anorexia, malaise, sorethroat, copious salivation, lacrimation, perspiration,
irritability, hyperexcitability, restlessness, drowsiness, mental depression, marked
insomia
Sensitive to light, sound, and changes in temp
Myalgia, numbness, tingling, burning or cold sensation along nerve pathway;
dilation of pupils
Stage of Excitement
Marked excitation, apprehension
Delirium, nuchal stiffness, involuntary twitching
Painful spasms of muscles of mouth, pharynx, and larynx on attempting to
swallow food or water or the mere sight of them hydrophobia
Aerophobia
Precipitated by mild stimuli touch or noise
Death spasm from or from cardiac / respiratory failure
Terminal Phase or Paralytic Stage
Quiet and unconscious
Loss of bowel and bladder control
Tachycardia, labored irregular respiration, steady rising temp
Spasm, progressively increasing paralysis
Death due to respiratory paralysis
TREATMENT:
No cure
No specific symptomatic/ supportive directed toward alleviation of
spasm
Employ continuing cardiac and pulmonary monitoring
Assess the extent and location of the bite biting incident/ status of the
animal
o Severe exposure
o Mild exposure
Wound treatment (local care)
o Cleanse thoroughly with soap and water (or ammonium compounds,
betadine, or benzalkonium cl)
o Anti - rabies serum
o Tetanus prophylaxis
o Antibiotics
o Suturing should be avoided
Antirabies sera
o Heterologous serum obtained by hyperimmunization of different
animal species i.e. horses
o HRIG Homologous reabies immunoglobulin human origin
Rabies Vaccine
Active immunization
o Administered 3 years duration
o Used for lower extremity bites
o Lyssavac (purified protein embryo), Imovax, Anti-rabies vaccine
Passive immunization
o 3 months
o Rabuman, Hyper Rab, Imogam
Nursing Intervention:
o Isolation of patient
o Provide comfort for the patient by:
Place padding of bedside or use restraints
Clean and dress wound with the use of gloves
Do not bathe the patient, wipe saliva or provide sputum jar
o Provide restful environment
Quiet, dark environment
Close windows, no faucets or running water should be heard
IVF should be covered
No sight of water or electric fans
MALARIA
Acute and chronic disease transmitted by mosquito bite confined mainly to tropical
areas.
Etiologic agent Protozoa of genus Plasmodia
Plasmodium Falciparum (malignant tertian)
o most serious, high parasitic densities in RBC with tendency to agglutinate and form
into microemboli. Most common in the Philippines
P. Vivax - non life threatening except for the very young and old.
o Manifests chills every 48 hrs on the 3rd day onward if not treated,
P. malarie (Quartan) less frequent, non life threatening, fever and chills occur every
72 hrs on the 4th day of onset
P. ovale - rare
Incubation period:
o 12days P. falciparum, 14 days P vivax and ovale, 30 days P. malariae
Period of communicability:
o If not treated /inadequate more than 3 yrs. P malariae, 1-2 yrs. P. vivax, 1 yr- P.
falciparum
Mode of transmission
o Mosquito bite
DIAGNOSTICS
Malarial smear film of blood is placed on a slide, stained and examined.
Rapid diagnostic test (RDT) done in field. 10 -15 mins result blood test.
Clinical Manifestions:
Rapidly rising fever with severe headache
Shaking chills
Diaphoresis, muscular pain
Splenomegaly, hepatomegaly
Hypotension
o May lasts for 12 hours daily or every 2 days.
Complicated Malaria
GIT
o Bleeding from GUT, N/V, Diarrhea, abdominal pain, gastric, tyhoid, choleric,
dysenteric
CNS or Cerebral Malaria
o Changes in sensorium
o Severe headache
o N/V
Hemolytic
Blackwater fever
o Reddish to mahogany colored urine due to hemoglobinuria
o Anuria death
Malarial lung disease
MANAGEMENTS:
Antimalarial drugs Chloroquine (all but P. Malarie), quinine, Sulfadoxine (resistant P
falciparum) Primaquine (relapse P vivax/ovale)
RBC replacement/ erythrocyte exchange transfusion
Nursing management:
Isolation of patient
Use mosquito nets
Eradicate mosquitos
Care of exposed persons case finding
I and O
BUN & creatinine dialysis could be life saving
ABG
TSB, ice cap on head
Hot drinks during chilling, lots of fluid
Monitoring of serum bilirubin
Keep clothes dry, watch for signs of bleeding
PREVENTION
o Mosquito breeding places should be destroyed
o Insecticides, insect repellant
o Blood donor screening.
DENGUE FEVER
Is an acute febrile disease cause by infection with one of the serotypes of dengue
virus which is transmitted by mosquito (Aedes aegypti).
Dengue hemorrhagic fever fatal characterized by bleeding and hypovolemic
shock
Etiologic agent Arbovirus group B
AKA: Chikungunya, O nyong nyong, west nile fever
Mode of Transmission: Bite of infected mosquito AEDES AEGYPTI
Incubation period 3-14 days
Period of communicability mosquito all throughout life
Sources of infection
Infected person- virus is present in the blood and will be the reservoir when
sucked by mosquitoes
Stagnant water = any
Diagnostic Tests:
Torniquet test
Platelet Count
Hematocrit
Manifestations
PRODROMAL symptoms
o malaise and anorexia up to 12 hrs.
o Fever and chills, head-ache, muscle pain
o N &V
FEBRILE Phase
o Fever persists (39-40 C)
o Rash - more prominent on the extremities and trunk
o (+) torniquet test- petechia more than 10.
o Skin appears purple with blanched areas with varied sizes ( Hermans
sign)
o Generalized or abdominal pain
o Hemorrhagic manifestations epistaxis, gum bleeding
CIRCULATORY Phase
o Fall of temp on 3rd to 5th day
o Restless, cool clammy skin
o Profound thrombocytopenia
o Bleeding and shock
o Pulse - rapid and weak
o Untreated shock --- coma death
o Treated recovery in 2 days
CLASSIFICATION
Grade 1
Grade 2
Grade 3
Grade 4
Treatment:
No specific antiviral therapy for dengue
Analgesic not aspirin for relief of pain
IV fluid
BT as necessary
O2 therapy
NURSING MANAGEMENT
1. Kept in mosquito free environment
2. Keep pt. at rest
3. VS monitoring
4. Ice bag on the bridge of nose and forehead.
5. Observe for signs of shock VS (BP low), cold clammy skin
PREVENTION:
Mosquito net
Eradication of breeding places of mosquito-
o house spraying
o change water of vases
o scrubbing vases once a week
o cleaning the surroundings
o keep water containers covered
o avoid too many hanging clothes inside the house
LEPTOSPIROSIS
Infectious bacterial disease carried by animals whose urine contaminates water or
food which is ingested or inoculated thru the skin.
Etiologic agent: spirochete Leptospira interrogans
o found in river, sewerage, floods
AKA: Weils disease, mud fever, Swineherds disease
Incubation Period: 6 -15 days
Period of Communicability found in urine between 10-20 days
MOT contact with skin of infected urine or feces of wild/domestic animals; ingestion,
inoculation
Diagnostic tests:
o Clinical manifestations
o Culture
SOURCE OF INFECTION
o Rats, dogs, mice
MANIFESTATIONS
o Septic Stage
Early
Fever (40 C), tachycardia, skin flushed, warm, petechiae
Severe
Multiorgan
Conjunctival affectation, jaundice, purpura, ARF, Hemoptysis, head-
ache, abdominal pain, jaundice
o Toxic stage with or w/o jaundice, meningeal irritation, oliguria shock,
coma , CHF
o Convalescence recovery
MANAGEMENT
1. IV antibiotic
Pen G Na
Tetracycline
Doxycycline
2. Dialysis peritoneal
3. IVF
4. Supportive
5. Symptomatic
Nursing Interventions
o Isolation of patient urine must properly disposed
o Care of exposed persons keep under close surveillance
o Control measures
Cleaning of the environment/ stagnant water
Eradicate rats
Avoid bathing or wading in contaminated pool of water
vaccination of animals (cattles,dogs,cats,pigs)
SCHISTOSOMIASIS
Parasitic disease caused by Schistosomiasis japonicum, Schistosomiasis mansoni,
Schistosomiasis Hematobium.
AKA: Bilharziasis, Snail fever.
Incubation Period: 2 6 weeks
MOT: Bathing, swimming, wading in water.
Vector: Oncomelania quadrasi
o Cercariae: most effective stage
Diagnostic test: Ova seen in fecalysis
Diagnostic procedures:
Fecalysis
Identification of eggs
Liver and rectal biosy
Immunodiagnostic tests / circumoval precipitin test and cercarial envelope
reactions.
CLINICAL MANIFESTATIONS:
Abdominal pain
Cough
Diarrhea
Eosinophilia - extremely high eosinophil granulocyte count.
Fever
Fatigue
Hepatosplenomegaly - the enlargement of both the liver and the spleen.
Colonic polyposis with bloody diarrhea (Schistosoma mansoni mostly)
Portal hypertension with hematemesis and splenomegaly (S. mansoni, S.
japonicum);
Cystitis and ureteritis with hematuria bladder cancer;
Pulmonary hypertension (S. mansoni, S. japonicum, more rarely S.
haematobium);
Glomerulonephritis; and central nervous system lesions.
Complications:
O Pulmonary hypertension
O Cor pulmonale
O Myocardial damage
O Portal cirrhosis
Treatment:
Trivalent antimony
o Tartar emetic administered thru vein
o Stibophen (FUADIN) given per IM
PRAZIQUANTEL per orem
Niridazole
Nursing Interventions:
o Administer prescribed drugs as ordered
o Prevent contact with cercaria-laden waters in endemic areas like streams
o Proper sanitation or disposal of feces
o Creation of a program on snail control chemical or changing snail environment
LEPROSY
Chronic systemic infection characterized by progressive cutaneous lesions
Etiologic agent: Mycobacterium leprae
o Acid fast bacilli that attack cutaneous tissues, peripheral nerves producing skin
lesions, anesthesia, infection and deformities.
Incubation period 5 1/2 mo - eight years.
MOT respiratory droplet, inoculation thru break in skin and mucous membrane.
Diagnosis:
1. Identification of S/s
2. Tissue biopsy
3. Tissue smear
4. Bloods inc. ESR
5. Lepromin skin test
6. Mitsuda reaction
MANIFESTATIONS
Corneal ulceration, photophobia blindness
Lesions are multiple, symmetrical and erythematous macules and papules
Later lesions enlarge and form plaques on nodules on earlobes, nose eyebrows
and forehead
Foot drop
Raised large erythemathous plaques appear on skin with clearly defined borders.
rough hairless and hypopigmented leaves an anesthetic scar.
Loss of eyebrows/eyelashes
Loss of function of sweat and sebaceous glands
Epistaxis
TREATMENT
multiple drug therapy
sulfone
rehab
occupational Health
isolation
moral support
PREVENTION
1. Report cases and suspects of leprosy
2. BCG vaccine may be protective if given during the first 6 months.
3. Nursing Interventions:
1. Isolation of patient until causative agent is still present
2. Care of exposed persons
1. Household contact Diaminodiphenylsulfone for 2 years
2. Observe carefully for symptoms of the disease.
HIV /AIDS
Chronic disease that depresses immune function
Characterized by opportunistic infections when T4/CD4 count drops <200
MOT sexual contact with infected unprotected, injection of blood/products,
placental transmission.
RNA virus
Retrovirus
Reverse
transcriptase
Protease
Diagnostic Tests
ELISA
Western Blot
CD4 count
Viral load testing
Home test kits
Manifestations
o Minor signs cough for one month, general pruritus, recurrent herpes zoster, oral
candidiasis, generalized lymphadenopathy
o Major signs loss of weight 10% BW, chronic diarrhea 1month up, prolonged fever
one month up.
Persistent lymphadenopathy
Cytopenias (low)
PCP
Kaposis sarcoma
Localized candida
Bacterial infections
TB
STD
Neurologic symptoms
Treatment
Started in CD4 counts of <200
Viral load >10,000 copies
All symptomatic regardless of counts
Note: CD4 reflects immune system destruction. Viral load- degree of viral activity
Nucleoside Reverse Transcriptase Inhibitors
Blocks reverse transcriptase
NRT
Acts by binding directly to the reverse transcriptase enzyme
Not used alone
Rapid development of resistance
Acts by binding directly to the reverse transcriptase enzyme
Not used alone
Rapid development of resistance
Protease Inhibitors
Introduced in 1995
Acts by blocking protease enzyme
Indinavir (Crixivan)
CDC Guidelines
o Combination of 2 NRTI + PI
Nursing Management
o Administer Antiviral meds as ordered
o Universal precaution
o Reverse isolation
gloves, needle stick injury prevention
o Assist in early diagnosis and management of complications
4 Cs
o Compliance info, + drugs
o Counselling education
o Contact tracing tracing out and tx for partners
o Condoms safe sex
GONORRHEA
A curable infection caused by the bacteria Neisseria gonorrhoea
AKA: Clap, Drip, G. vulvovaginitis
MOT: transmitted during vaginal, anal, and oral sex
Incubation period: 3-10 days initial manifestations
Period of communicability: considered infectious from the time of exposure
until treatment is successful
Manifestations:
Urethritis both male and female
Signs and Symptoms: dysuria and purulent discharge
Cervicitis
Upper Genital Tract females (PID)
Endometritis, Salpingitis,
Pelvic Abscess
Complications :
PID
Infertility
Complications:
Upper Genital Tract male
o Epididymitis, Prostatitis, Seminal Vesiculitis
Disseminated Gonococcal Infection (DGI)
o Tenosynovitis or Polyarthritis, skin lesions and fever
Anorectal Infection
Pharyngeal Infection
Gonococcal Conjuctivitis
o Opthalmia Neonatorum
Meningitis, Endocarditis
Diagnosis:
Culture & Sensitivity
Blood tests for N. gonorrhoeae antibodies
Treatment:
ANTIBIOTICS
Penicillin
Single dose Ceftriaxone IM + doxycycline PO BID for 1 week
Prophylaxis: Silver nitrate, Tetracycline, Erythromycin
Nursing Interventions:
o Case finding
o Health teaching on importance of monogamous sexual relationship
o Treatment should be both partners to prevent reinfection
o Instruct possible complications like infertility
o Educate about s/s and importance of taking antibiotic for the entire therapy
SYPHILIS
a curable, bacterial infection, that left untreated will progress through four stages
with increasingly serious symptoms.
Etiologic agent: Treponema pallidum
AKA: Lues, The pox, Bad blood
Type of Infection: Bacterial
Modes of transmission :
o Through sexual contact/ intercourse, kissing
o abrasions
o Can be passed from infected mother to unborn child (transplacental)
Symptoms:
o Primary syphilis (10 90 days after infection)
Chancre a firm, painless skin ulceration localized at the point of
initial exposure to the bacterium appear on the genitals
can also appear on the lips, tongue, and other body parts.
o Secondary syphilis (last 2 6 weeks)
syphilis rash - an infectious brown skin rash that typically occurs on
the bottom of the feet and the palms of the hand
condylomata lata - flat broad whitish lesions
Fever, sore throat, swollen glands, and hair loss can also be
experienced
Third stage
o Will manifest 1 10 years after the infection
o characterised by gummas - soft, tumor-like growths
seen in the skin and mucous membranes occurs in bones
o joint and bone damage
o increasing blindness
o Numbness in the extremities, or difficulty in coordinating movements.
Neurosyphilis
generalized paresis of the insane which results in personality changes,
changes in emotional affect, hyperactive reflexes
cardiovascular syphilis
aortitis, aortic aneurysm, Aneurysm of sinus of valsalva and aortic
regurgitation, - death
Consequences in Infants
Congenital syphilis
extremely dangerous
Deformities
Seizures
Blindness
Damage to the brain, bones, teeth, and ears.
Prevention:
Abstinence
Mutual monogamy
Latex condoms for vaginal and anal sex
Nursing interventions
o Case finding
o Health teaching and guidance along preventive measures
o Utilization of community health facilities
o Assist in interpretation and diagnosis
o Reinforce ff up treatment
o VD control program participation
o Medical examination of patients contacts
HEPATITIS B
serious disease caused by a virus that attacks the liver
Etiologic agent: hepatitis B virus (HBV)
Source of infections: Blood and body secretions
Risk factors
multiple sex partners or diagnosis of a sexually transmitted disease
Sex contacts of infected persons
Injection-drug users
Household contacts of chronically infected persons
Infants born to infected mothers
Infants/children of immigrants from areas with high rates of HBV infection
Health-care and public safety workerr
Hemodialysis patients
Complications:
Lifelong infection
Liver cirrhosis
Liver cancer
Liver failure
Death
Prevention:
Hepatitis B vaccine has been available since 1982.
o Routine vaccination of 0-18 year olds
o Vaccination of risk groups of all ages
Immune globulin if exposed
MEDICAL MANAGEMENT:
Interferon alfa-2b
Lamivudine
Telbivudine
Entecavir
Adefovir dipivoxil
Nursing Interventions:
o Blood and body secretions precautions
o Prevention- Hepa B vaccine
o Proper rest periods
o Prevent stress physio/psychological
o Proper NTN, increase in CHO, high in CHON, low fats, Vit. K rich foods and
minerals
o Assistance to prevent injury, promote safety AAT
o WOF signs and symptoms bleeding, edema
o Health education on safe sex.
Diagnostic Test:
Chest X-ray (CXR)- abnormal with patchy infiltrates
WBC and PLT CT. - LOW
ELISA test detects antibodies to SARS
o but only 21 days after the onset of symptoms
Immunofluorescence assay, can detect antibodies 10 days after the onset of the
disease.
o labour and time intensive test
Polymerase chain reaction (PCR) test that can detect genetic material of the
SARS virus in specimens ranging from blood, sputum, tissue samples and stools
CXR - increased opacity in both lungs, indicative of pneumonia
SARS may be suspected
fever of 38 C (100.4 F) or more AND
Either a history of:
o Contact (sexual or casual) with someone with a diagnosis of SARS within
the last 10 days OR
o Travel to any of the regions identified by the WHO as areas with recent
local transmission of SARS (affected regions as of 10 May 2003 were parts
of China, Hong Kong, Singapore and the province of Ontario, Canada).
probable case of SARS has the above findings plus positive chest x-ray findings of
atypical pneumonia or respiratory distress syndrome
Treatment
Supportive with antipyretics, supplemental oxygen and ventilatory support as
needed.
Suspected cases of SARS must be isolated, preferably in negative pressure
rooms, with full barrier nursing precautions taken for any necessary contact with
these patients
steroids
antiviral drug
SARS vaccine
Tuberculosis*
Leprosy*
Schistosomiasis*
Filariasis
Malaria*
Dengue Hemorrhagic Fever (H-Fever)*
Measles*
Chicken Pox (Varicella)
Mumps (Epidemic Parotitis)*
Diptheria
Whooping Cough (Pertussis)
Tetanus Neonatorum and Tetanus among older age groups*
Influenza
Pneumonias
Cholera (El Tor)*
Typhoid Fever*
Bacillary Dysentery (Shigellosis)*
Soil Transmitted Helminthiases
Paragonimiasis
Hepatitis A*
Paralytic Shellfish Poisoning (PSP I RED TIDE POISONING)
Leptospirosis*
Rabies*
Scabies
Anthrax
Sexually Transmitted Infections
i. Gonorrhea*
ii. Syphilis*
iii. Chlamydia
iv. Gardianella Vaginitis
v. Trichomoniasis
vi. Hepatitis B*
HIV/AIDS*
Meningococcemia
Bird Flu or Avian influenza
SARS Severe Acute Respiratory Syndrome*
Policies of EPI:
I. Coverage--------------------------------------
A. Target Setting
B. FIC ( Full Immunized Child )
C. Wastage Allowance
OBJECTIVES OF EPI: To reduce morbidity and mortality rates among infants and
children from 6 or 7 immunizable disease
II. Cold Chain
III. Immunization Technical Responsibilities of PHN
IV. Surveillance--------------------------------
Planning, Supervision, and Training---
Mobilization, Monitoring and Health Education Administrative and Supportive
Role of PHN
Referral, Research and Evaluation ---
I. Coverage
A. Target Setting:
1. Target Population is the population group meant to be benefited by the EPI Programs
where DOH is responsible.
a. Infants ( 0 12 ) get the 3% of population
b. School Entrants get the 3% of population ( dictum of DOH ) = 6 years
c. Pregnant Women get the 3.5 % of population ( MWKA ) = 15 49 years
2. Eligible Population ( EP ) rae those qualified to receive specific immunizations where
PHW is responsible PHN, RHM, MO
*3 Population Groups to benefit
a. Infants (I) BCG, DPT, OPV, HBV, MV
b. School Entrants (S.E) Booster of BCG
c. Pregnant Women (PW) Tetanus Toxoid
*To determine Eligible Population:
EP = Population of the Community x 0.03 (Infants and School Entrants) or
X 0.035 (Pregnant Women)
*Example: Lanting Community with a population of 7000
a.) DPT = for infants
EP = 7000 X 0.03 = 210 to receive DPT
b.) Tetanus Toxiod = for pregnant women
EP = 7000 X .035 = 245 to receive TT
c.) Booster BCG = for school entrants
EP = 7000 X 0.03 = 210 to receive booster BCG
B. Fully Immunized Child ( FIC ) is a child who receives the 5 sets of vaccines
(BCG, DPT, OPV, Hepa B and Measles and who receives 11 doses of vaccines.
c. Wastage Allowance
- DOH doesnt ptoduce vaccines biologically and therefore dependent on suppliers
abroad: Germany and Switzerland to economize:
1. Be aware of the availability of vaccines:
Example: BCG
CHN: vial Private Practice: ampule
Frozen powder with a diluent
( 1 ml per content )
-Follow DOH Dictum: On the day of immunization, if 50% and above of computed
recipents arrive in the health center, open a vial but if less than 50%, dont open.
Example: In 20 recipients, 10 arrive = open a vial
-Half life of Vaccines is the duration of potency:
a. Vaccine with 4 hours half life: BCG, MV ( need to mix )
*If open at 8:00 am, its good till 12:00 noon
At 12:30 pm, dont give anymore because its not potent anymore.
b. Vaccine with 8 hours half life: DPT, OPV, HBV, TT (already in solution / liquid form
ready to administer)
months)
Primary Dose TT2 4 weeks after TT1 3 years immunity
1st Booster TT3 6 months after 5 years immunity
TT2
nd
2 Booster TT4 1 year after TT3 10 years immunity
3rd Booster TT5 1 year after TT4 Lifetime immunity
Examples:
1. Mrs Dela Cruz received the 1st booster dose (TT3) on November 20, 2004. When is
the 2nd booster? November 20, 2005
2. As a child, you have 3 doses of DPT. Now you become pregnant. What you need to
receive are the 3 booster doses only-TT3, TT4 & TT5 respectively.
3. If as a child, only 1 dose of DPT was given, is there a definite immunity? Theres no
definite # of years of immunity. If until 3 years she failed to receive vaccine, she got to
start with the 1st dose.
RHCDS
2. Proper Transport
- Vaccines are to be transported from the health center to the area of immunization
(community: focused, based & oriented)
- Tools provided by DOH: Vaccine Carrier which maybe
a. Black: use by staff of HC during epidemic & needs 5 cold dogs
b. White: use by student affiliates & needs 4 cold dogs
- Cold Dogs: 4 plastic containers filled with water which is placed in the freezer
a day before immunization which is used as freezant to keep vaccine potent
BCG, OPV & MV are composed of live attenuated bacteria & virus so before
discarding them, disinfect 1st with 1% Hcl or any disinfectant like zonrox,
chlorox or dumex
BCG (Bacilli Calmette-Guerin Vaccine): live attenuated bacteria
OPV & Measles Vaccine: live attenuated virus
I. Immunization
Guiding Principles for HW in Administering Vaccines & Screening of Children for
Immunizations:
1. No BCG for a child born clinically positive to AIDS because they have a damage
immune system & introducing bacteria will further aggravate their condition
2. There are no contraindications such as slight fever, LBM, cough & colds and
malnutrition, in giving the immunization unless upon assessment of the practitioner
that the child has serious medical problems that warrants hospitalization
3. In giving immunization with multiple doses such as DPT, OPV & HBV, continue
counting in giving the doses. Never count back even though the interval exceeds
weeks, months or years. As long as the child is on the eligible age
Example: DPT, OPV & HBV
1st dose: At 6 weeks (1 months), the child was given vaccination
2nd dose: The mother brought back the child when he was 8 months old instead at
10 weeks (2 months). PHN should still give the 2nd dose
3rd dose: The mother brought back the child at 2 years old. PHN should still give
the vaccine because child is still at the eligible age (0-59 months or 4 years & 11
months or 5 years old) to receive vaccine
4. DPT: it is a normal reaction for a child to develop high grade fever because of the
pertussis component (killed bacteria)
SOP Management:
Paracetamol q 4 hours RTC for the 1st 2 days (or 3, 4 days if still febrile)
If after 1st dose of DPT, the child develops high grade fever with convulsion, DPT 2
& 3 are not given anymore because convulsion affects the brain cells resulting to
brain damage
DPT vaccine is only for prophylactic/ preventive use
IMMUNITY
Natural Artificial
Provided by nature Accepts vaccine
No vaccine was given
Duration is longer/even for a lifetime Duration is shorter period
Example:
BCG-vaccine for protection from TB
gives 7-10 years immunity so booster
is needed
HBV-after 3 doses booster is needed
after 1 year
Active=person himself is involved in Active=person himself has no
the production of antibodies participation and done by another
1. Carrier (person harbors the disease person
but asymptomatic) of the disease Upon receiving vaccine (antigen) for
2. Constant exposure to disease immunizable diseases such as BCG,
3. Acquired or experienced the disease DPT, OPV, MV and HBV
Passive Passive
1. Breastfeeding IgA (present in 1. Serum (Blood):
colostrums) HBV
2. Perinatal immunity is acquired ATS (Anti-Tetanus Serum)
during the term of pregnancy ADS (Anti-Diptheria Serum)
2. Antitoxin: poison or causes infection
TAT (Tetanus Antitoxin)
DAT (Diptheria Antitoxin)
3. Immunoglobulins: IgA, IgD, IgE, IgG
& IgM where IgG is most predominant
Fresh always
Emotional bonding
Economical
Digestible: contains lactalbumin, a protein substance
Immunity: colostrum contains Ig A that protects baby for the 1st 3 months
Nutritious ( optional )
GIT diseases such as diarrhea is minimize / lessen because its sterile
3. Measles: immunization preventive and prophylactic
4. Oresol: a management for diarrhea to prevent dehydration
2 Concepts of Diarrhea:
a. Frequency of passing out stool = 3x/day
b. Consistency of the stool = watery
ROLE OF BREASTFEEDING IN THE
CONTROL OF DIARRHEAL DISEASES
PROGRAM
1. Two problems in CDD
1. High child mortality due to
diarrhea
2. High diarrhea incidence among under fives
2. Highest incidence in age 6 23 months
3. Highest mortality in the first 2 years of
life
4. Main causes of death in diarrhea :
DEHYDRATION
MALNUTRITION
5. To prevent dehydration, give home fluids
am as soon as diarrhea starts and if
dehydration is present, rehydrate early,
correctly and effectively by giving ORS
6. For undernutrition, continue feeding
during diarrhea especially breastfeeding.
7. Interventions to prevent diarrhea
1. breastfeeding
2. improved weaning practices
3. use of plenty of clean water
4. hand washing
5. use of latrines
6. proper disposal of stools of
small children
7. measles immunization
8. Risk of severe diarrhea 10-30x higher in
bottle fed infants than in breastfed
infants.
9. Advantages of breastfeeding in relation
to CDD
1.Breast milk is sterile
2.Presence of antibodies protection against
diarrhea
3.Intestinal Flora in BF infants prevents growth
of diarrhea causing bacteria.
10. Breastfeeding decreases incidence
rate by 8-20% and mortality by 24-27% in
infants under 6 months of age.
11. When to wean?
4-6 months soft mashed foods 2x a day
6 months variety of
foods 4x a day
12. Summary of WHO-CDD recommended
strategies to prevent diarrhea
1. Improved Nutrition
- exclusive breastfeeding for the first 4-6 months
of life and partially for at least one year.
- Improved weaning practices
2.Use of safe water
- collecting plenty of water from the cleanest
source
- protecting water from contamination at the
source and in the home
3.Good personal and domestic hygiene
- handwashing
- use of latrines
- proper disposal of stools of young children
4.Measles immunization.
3 Categories of Dehydration:
a. No dehydration-uses oresol
b. Some dehydration-uses oresol
c. Severe dehydration-uses IVF
Objectives/Plan/Policies of the Use of the following Program:
a. Plan A: for prevention of dehydration
b. Plan B: for treatment of dehydration-mild & moderate
c. Plan C: for treatment of dehydration-severe
Oresol is given/LBM or
every time stool is
passed out:
< 2 years old: 50-100ml.
always give the
maximum amount
2-10 years old: 100-200
ml.
10 years old & above: as
much as tolerated &
desired
2. Increase feeding:
3. Fast referral
1. Condition Some dehydration Plan B-Treatment of mild
a. Restless & Moderate DHN using
b. Irritable oresol
2. Sunken fontanel
3. Sunken eyeballs & If less than 2 years old:
absent tears use age in months
4. Dry mouth, tongue & If < 4 months: 200-400
lips ml.
Eagerness to drink 5-11 months: 400-600 ml.
5. Skin returns back 12-23 months: 600-800
slowly ml.
2-4 y/o: 800-1200 ml.
5-14 y/o: 1200-2200 ml.
15 & above: 2200-4000
ml.
TYPES OF DIARRHEA
o ACUTE : < 14DAYS
o PERSISTENT: 14 DAYS or more
o DYSENTERY: Blood in the stool; with or without mucus
CLASSIFY DEHYDRATION
SEVERE DEHYDRATION
Two of the following:
Abnormally sleepy
Sunken eyes
Drinks poorly
Skin pinch goes very slowly
Treat PLAN C: Referral to hospital for IVF!!!
NO DEHYDRATION
Not enough signs to classify some or severe
Treat PLAN A
Give extra fluids
50-100ml after each watery stool (0-2y/o)
100-200ml (2 y/o & above)
as tolerated (10y/o & above)
Continue feeding
Return if with danger sign/s.
Program:
1. Assessment:
History: Subjective
Age
Cough and Duration
Able to Drink or stop feeding
Fever ---- duration
Convulsion
Treatment:
1. Refer urgently to hospital
2. 1st dose of antibiotics
3. Treatment of Fever ( TSB ) * Wheeze (NEBULIZE)
4. Antimalarial
2. PNEUMONIA:
Signs and Symptoms:
a. Chest in drawing
b. Nasal flaring
c. Grunting
d. Cyanosis
2 Types:
a. Severe Pneumonia
Symptoms: Chest indrawing, cyanosis, nasal flaring, grunting.
Treatment: Same with very severe but anti malarial is not given.
3. NO PNEUMONIA
Assess for other problems and provide home care.
No Chest indrawing, No fever
If with sore throat in children: Mild, warm tea with syrup.
If chronic, refer.
2. PNEUMONIA
Symptoms: Severe Chest indrawing and Fast Breathing
Treatment: Same as severe.
BABY:
*Provide Antibodies.
*Contains Lactoferin ( Binds with Iron )
*Leukocytes
*Contains Bifidus factor
Promotes growth of the Lactobacillus inhibits the growth of pathogenic
bacilli.
Positions in BF THE BABY:
1. Cradle Hold head and neck are supported
2. Football Hold
3. Side Lying Position
Best for Babies
Reduce Incidence of Allergens
Economical
Antibodies Present
Stool Inoffensive ( Golden Yellow )
Temperature always ideal
Fresh Milk never goes off
Emotionally Bonding
Easy once established
Digested easily
Immediately available
Nutritionally optimal
Gastroenteritis greatly reduced
Garantisadong Pambata ( GP )
-Garantisadong Pambata is a biannual week long delivery of a package of health
services to children between the ages of 0 59 months old with the purpose of reducing
morbidity and mortality among under fives through the promotion of positive Filipino
values for proper children growth and development.
1. WHAT ARE THE HEALTH SERVICES OFFERED IN GP AND WHO ARE THE
TARGETS?
GP offers the following:
1.1 Routine Health Services:
-*The child should not have received megadose of Vitamin A above the recommended
dosage within the past 4 weeks except if the child has measles or signs and symptoms of
Vitamin A deficiency.
-**For any between 12 23 months, who missed any of his routine immunization, the
health worker should give the child the necessary antigen to complete FIC and shall be
recorded as such.
Garantisadong Pambata ( GP )
Sangkap Pinoy
-Vitamin A, Iron and Iodine
-Sources: green leafy and yellow vegetables, fruits, liver, seafoods, iodized, salt, pan de
bida and other fortified foods.
These micronutrients are not produced by the body, and must be taken in the food we
eat; essential in the normal process of growth and development:
a.) Helps the body to regulate itself
b.) Necesary in energy metabolism
c.) Vital in brain cell formation and mental developmet
d.) Necessary in the body immune system to protect the body from severe infection.
e.) Eating Sangkap Pinoy rich foods can prevent and control:
1. Protein Energy Malnutrition
2. Vital A deficiency
3. Iron Deficiency Anemia
4. Iodine Deficiency Disorder
Breastfeeding
-Breast milk is best for babies up to 2 years old. Exclusive breastfeeding is recommended
for the first six minths of life. At about six months, give carefully selected nutritious foods
as supplements.
-Breastfeeding provides physical and psychological benefits for children and mothers as
well as economic benefits for families and societies.
BENEFITS:
For INFANTS
a. Provides a nutritional complete food for the young infant.
b. Strengthens the infants immune system, preventing many infections.
c. Safely rehydrates and provides essential nutrients to a sick child, especially to those
suffering from diarrheal diseases.
d. Reduces the infants exposure to infection.
Mission:
*To provide the means and opportunities by which married couples of reproductive age
desirous of spacing and limiting their pregnancies can realize their reproductive goals.
TYPES OF METHODS:
A. NATURAL METHODS
1. Calendar or Rhythm Method
2. Basal Body Temperature Method
3. Cervical Mucus Method
4. Sympto Thermal Method
5. Lactational Amennorhea
B. ARTIFICIAL METHODS
I. CHEMICAL METHODS
1. Ovulation suppressant such as PILLS
2. Depo Provera
3. Spermicidals
4. Implant
II. MECHANICAL METHODS
1. Male and Female Condom
2. Intrauterine Device
3. Cervical Cap / Diaphragm
III. SURGICAL METHODS
1. Vasectomy
2. Tubal Ligation
*MC ( MATERNAL CARE )
*BF ( BREAST FEEDING )
*MRP ( MALNUTRITION REHABILITATION PROGRAM )
*VAD (VITAMIN A DEFICIENCY )
*IDD / IDA ( IODINE DEFICIENCY DISORDERS / IRON DEFICIENCY ANEMIA )
*FP ( FAMILY PLANNING )
Research in community health serves a number of purposes, among which are: (1) improve
our understanding of clients and their specific contexts;
(2) provide data needed for program and policy development and evaluation;
(3) improve the delivery of health services and implementation of existing programs;
(4) improve cost-effectiveness of programs; and (5) project a good image of nurses.
The PHN can initiate small researches on the major concerns in health service delivery and
in the management of the health facility. Research topics that could be studied by the PHN by
himself/herself include, among others, socio-demographic profile of those who utilize health
services, client waiting time, referral from and to the health center, perception of clients on the
delivery of health services, response of clients to different health or nursing interventions,
supply management and effects of specific health education activities.
Research also contributes to what is called evidence-based practice. The practices that were
passed on and were considered as gospel truth in the past should be examined and tested
through research. The challenge, not only PHNs but to major decision makers in the local
health system is to integrate research into the management and operation of the health
facility.
-HEALTH INDICES
I. Basic Health Indicators
2 Indicators to assess a national health situation
A. Nutrition
B. Disease Patterns
Context of CHN: Health Situation
**Leading Causes of Morbidity**
10 Leading Causes of Morbidity
1. Pneumonia -- Bacterial
2. Diarrhea
3. Bronchitis
4. Influenza -- Respiratory
5. Hypertension
6. TB Respiratory
7. Diseases of the Heart
8. Malaria
9. Chickenpox
10. Measles
-Health Care Delivery System the totality of all policies, equipment, products, human
resources and services whichaddress the health needs, problems and concerns of the
people. It is large, complex, multi level and multi disciplinary.
Categories:
According to Increasing According to the Type of Service
Complexity of the Services
Provided
Type Service Type Service
Primary Health Promotion, Health Information
Preventive Care, Promotion Dissemination
Continuing Care for and illness
common health prevention
problems, attention
to psychological and
social care, referrals
Secondary Surgery, Medical Diagnosis Screening
services by and
specialists Treatment
Tertiary Advanced, Rehabilitation PT/OT
specialized,
diagnostic,
therapeutic and
rehabilitative care
GOVERNMENT SECTORS
DEPARTMENT OF HEALTH (DOH)
VISION:
-Health for all by year 2000 and Health in the Hands of the People by 2020(OLD).
-A global leader for attaining better health outcomes, competitive and responsive health
care system, and equitable health financing(NEW VISION by 2030).
MISSION:
-In partnership with the people, provide equity, quality and access to health care
especially the marginalized.(OLD)
-To guarantee equitable, sustainable and quality health for all Filipinos, especially the
poor, and to lead the quest for excellence in health.(NEW)
5 Major Functions:
1. Ensure equal access to basic health services
2. Ensure formulation of national policies for proper division of labor and proper
coordination of operations among the government agency jurisdictions
3. Ensure a minimum level of implementation nationwide of services regarded as public
health goods
4. Plan and establish arrangements for the public health systems to achieve economies
of scale Phil Health.
5. Maintain a medium of regulations and standards to protect consumers and guide
providers Sentrong Sigla = Training and infrastructure
-LOCAL GOVERNMENT UNIT / NON GOVERNMENT SECTORS
R.A. 7160 Local Govt Code Local health board- Governor
Municipal health officer- mayor
Assistant - municipal
Provincial health officer
-Private Sector
-Composed of both commercial and business organization, non business
organizations
Commercial/Business Non-commercial
Profit-oriented Orientation to social development, relief
and rehabilitation, community
organizing
Manufacturing Socio-civic groups
companies Religious organizations/foundations
Advertising agencies
Private practitioners
Private institutions
GOAL:
*To improve health indicators through access.
*To enable the Filipino population to achieve a level of health which will allow Filipino to
lead socially and economically productive life, with longer life expectancy, low infant
mortality, low maternal mortality and less disability through measures that will guarantee
access of everyone to essential health care.
BROAD OBJECTIVES:
*promote equity in health status among all segments of society
*address specific health problems of the population
*upgrade the status and transform the HCDS into a responsive, dynamic and highly
efficient, and effective one in the provision of solutions to changing the health needs of
the population
*promote active and sustained peoples participation in health care
23 IN 1993
Refers to the 23 programs, projects, activities of the DOH
for the year 1993, which marks the beginning of its journey
towards DOG vision.
C. Vital Statistics
VITAL STATISTICS
Statistics refers to a systematic approach of obtaining, organizing and analyzing
numerical facts so that conclusion may be drawn from them.
Vital Statistics refers to the systematic study of vital events such as births, illnesses,
marriages, divorce, separation and deaths.
Statistics of disease (morbidity) and death (mortality) indicate the state of health of a
community and the success or failure of health work.
Health Indicators a list of information which would determine the health of a particular
community like population. Crude birth rate, crude death rate, infant and maternal death
rates, neonatal death rates and tuberculosis death rate
Health Indicators
Birth
Death
Marriages
Migration
Sources of Data:
*Population census
*Registration of Vital Data
*Health Survey
*Studies and researches
Ratio is used to describe the relationship between two (2) numerical quanitities or
measures of events without taking particular considerations to the time or place. These
quantities need not necessarily represent the same entities; although the unit of measure
must be the same for both numerator and denominator of the ratio.
Crude or General Rates referred to the total living population. It must be presumed
that the total population was exposed to the risk of the occurrence of the event.
Specified Rate - the relationship is for a specific population class or group. It limits the
occurrence of the event to the portion of the population definitely exposed to it.
Crude Birth Rate a measure of one characteristic of the natural growth or increase of a
population.
Crude Death Rate a measure of one mortality from all causes which may result in a
decrease of population.
Infant Mortality Rate measure the risk of dying during 1st year of like. It is a good
index of the general health condition of a community since it reflects the changes in
environment and medical condition of a community.
Maternal Mortality Rate measures the risk of dying from causes related to pregnancy,
childbirth, and puerperium. It is an index of the obstetrical care needed and received by
women in a community.
a. Measures risk of dying from causes associated with childbirth
b. Affected by:
Maternal health practices
Diagnostic ascertainment of maternal condition or cause of death
Completeness of registration of birth
Fetal Death Rate measures pregnancy wastage. Death of the product of conception
occurs prior to its complete expulsion, irrespective of duration of pregnancy.
Neonatal Death Rate measures the risk of dying the 1st month of life. It serves as an
index of the effects of prenatal care and obstetrical management of the newborn.
Specific Death Rate describes more accurately the risk of exposure of certain classes
of groups to particular diseases. To understand the forces of mortality, the rates should
be made specific provided the data are available for both the population and the event in
their specifications. Specific rates render more comparable and thus reveal the problem
of public health.
Prevalence Rate measures the proportion of the population which exhibits a particular
disease at a particular time. This can only be detremined following a survey of the
population concerned, deals with the total (new and old) number of cases.
Swaroops Index
Morbidity Rate
*Incidence Rate
a. Measures the development of a disease in a group exposed to the risk of the disease
in a period of time
b. Can be made specific for age and sex
*Attack Rate
a. Used for a limited population group and time period, usually during an outbreak or
epidemic
Prevalence Rate
a. Useful in describing the occurrence of chronic conditions and as basis for making
decisions in the administration of health services
b. Useful also in computing for carrier rates and antibody levels
A. Point Prevalence
B. Period Prevalence
Adjusted or Standardized Rate to render the rates of 2 communities comparable,
adjustment for the differences in age, sex, and any other factors which influence vital
events have to be made.
Methods:
*By applying observed specific rates to some standard population.
*By applying specific rates of standard population to corresponding classes or groups of
the local population.
Presentation of Data
The following are most commonly used graphs in presenting data:
Line or Curved graphs shows peaks, valleys and seasonal trends.
Also used to show the trends of birth and death rates over a period of time.
Bar graphs each bar represents or expresses a quantity in terms of rates or
percentages of a particular observation like causes of illness and deaths.
For comparison of data.
Area diagram (Pie Charts) shows the relative importance of parts of the whole.
b. PD 651 requires all health workers to register births within 30 days following
delivery
D. Epidemiology
EPIDEMIOLOGY-
-**The study of distribution of disease or physiologic conditions such as deformities
or disabilities and even death among human populations. And the factors affecting such
distribution.
-**Study of occurrences and distribution of diseases as well as the distribution and
determinants of health state or events in a specified population, and the application of
this study to the control of health problems. This emphasizes that epidemiologist are
concerned not only with deaths, illness and disability, but also with more positive health
states and with the means to improve health.
-**Epidemiology is the backbone of the prevention of diseases.
Aim: To identify factors of causation as basis for determining preventive and control
measures.
Uses of Epidemiology:
According to Morris, epidemiology is used to:
1. Study the history of the health population and the rise and fall of diseases and
changes in their character.
2. Diagnose the health of the community and the condition of people to measure the
distribution and dimension of illness in terms of incidence, prevalence, disability and
mortality, to set health problems in perspective and to define their relative importance
and to identify groups needing special attention.
3. Study the work of health services with a view of improving them. Operational research
shows how community expectations can result in the actual provisions of service.
4. Estimate the risk of disease, accident, defects and the chances of avoiding them.
5. Identify syndromes by describing the distribution and association of clinical
phenomena in the population.
6. Complete the clinical picture of chronic disease and describe their natural history.
7. Search for causes of health and disease by comparing the experience of groups that
are clearly defined by their composition, inheritance, experience, behavior, and
environment.
Epidemiological triangle: Agent, Host and Environment.
Agents of Disease:
*Nutritive elements in excess or in deficiencies.
*Chemical Agents
*Physical Agenta
*Infectious Agnets
Host Factor (intrinsic factors) influence exposure, susceptibility or response to
agents.
*Genetics
*Age
*Sex
*Ethnic group
*Physiologic functioning
*Immunologic experience
*Inter current to pre existing disease
*Human behavior
Environmental factors (extrinsic factors) influence existence of the agent, exposure
or susceptibility to agents.
*Physical environment
*Biologic environment
*Socio economic environment
The Epidemiologic Triangle consists of three component host, environment and agent.
The model implies that each must be analyzed and understood for comprehensions and
prediction of patterns of a disease. A change in any of the component will alter an
existing equilibrium to increase or decrease the frequency of the disease.
Preventive strategies:
1.Change the peoples behavior to manipulate the environment and reduce their
exposure to biological and non biological disease agents.
2. Manipulate the environment and prevent production or presence of disease agents.
3. Increase mans resistance or imunity to disase agents.
DESCRIPTIVE PHASE - Deals with the collection, organization, and analysisof data
regarding the occurrence of disease other health conditions.
A. VERIFICATION OF DIAGNOSIS
-Stating ones definition of a disease / diagnosis based on the presenting signs and
symptoms.
Consider Two Factors:
1. Sensitivity indicates the strength of association between a sign / symptom and the
disease; picks up most cases and avoids FALSE NEGATIVES.
2. Specificity shows the uniqueness of the association between a sign / symptoms and
the disease; excludes non cases or avoids FALSE POSITIVES.
*Causal when there is evidence that shows that certain factors increase the probability
of occurrence of a disease and a change in one or more of these factors produces a
change in the occurrence of the disease
*Non Causal
a. Spurious due to chance or bias caused by certain procedures / aspects involved in
study.
b. Indirect when a factor and disease are associated only because both are related to
some common underlying condition.
Descriptive VS Analytical
Provides information on patterns of Test Hypothesis about of disease.
disease in terms of person, place and
causes characteristics.
*Correlational *Case Reports Observational Intervention
*Ecologic *Case Series (Experimental)
*Cross Sectional
surveys
*Case control *Trials
*Cohort
Experimental Non - Experimental
With manipulation Mere observation of study conditions
*Clinical Trials *Cohort
*Field Trials *Case Control
*Community Intervention Trials *Proportional Mortality Studies
*Cross Sectional
*Ecologic
E. Demography
DEMOGRAPHY
-The emprical, statistical and mathematical study of human population; derived from two
Greek word snyos, which means people and ypagly which means to draw or write.
-Focus on three common and observable human events:
a. Population compposition or structure
b. Distribution of population in space
c. Population size
-Sources of Demographic Data
a. Census complete enumeration of the population.
b. Sample Surveys
c. Registration system
Two ways of Assigning People
1. De Jure people are assigned to places where they usually live regardless of where
they are at the time of the census.
2. De Facto people are assigned to the place where they are physically present at
the time of the census, regardless of their usual place of residence.
COMPONENTS
1. Population Composition pertains to all measurable characteristics of the people
who make up a given population.
a. Sex Ratio
c. Age and Sex Composition graphical presentation of the age and sex composition
of a population through the use of a POPULATION PYRAMID
d. Median Age age below which 50% of the population fall and above which 50% of
the population fall.
2. Population Distribution
a. Urban Rural Distribution shows the proportion of people living in urban compared
to the rural areas.
b. Rate of Natural Increase difference between CBR and CDR of a specific population
within a specified time.
Objectives:
- To provide summary of data on health services delivery and selected program
accomplished indicators at the barangay municipality / city, district, provincial, regional
and national events.
-To provide data which when combined with data from other sources, ca be used for
program monitoring and evaluation purposes.
-To provide a standardized, facility level data base which can be assessed for a more in
depth study /studies.
-To ensure that the data reported to the FHSIS are useful and accurate and are
disseminated in a timely and easy to use fashion.
-To minimize the recording and reporting burden at the service delivery level in order to
allow more time for patient care and promotive activities.
Importance of FHSIS
- Helps local government determine public health priorities.
- Basis for monitoring and evaluatinghealth program implementation.
- Basis for planning, budgeting, logistics and decision making at all levels.
- Source of data to detect unusual occurrence of a disease.
- Needed to monitor health status of the community.
- Helps midwives in following up clients.
- Documentation of RHM / PHN day to day activities.
Components:
*FAMILY TREATMENT RECORD (Cuevas, 2007) /
INDIVIDUAL RECORD (Famorca, 2013) / *INDIVIDUAL TREATMENT RECORD
*TARGET CLIENT LIST
*REPORTING FORMS / SUMMARY TABLE
*OUTPUT REPORTS /MONTHLY CONSOLIDATION TABLE (MCT)
Concept:
*TREATMENT RECORD Fundamental building block or foundation of FHSIS.
This is the document, form or pieces of paper upon which the presenting
symptoms or complaints of the patient on consultation and the diagnosis, treatment and
date of treatment if recorded.
*CLIENT LIST Second building block of the FHSIS and are intended to serve several
purposes.
First is to plan and carry out patient care and service delivery. Such lists will be
of considerable value to midwives / nurses in monitoring service delivery to clients in
general and in particular to groups of patients identified as targets or eligibles for one
or another program of the Department.
The second purpose of Target Client Lists is to facilitate the monitoring and
supervision of service delivery activities.
The Third purpose is to report services delivered.
The fourt purpose of the Target Client Lists is to provided a clinic level data
base which can be accessed for further studies.
3. SUMMARY TABLE
- Accomplished by Midwife
- 12 column table = 12 months of calendar year
- monthly summary of morbidity / monthly trends of disease
- serves as a source for the 10 leading causes of morbidity.
FLOW OF REPORT
OFFICE PERSON RECORDING FORMS FREQUENCY SCHEDULE OF
TOOLS SUBMISSION
BHS Midwife -ITR Monthly Monthly Every 2nd week
-TCL Form (M1 of the
-ST AND M2 ) succeeding
month
A-BHS Annually
Form Every 2nd week
of january
RHU PHN -ST Quarterly Quarterly Every 3rd week
-MCT Form (Q1 of the 1st month
AND Q2) of succeeding
quarter
Annual Every 3rd week
Forms of January
-A1
-A2
-A3
B. Target-setting
TARGET SETTING
-Involves the calculation of the eligible population for immunization services. Since the
Universal Child Immunization goal of 80% was achieved in 1989, the target for
immunizations since 1992 onwards has increased to 90%. The two most important goals
are the following:
Sustainability of the high coverage and,
Maintenance of quality immunization Services
a. Eligible Population
1. Infants for EPI in a barangay, municipality, district, province/city and region, target
setting is based on 3% of the total population.
2. BCG School Entrants use 3% of the total population in calculating the number of
children entering first grade in one year.
3. Pregnant Women All pregnant women are eligible for EPI. Target Setting must
include the number of pregnancies that will terminate in live births (3% of the total
population) plus the number of the pregnancies (0.5 % of the total population): thus, the
percentage of eligible women in the total population is 3.5%.
-Step Three: Determine the wastage rate of antigen or use the wastage multiplier. From
step two, multiply the product with the wastage multiplier to get the annual needs
including the wastage allowance.
-Step Four: Determine the number of ampoules or vials needed by dividing the annual
dose by the dose per vial or ampule
ANNUAL VACCINE NEEDS PER VIAL DOSE = Annual Vaccine / Dose per vial or ampule
-Step Five: Determine the vaccine need per month or quarter
Step Six: Determine the vaccine need per month or quarter with reserve stock
Step Three: Multiply the monthly eligible population by the number of doses required for
each antigen
MONTHLY INJECTIONS = Monthly eligible population X doses required per antigen
Step Four: Determine the total requirement including additional allowance for syringes
and needles.
TOTAL REQUIRED SYRINGES = Monthly injections X 1.25 for syringes
C. Environmental Sanitation
ENVIRONMENTAL SANITATION
-is defined as the study of all factors in mans physical environment which may exercise a
deleterious effect on his health, well being and survival.
Goal: to eradicate and control environmental factors in disease transmission through the
provision of basic services and facilities to all house holds.
COMPONENTS:
Water Supply Sanitation Program
Proper Excreta and Sewage Disposal Program
Insect and Rodent Control
Food Sanitation Program
Hospital Waste Management Program
Strategies on Health Risk Minimization due to Environmental Pollution
Rural Areas blind drainage type of wastewater collection and disposal facilities shall
be emphasized until such time that sewer facilities and off site treatment facilities are
available.
VII. Safe and Quality Care, Health Education, and Communication, Collaboration and
Teamwork
A. Principles and Theories of Growth and Development (Pediatric Nursing)
PRINCIPLES OF GROWTH AND DEVELOPMENT
PRINCIPLES EXAMPLES
Growth and development are continuous Although there are highs and lows in terms
processes from conception until death of the rate at which growth and
development proceed, a child grows new
cells and learns new skills at all times. An
example of how the rate of growth
changes is a comparison between that of
the first year and later in life. An infants
triples birthweights and increases height
by 50% during the first year of life. If this
tremendous growth rate were to continue,
the 5 ye-old child, when ready to begin
school, would weigh 1,600 Ib. And be 12
ft. 6 in. Tall.
Growth and development proceed in an Growth in height occurs in only one
orderly sequence. sequence from smaller to larger.
Development also proceeds in a
predictable order. For example, the
majority of children sit before they creep,
creep before they stand, stand before they
walk, and walk before they run. Some
children may skip a stage ( or pass
through it so quickly that the parents do
not observe the stage) or progress in a
different order, but most children follow a
predictable sequence of growth and
development.
Different children pass through the All stages of development have a range of
predictable stages at different rates. time rather than a certain point at which
they are usually accomplished. Two
children may pass through the motor
sequence at different rates. For example,
one child begins walking at 9 months while
another at 14 months. Both are developing
normally. They are both following the
predictable sequence; they are merely
developing at different rates.
All body systems do not develop at the Certain body tissues mature more rapidly
same rate. than others. For example, neurologic
tissue experiences its peak growth during
the first year of life, whereas genital
tissues grows little until puberty.
Development is cephalocaudal. Cephalo is a Greek word meaning head;
Caudal means tail. Development
proceeds from head to tail. A newborn can
lift only his or her head off the bed when
he or she lies in a prone position. By age 2
months., the infant can lift his or her head
and chest off the bed; by 4 months., he or
she can lift his or her head, chest, and part
of the abdomen; by 5 months., the infant
has enough control to turn over ; by 9
months., he or she can control the legs
enough to crawl; and by 1 year., the child
can stand upright and perhaps walk. Motor
development has proceeded in a
cephalocaudal order from the head to
the lower extremities.
Development proceeds from proximal to This principle is closely related to
distal body part. cephalocaudal development. It can be
illustrated by tracing the progress of upper
extremity development. A newborn makes
;ittle use of the arms or hands. Any
movement, except to put a thumb in the
mouth, is a flailing motin. By age 3 or 4
months., the infant has enough arm control
to support the upper body weight on the
forearms, and the infant can coordinate
the hand to sccop up objects. By 10
months., the infant can coordinate the arm,
thumb, and index fingers, sufficiently well
to use a pincer-like grasp or be able to
pick up an object as fine as a piece of
breakfast cereal on a high-chair train.
Development proceeds from gross to This principle parallels the proceeding one.
refined skills. Because the child is able to control distal
body parts such as fingers, he or she is
able to perform fine motor skills ( a 3-year-
old colors best with a large crayon; a 12
yr-old can write with a fine pen).
There is an optimum time for initiation of A child cannot learn a task until his or her
experiences or learning. nervous system is mature enogh to allow
that particular learning. A child cannot
learn to sit, for example, no matter how
much thechilds parentshave him or her
practice, until the nervous system has
matured enough to allow back control. A
child who is not given the opportunity to
learn developmental tasks at the
appropriate or targert times for such
tasks may have ,ore difficulty than the
usual child learning the tasks later on. A
child who is confined to a body cast at 12
months., which is the time he or she would
normally learn to walk, may take a long
time to learn this skill once free of the cast
at, say, age 2 years old. The child has
passed the time of optimal learning fo that
particular skill.
Neonatal reflexes must be lost before An infant cannot grasp with skill until the
development can proceed. grasp reflex has faded nor stand steadily
until the walking reflex has faded.
Neonatal reflexes are replaced by
purposeful movements.
A great deal of skill and behavior is An infants practices taking a first step over
learned by practice. and over before he or she accomplishes
this securely. If a child falls behind the
normal growth and development rate
because of illness, he or she is capable of
catch-up growth to bring him or her on
equal footing again with his or her age
group.
THEORIES OF DEVELOPMENT
1. Definition of Theories
Theory a systematic statement of principles that provides a framework for explaining
some phenomenon. Developmental theories provide road maps for explaining human
development.
Developmental Task a skill or a growth responsibility arising at a particular time in an
individuals life, the achievement of which will provide a foundation for the
accomplishment of future tasks. It is not so much chronological as the completion of
developmental tasks that defines whether a child has passed from one developmental
stage of childhood to another. For example, a child is not a toddler just because he or
she is 1 year plus 1 day old; he or she becomes a toddler when he or she has passed
through the development stage of infancy.
A. TEST III
1. Client in Pain
CLIENT IN PAIN
GLOSSARY
addiction: a behavioral pattern of substance use characterized by a compulsion to take
the substance (drug or alcohol) primarily to experience its psychic effects.
agonist: a substance that when combined with the receptor produces the drug effect or
desired effect.
Endorphins and morphine are agonists on the opioid receptors.
algogenic: causing pain.
antagonist: a substance that blocks or reverses the effects of the agonist by occupying
the receptor site without producing the drug effect.
balanced analgesia: using more than one form of analgesia concurrently to obtain more
pain relief with fewer side effects.
breakthrough pain: a sudden and temporary increase in pain occurring in a patient
being managed with opioid analgesia.
dependence: occurs when a patient who has been taking opioids experiences a
withdrawal syndrome when the opioids are discontinued; often occurs with opioid
tolerance and does not indicate an addiction.
endorphins and enkephalins: morphinelike substances produced by the body. Primarily
found in the central nervous system, they have the potential to reduce pain.
intractable pain: pain not relieved by conventional treatment.
neuropathic pain: pain caused by neurologic disturbance; may not be associated with
tissue damage.
nociception: activation of sensory transduction in nerves by thermal, mechanical, or
chemical energy impinging on specialized nerve endings; the nerves involved
convey information about tissue damage to the central nervous system.
nociceptor: a receptor preferentially sensitive to a noxious stimulus.
non-nociceptor: nerve fiber that usually does not transmit pain.
opioid: a morphinelike compound that produces bodily effects including pain relief,
sedation, constipation, and respiratory depression.
pain: an unpleasant sensory and emotional experience resulting from actual or potential
tissue damage.
pain threshold: the point at which a stimulus is perceived as painful.
- minimum amount of stimulus required to cause sensation of pain.
pain tolerance: the maximum intensity or duration of pain that a person is able to
endure.
- maximum pain a client is willing or able to endure.
patient-controlled analgesia (PCA): self-administration of analgesic agents by a patient
instructed about the procedure.
Phantom pain: pain experienced in missing body part.
placebo effect: analgesia that results from the expectation that a substance will work,
not from the actual substance itself.
prostaglandins: chemical substances that increase the sensitivity of pain receptors by
enhancing the pain-provoking effect of bradykinin.
radiating pain: pain experienced at source and extending to other areas.
referred pain: pain perceived as coming from an area different from that in which the
pathology is occurring.
- pain experienced in an area different from site of tissue trauma.
sensitization: a heightened response seen after exposure to a noxious stimulus.
Response to the same stimulus is to feel more pain.
tolerance: occurs when a person who has been taking opioids becomes less sensitive to
their analgesic properties (and usually side effects); characterized by the need for
increasing doses to maintain the same level of pain relief.
Pain
-Is defined as an unpleasant sensory and emotional experience associated with actual or
potential tissue damage (Merskey and Bogduk, 1994).
-Dimensions includes: Physical, Emotional, Cognitive, Socio-cultural and Spiritual
aspects.
-Pain occurs as the result of many disorders, diagnostic tests, and treatments; it disables
and distresses more people than any single disease.
1. Referred to as fifth vital sign.
2. Subjective; pain is whatever client says it is.
3. Perception of the clients pain is influenced by multiple factors (e.g., previous pain
experience and emotional, physical, and psychological status)
-The International Association for the Study of Pain (IASP) defines pain as an
unpleasant sensory and emotional experience associated with actual or potential tissue
damage, or described in terms of such damage. Although there are many
definitions and descriptors of pain, the one most relevant for nurses is that pain is
whatever the person experiencing it says it is, and existing whenever the person
says it does (McCaffery, 1979).
Types of PAIN
1. According to LOCATION
a. Referred pain
-perceived pain in an area but the source in another area.
-because fibers innervating this areas are close to innervating some tissues.
b. Visceral Pain
-usually diffuse, poorly localized, dull, pain, vague
-visceral organs are innervated by the sympathetic nerves to the spinal cord.
-rarely causes severe pain.
2. According to DURATION
a. Acute pain: mild to severe pain lasting lessthan 6 months.
-usually associated with specific injury; involves sympathetic nervous system response.
-leads to increased pulse rate and volume, rate and depth of respirations, blood pressure
(BP), and glucose level.
-urine production and peristalsis decrease.
b. Chronic pain: mild to severe pain lasting longer than 6 months.
-associated with parasympathetic nervous system.
-client may not exhibit signs and symptoms associated with acute pain.
-may lead to depression and decreased functional status.
3 TYPES OF CHRONIC PAIN:
1. Chronic Nonmalignant Pain
- > than 6 months, no foreseeable end
- Makes it difficult to live a normal life
2. Chronic Intermittent Pain
- Refers to exacerbation & recurrence of chronic condition.
- pain occurs at specific periods
- Ex. Migraine, Sickle cell
3. Chronic Malignant Pain
- have qualities of both Acute and Chronic Pain
c. Cancer related Pain: Pain associated with cancer may be acute or chronic. -Pain
resulting from cancer is so ubiquitous that when cancer patients are asked about
possible outcomes, pain is reported to be the most feared outcome (Munoz Sastre,
Albaret, Maria Raich Escursell, et al., 2006).
-Pain in patients with cancer can be directly associated with the cancer (eg, bony
infiltration with tumor cells or nerve compression), a result of cancer treatment (eg,
surgery or radiation), or not associated with the cancer (eg, trauma). However, most pain
associated with cancer is a direct result of tumor involvement.
3. According to INTENSITY
- clients report of pain MOST important indicator of the existence & intensity of pain.
- Assess of what level of comfort is acceptable
- Use of Pain Intensity Scale, Pain Rating Scale, Visual Analog Scale (VAS)
Factors Affecting Perception of Pain:
1. Amount of perception
2. State of Consciousness
3. The Level of Activities
4. The Clients Expectation
4. According to ETIOLOGY
b. Physiologic Pain
- Experienced when an intact, properly functioning nervous system sends signals that
the tissues are damaged, requiring attention and proper care.
- Subcategories: Somatic and Visceral
c. Neuropathic Pain
- experienced by people who have damaged or malfunctioning nerves
- may be due to: Illness, Injury, Undetermined reasons
A delta fibers
- transmits signals more rapidly
- delivers information on pain producing stimulus
- determine the location, severity and type of pain
- perceived as sharp, cutting, stubbing sensation
A beta fibers
- thicker neurons that release inhibiting neurotransmitters
- Dominant stimulation causes gating mechanism to close
C fibers
- conducted more slowly along pain pathway
- characterized as dull, burning sensations, associated with sufferings
- engages brain stem and cerebral regions contributing to emotional, cognitive and
situational components of pain
2. Transmission
I. Pain impulses travels from peripheral nerve fibers to the spinal cord
PAN membranes become depolarized
II. Ascension via spinothalamic tracts to the brain stem & thalamus
PAN neurotransmitters
III. Transmission of signals between the thalamus and somatic sensory cortex
Spinothlamic Tract (STT) segregates
4 thalamic nuclei
Perception
3. Perception
- client becomes conscious of the pain
- occurs in cortical structures
4. Modulation
- descending system
-descending fibers release substance which inhibits the ascending noxious impulses in
the dorsal horn
STIMULATION OF NOCICEPTORS
Mechanical instruments, and equipment
Thermal flames, hot liquids, steam
Chemical noxious substances
PAIN REACTION
Factors that Decsrease an Individuals Tolerance to Pain
- Prolonged pain that is sufficiently relieved
- Fatigue accompanied by inability to sleep
- Increase fear and anxiety
- Unresolved anger
- Depression / Isolation
Physiologic reaction to Pain
- Involved the activation of the sympathetic Nervous System
- Evoked the fight and flight reaction
- With catecholamine release from the adrenal medulla
Physical Responses
- Moving away
- Protecting body area
- Restlessness
- Facial expressions biting lips,grimace, staring
- Voluntary and involuntary protective body movements
Psychological Responses
- Verbal statements praying, swearing, cursing, repeating
- Non sensual phrases
- Altered response to environment
- Vocal behaviors moan, scream, sighing, crying
- Body movements rocking, rubbing, pounding, biting
- Physical contact to others
- Facial expressions grimace, tight lips, clenched teeth
PAIN HISTORY
- Previous pain treatment and effectiveness
- When and what analgesics were last given
- Other meds being taken
- Allergies to medication or food
ASSESSMENT
P Provoking factors (what makes pain worst/relieved)
Q Quality or quantity (dull, sharp, crushing, stabbing)
R Region and Radiation (diffused/ all over)
S Severity or intensity
T Timing (onset, duration, frequency, cause)
C Characteristics
O Onset
L Location
D Duration
E Exacerbation (what makes it worst?)
R Radiation (whether t spreads)
R Relief
P Provoking factors
A Alleviating factors/area
I Intensity
N Nature (characteristics)
MEASUREMENT OF PAIN
A Pain reporting is the single best measure of pain
A Pain location
U Drawing on the body, point & mark all areas where the pain is felt
A Pain intensity
U Numerical scale (0-10)
U Wong-Bakers Faces pain Rating (1-6 faces)
U Visual analogue scale (horizontal mark
A Pain quality
U Use of verbal descriptor scale
A Pain pattern
U Precipitating factors: what initiates (physical exertion, environmental & emo
factors)
U Alleviating factors: herbal teas, meds, test, hot or cold application, prayer,
distraction
U Associated symptoms: N/V, dizziness, diarrhea
U Effect on ADL
U Coping Resources
U Affecting responses: Anxiety, fear, exhaustion, depression or sense of
failure
U The use of the standardized assessment tools help make the pain less
abstract for the patient
U When the pain is a more concrete experience, the patient feels empowered
to cope
B. DIAGNOSIS
1) Pain
2) Activity intolerance
3) Altered family processes
4) Anxiety
5) Chronic pain
6) Constipation
7) Fear
8) Risk for altered thought processes
9) Risk for self- harm
10) Hopelessness
11) Ineffective individual coping
12) Powerlessness
13) Sleep pattern disturbance
ADJUVANT MEDICATIONS
- may be used with an analgesic or be used alone
- blocks cellular reuptake of serotonin /& epinephrine via descending pain inhibitory
system
- Selective Serotinin Reuptake Inhibitors:
Y Fluoxetine (Prozac)
Y Paroxtine (Foxil)
Y Sertraline (Zoloft)
- Anti- anxiety agents:
Y Diazepham mediate pain by allowing the movement of chloride inos result to
hyperpolarization of postsynaptic membrane, making it less receptive to incoming
nociceptive stimuli.
Y Anti- convulsants - situations associated with nerve injury ex. Phenetoin
Y Corticosteroids - reduce edema & inflammation
Nerve Blocks
- temporary or permanently interrupting transmission of nociceptive input by
application of local anesthetics or neurolytic agents (alcohol or phenol)
- successful for more localized chronic pain
- injection of anesthetics close to the nerves, thereby blocking their conductivity
- commonly used for operative procedures
- Ex. Plenux block for anesthesia of an extremity: brachial plexus block, epidural
block
NEUROSURGICAL INTERVENTIONS
Rhizotomy sensory nerve roots are destroyed where they enter the spinal cord
Cordotomy pain pathways are at the midline portion of the spinal cord before
S Imagery
- Develop sensory images that focus away from the pain sensation & emphasize
other sensory experiences & pleasant memories.
S Hypnosis
- a state of altered consciousness characterized by extreme responsiveness to
suggestion
S Relaxation techniques
- deep breathing, music, low rhythmic breathing, progressive relaxation exercises
- biofeedback teach self control over physiologic variables that relate to pain like
muscle contraction & blood flow
S Therapeutic touch
- realign aberrant fields
- pass hands over the clients body at a distance of 2-6 inches to sense changes in
the field & return it to normal
S Spiritual intervention
- encompasses a persons innermost concerns & values
- make peace with their past, being, spiritually aware in the present & making
commitment to go forward the life despite the pain.
- Prayer, caring.
2. Peri-operative Care
GLOSSARY
ambulatory surgery: includes outpatient, same-day, or short-stay surgery that does not
require an overnight hospital stay
informed consent: the patients autonomous decision about whether to undergo a
surgical procedure, based on the nature of the condition, the treatment options,
and the risks and benefits involved
intraoperative phase: period of time that begins with transfer of the patient to the
operating room table and continues until the patient is admitted to the postanesthesia
care unit
perioperative phase: period of time that constitutes the surgical experience; includes
the preoperative, intraoperative, and postoperative phases of nursing care
postoperative phase: period of time that begins with the admission of the patient to the
postanesthesia care unit and ends after follow-up evaluation in the clinical setting or
home
preadmission testing: diagnostic testing performed before admission to the hospital
preoperative phase: period of time from when the decision for surgical intervention is
made to when the patient is transferred to the operating room table
Surgery
Surgery is an invasive medical procedure performed to diagnose or treat illness, injury,
or deformity. Although surgery is a medical treatment, the nurse assumes an active role
in caring for the patient before, during, and after surgery. Interdisciplinary care and
independent nursing care together prevent complications
and promote the surgical patients optimal recovery.
Reconstructive Rebuild tissue/organ that has been Skin graft after a burn,
/Restorative damaged total joint replacement
Colostomy,debride-
Palliative Alleviate symptoms of a disease ment of necrotic tissue,
(not curative) resection of nerve
roots(Bowel resection
in patient with terminal
cancer).
I. Preoperative Care
A. Obtaining informed consent***
1. The surgeon is responsible for explaining the surgical procedure to the client and
answering the clients questions. Often, the nurse is responsible for obtaining the clients
signature on the consent form for surgery, which indicates the clients
agreement to the procedure based on the surgeons explanation.
2. The nurse may witness the clients signing of the consent form, but the nurse must be
sure that the client has understood the surgeons explanation
of the surgery.
3. The nurse needs to document the witnessing of the signing of the consent form after
the client acknowledges understanding the procedure.
4. Minors (clients younger than 18 years) may need a parent or legal guardian to sign the
consent form.
5. Older clients may need a legal guardian to sign the consent form.
6. Psychiatric clients have a right to refuse treatment until a court has legally determined
that they are unable to make decisions for themselves.
7. No sedation should be administered to the client before the client signs the consent
form.
8. Obtaining telephone consent from a legal guardian or power of attorney for health care
is an acceptable practice if clients are unable to give consent themselves. The nurse
must engage another nurse as a witness to the consent given over the telephone.
B. Nutrition
1. Review the surgeons prescriptions regarding the NPO (nothing by mouth) status
before surgery.***
2. Withhold solid foods and liquids as prescribed to avoid aspiration, usually for 6 to 8
hours before general anesthesia and for approximately 3 hours before surgery with local
anesthesia (as prescribed).
3. Insert an intravenous (IV) line and administer IV fluids, if prescribed; per agency policy,
the IV catheter size should be large enough to administer blood products if they are
required.
C. Elimination
1. If the client is to have intestinal or abdominal surgery, per surgeons preference an
enema, laxative, or both may be prescribed for the day or night before surgery.
2. The client should void immediately before surgery.
3. Insert an indwelling urinary catheter, if prescribed; urinary catheter collection bags
should be emptied immediately before surgery, and the nurse should document the
amount and characteristics of the urine.
D. Surgical site
1. Clean the surgical site with a mild antiseptic or antibacterial soap on the night before
surgery, as prescribed.
2. Shave the operative site, as prescribed; shaving may be done in the operative area.
!Hair on the head or face (including the eyebrows) should be shaved only if prescribed.
Client Teaching
Deep Breathing and Coughing Exercises
*Instruct the client that a sitting position gives the best lung expansion for coughing and
deep breathing exercises.
*Instruct the client to breath deeply 3 times, inhaling through the nostrils and exhaling
slowly through pursed lips.
*Instruct the client that the third breath should be held for 3 seconds; then the client
should cough deeply 3 times.
*The client should perform this exercise every 1 to 2 hours.
Incentive Spirometry
*Instruct the client to assume a sitting or upright position.
*Instruct the client to place the mouth tightly around the mouthpiece.
*Instruct the client to inhale slowly to raise and maintain the flow rate indicator, usually
between the 600 and 900 marks on the device.
*Instruct the client to hold the breath for 5 seconds and then to exhale through pursed
lips.
*Instruct the client to repeat this process 10 times every hour.
Leg and Foot Exercises
*Gastrocnemius (calf) pumping: Instruct the client to move both ankles by pointing the
toes up and then down.
*Quadriceps (thigh) setting: Instruct the client to press the back of the knees against
the bed and then to relax the knees; this contracts and relaxes the thigh and calf muscles
to prevent thrombus formation.
*Foot circles: Instruct the client to rotate each foot in a circle.
*Hip and knee movements: Instruct the client to flex the knee and thigh and to
straighten the leg, holding the position for 5 seconds before lowering (not performed if the
client is having abdominal surgery or if the client has a back
problem).
Splinting the Incision
*If the surgical incision is abdominal or thoracic, instruct the client to place a pillow, or 1
hand with the other hand on top, over the incisional area.
*During deep breathing and coughing, the client presses gently against the incisional
area to splint or support it.
8. Instruct the client in leg and foot exercises to prevent venous stasis of blood and to
facilitate venous blood return
9. Instruct the client in how to splint an incision, turn, and reposition
10. Inform the client of any invasive devices that may be needed after surgery, such as a
nasogastric tube, drain, urinary catheter, epidural catheter, or IV or subclavian lines.
11. Instruct the client not to pull on any of the invasive devices; they will be removed as
soon as possible.
Psychosocial preparation
1. Be alert to the clients level of anxiety.
2. Answer any questions or concerns that the client may have regarding surgery.
3. Allow time for privacy for the client to prepare psychologically for surgery.
4. Provide support and assistance as needed.
5. Take cultural aspects into consideration when providing care.
Preoperative checklist
1. Ensure that the client is wearing an identification bracelet.
2. Assess for allergies, including an allergy to latex.
3. Review the preoperative checklist to be sure that each item is addressed before the
client is transported to surgery.
4. Follow agency policies regarding preoperative procedures, including informed
consents, preoperative checklists, prescribed laboratory or radiological tests, and any
other preoperative procedure.
5. Ensure that informed consent forms have been signed for the operative procedure,
any blood transfusions, disposal of a limb, or surgical sterilization procedures.
6. Ensure that a history and physical examination have been completed and documented
in the clients record
7. Ensure that consultation requests have been completed and documented in the
clients record.
8. Ensure that prescribed laboratory results are documented in the clients record.
9. Ensure that electrocardiogram and chest radiography reports are documented in the
clients record.
10. Ensure that a blood type, screen, and crossmatch are performed and documented in
the clients record within the established time frame per agency policy.
11. Remove jewelry, makeup, dentures, hairpins, nail polish (depending on agency
procedures), glasses, and prostheses.
12. Document that valuables have been given to the clients family members or locked in
the hospital safe.
13. Document the last time that the client ate or drank.
14. Document that the client voided before surgery.
15. Document that the prescribed preoperative medications were given.
Anticonvulsants Insulin
Long-term use of certain anticonvulsants The need for insulin after surgery in a
can alter the metabolism of anesthetic diabetic may be reduced because the
agents. clients nutritional intake is decreased, or the
need for insulin may be increased because
Antidepressants of the stress response and intravenous
Antidepressants maylower the blood administration of glucose solutions.
pressure during anesthesia.
Antidysrhythmics
Antidysrhythmic medications reduce
cardiac contractility and impair cardiac
conduction during anesthesia.
Adapted from Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St.
Louis, 2013, Mosby.
Respiratory Tissue Properties Respiratory vessels and airways are implanted in elastic
tissues which have the following properties:
a. Compliance is the elastic property related to elastic and collagen fibers. It changes
with the changes in respiratory system pressures and/or changes in lung fluid content.
Higer compliance occurs in a lung that is more easily distended. Lower compliance
occurs in a lung that is not easily distended
b. Elastic recoil is the ability of the lungs to return to their original shaped after air is
expelled. Recoil is present because of opposing forces created by the movements of the
lungs and chest wall.
c. Distensibility makes inflation more difficult through increased volume of lung fluid
content or consolidation of lung tissue.
d. Stiffness is the resistance of the lungs tostretch and to accommodate air volume.
Ncreasing lung stiffiness lowers compliance.
Tidal volume (VT): 5 10 Ml /kg (or 500 Ml total); air volume inspired and
expired during one breathing cycled.
Inspiratory reserve volume (IRV): 1,800 to 2,000mL; maximum air volume
inspired with forced inspiration ( i.e., movement of air from the atmosphere into the
respiratory system) following normal inspiration.
Expiratory reserve volume (ERV): 1,400 mL; air volume that can be expired with
force following normal expiration.
Residual volume (RV): 1,000 to 1,200 mL air volume remaining in the lungs
following forced expiration.
Total lung capacity (TLC): 5,000 to 6,000 mL; maximum capacity of the lungs.
TLC = IRV + VT + ERV + RV
Inspiratory capacity (IC): maximum air volume that can be inhaled following a
normal exhalation. IC = VT + IRV
Vital vapacity (VC): 4,500 to 4,800 mL; maximum air volume that can be exhaled
after a maximum inhalation. VC = IRV + VT + ERV
Functional residual capacity (FRC): 2,000 to 2,400 mL; residual air volume int
the lungs after a normal exhalation. FRC = ERV + RV.
Body position Gravity accountsfor greater ventilation in dependent areas of the lungs.
An upright, sitting or standing position allows for the path of least resistance into the more
compliant lung bases.
Perfusion is the quality of blood flow through the pulmonary capillary bed and to the
respiratory system structure. The respiratory system circulation includes the pulmonary
circulation and bronchial circulation.
Diffusion is the movement of gas from an area of higher pressure to lower pressure.O2
diffuses from the atmosphere into the alveoli, across the pulmonary capillary membrane
and into the pulmonary capillaries for circulation throughout the body. CO2 diffuses out of
the pulmonary capillaries across the capillary membrane and into the alveoli to be
exhaled. Diffusion continues until pressure differences become equal between the two
areas
II. Assessment
*Nursing and Health History
The health history focuses on the physical and functional problems and the effects of
these problems on the patient, including the ability to carry out activities of daily living.
Several common symptoms related to the respiratory system are discussed in detail
below. If the patient is experiencing severe dyspnea, the nurse may need to modify or
abbreviate the questions asked and the timing of the health history to
avoid increasing the patients breathlessness and anxiety.
In addition to identifying the chief reason why the patient is seeking health care, the
nurse tries to determine when the health problem or symptom started, how long it lasted,
if it was relieved at any time, and how relief was obtained. The nurse obtains information
about precipitating factors, duration, severity, and associated factors or symptoms.
Common Symptoms
The major signs and symptoms of respiratory disease are dyspnea, cough, sputum
production, chest pain, wheezing, and hemoptysis. The nurse also assesses the
impact of signs and symptoms on the patients ability to perform activities of daily living
and to participate in usual work and family activities.
-Dyspnea (subjective feeling of difficult or labored breathing, breathlessness, shortness
of breath) is a symptoms common to many pulmonary and cardiac disorders, particularly
when there is decreased lung compliance or increased airway resistance. Dyspnea may
also be associated with neurologic or neuromuscular disorders (eg, myasthenia gravis,
Guillain-Barr syndrome, muscular dystrophy, postpolio syndrome) that affect respiratory
function. Dyspnea can also occur after physical exercise in people without disease (Davis
& Holliday, 2005; Porth & Matfin, 2009).
The circumstance that produces the dyspnea must be determined. Therefore, it is
important to ask the patient the following questions:
How much exertion triggers shortness of breath? Does it occur at rest? With exercise?
Running? Climbing stairs?
Is there an associated cough?
Is the shortness of breath related to other symptoms?
Was the onset of shortness of breath sudden or gradual?
At what time of day or night does the shortness of breath occur?
Is the shortness of breath worse when laying flat?
Is the shortness of breath worse while walking? If so, when walking how far? How fast?
How severe is the shortness of breath? On a scale of 1 to 10, if 1 is breathing without
any effort and 10 is breathing that is as difficult as it could possibly be,
how hard is it to breathe?
It is especially important to assess the patients rating of the intensity of
breathlessness, the effort required to breathe, and the severity of the breathlessness or
dyspnea. Patients use a variety of terms and phrases to describe breathlessness, and
the nurse needs to clarify what terms are most familiar to the patient and what these
terms mean. Visual analogue or other scales can be used to assess changes in the
severity of dyspnea over time (Dorman, Byrne & Edwards, 2007; Porth & Matfin, 2009).
- Coughing is a reflex that protects the lungs from the accumulation of secretions or the
inhalation of foreign bodies. Its presence or absence can be a diagnostic clue because
some disorders cause coughing and others suppress it. The cough
reflex may be impaired by weakness or paralysis of the respiratory muscles, prolonged
inactivity, the presence of a nasogastric tube, or depressed function of the medullary
centers in the brain (eg, anesthesia, brain disorders) (Irwin,
Baumann, Bolser, et al., 2006; Porth & Matfin, 2009).
- Cough results from irritation of the mucous membranes anywhere in the respiratory
tract. The stimulus that produces a cough may arise from an infectious process or from
an airborne irritant, such as smoke, smog, dust, or a gas. A
persistent and frequent cough can be exhausting and cause pain. Cough may indicate
serious pulmonary disease or a variety of other problems as well, including cardiac
disease, medication reactions (eg, amiodarone [Cordarone], angiotensin - converting
enzyme [ACE] inhibitors), smoking, and gastroesophageal reflux disease (Irwin, et al.,
2006).
- To help determine the cause of the cough, the nurse describes the cough: dry, hacking,
brassy, wheezing, loose, or severe.
*A dry, irritative cough is characteristic of an upper respiratory tract infection of viral
origin, or it may be a side effect of ACE inhibitor therapy.
*An irritative, high-pitched cough can be caused by laryngotracheitis.
*A brassy cough is the result of a tracheal lesion.
*while a severe or changing cough may indicate bronchogenic carcinoma. Pleuritic chest
pain that accompanies coughing may indicate pleural or chest wall (musculoskeletal)
involvement.
- The nurse inquires about the onset and time of coughing. Coughing at night may
indicate the onset of left-sided heart failure or bronchial asthma. A cough in the morning
with sputum production may indicate bronchitis. A cough that worsens when the patient is
supine suggests postnasal drip (rhinosinusitis). Coughing after food intake may indicate
aspiration of material into the tracheobronchial tree. A
cough of recent onset is usually from an acute infection.
- Secretions are of different types:
a. Sputum is an aggregation of secretions from the tracheobronchial tree, mouth,
pharynx, (saliva), nose and sinuses.
b. Phlegm refers to secretions of the tracheobronchial tree and lungs. A healthy adult
may have a volume of 100mL/24 hrs.
Sputum Production A patient who coughs long enough almost invariably produces
sputum. Sputum production is the reaction of the lungs to any constantly recurring irritant.
It also may be associated with a nasal discharge. The nature of the sputum is often
indicative of its cause. A profuse amount of purulent sputum (thick and yellow, green, or
rust colored) or a change in color of the sputum is a common sign of a bacterial
infection. Thin, mucoid sputum frequently results from viral bronchitis. A gradual
increase of sputum over time may occur with chronic bronchitis or bronchiectasis. Pink
tinged mucoid sputum suggests a lung tumor. Profuse, frothy, pink material, often
welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and
bad breath point to the presence of a lung abscess, bronchiectasis, or an infection
caused by fusospirochetal or other anaerobic organisms.
Chest Pain or discomfort may be associated with pulmonary or cardiac disease. Chest
pain asccociated iwth pulmonary conditions may be sharp, stabbing, and intermittent, or
it may be dull, aching, and persistent. The pain is usually felt on the side where the
pathologic process is located, but it may be referred elsewhere for example to the neck,
back, or abdomen.
- Chest pain may occur with pneumonia, pulmonary embolism with lung infarction,
pleurisy, or as a late symptom of bronchogenic carcinoma. In carcinoma, the pain may be
dull and persistent because the cancer has invaded the chest wall, mediastinum, or
spine.
- Lung disease does not always cause thoracic pain because the lungs and the visceral
pleura lack sensory nerves and are insensitive to pain stimuli. However, the parietal
pleura has a rich supply of sensory nerves that are stimulated by inflammation and
stretching of the membrane. Pleuritic pain from irritation of the parietal pleura is sharp
and seems to catch on inspiration; patients often describe it as being like stabbing of a
knife. Patients are more comfortable when they lay on the affected side because this
splints the chest wall, limits expansion and contraction of the lung, and reduces the
friction between the injured or diseased
pleurae on that side. Pain associated with cough may be reduced manually by splinting
the rib cage.
- Factors to consider:
a. onset, location, and radiation
b. duration and character or quality
c. factors that precipitate that relieve pain
d. effect of the pain or the activiity.
Cyanosis is a condition wherein the Hgb is reduced to 5g / dl or more.
Normal: 15 g/dl or 6.95 vol.
- Types:
a. Peripheral cyanosis refers to the bluish discoloration of the extremities and the
nailbeds.
Causes:
- reduced oxyhemoglobin in the systematic capillaries.
- peripheral vasoconstriction.
- strenuous exercise due to increased utilization of oxygen.
- reduced blood flow which is usually physiological in nature.
b. Central cyanosis refers to the bluish discoloration of the lips, tongue, face and
mucous membrane. It results from insufficient oxygen of hemoglobin. It is always
pathologic.
c. Differential cyanosis refers to the condition wherein the upper half of the body is pink
and the lower part is blue or vice versa. It indicates severe heart disease.
Factors that alter the appearance of cyanosis:
1. Pigmentation and Thickness: Cyanosis is a subjective assessment and is therefore not
a reliable sign of the state of oxygenation.
*very thin, unpigmented skin, especially where capillaries are superficial and numerous
(e.g., the tip of the tongue, the buccal mucosa, the cutaneous surfaces of the lips, the tips
of the finger and toes, the nailbeds, the earlobes and the tip of nose must be observed).
*Some areas are highly vascular (e.g., heels). In newborns, these afford easy
determinatin.
*The mucous membrane is an important site for detection of cyanosis in clients with
dark skin.
2. The type and amount of light used in making the assessment: Natural light is best;
fluorescent light is less desirable.
3. The absolute amount of reduced hemoglobin, rather than the relative amount of
oxyhemoglobin and reduced hemoglobin. A client who is anemic may not appear
cyanotic, even though marked degrees of desaturation exist. On the other hand, a client
with polycythemia may develop cyanosiswith a lesser degree of dessaturation than the
normal individual.
4. Observers perception: Factors to consider
*activity and environment (Does color become worse when crying?)
*duration
*distribution (Is it limited to the extremities?)
Voice quality Does the client speak in jerky sentences? Are the sounds weak? Is
hoarseness present?
Stridor is a harsh, high pitch sound usually associated with an obstruction in the upper
trachea or vocal cord. It is an emergency.
- Auscultation:
a. Normal breath sounds
- Vesicular sounds are heard over most of the lung inspiration > expiration.
- Bronchovesicular sounds are heard near mainstem bronchi:
Inspiration = Expiration.
- Bronchial /Tubular sounds are heard over the trachea:
Expiration > Inspiration
Breath Sounds
Duration of Intensity of Pitch of Location where
Sounds Expiratory Expiratory Heard Normally
Sounds Sound
Vesicular Inspiratory sounds last Soft Relatively low Entire lung field
longer than expiratory except over the
ones. upper sternum and
between the
scapulae.
Broncho- Inspiratory and Intermediate Intermediate Often in the 1st and
vesicular expiratory sounds are 2nd Interspaces
about equal. anteriorly and
between the
scapulae (over the
main bronchus).
Bronchial Expiratory sounds last Loud Relatively Over the
longer than inspiratory high manubrium, if heard
ones. at all.
Tracheal Inspiratory and Very loud Relatively Over the trachea in
expiratory sounds are high the neck.
about equal.
*The thickness of the bars indicates intensity of breath sounds; the steeper their incline,
the higher the pitch of the sounds.
b. Abnormal Breath sounds
- Rales are discrete, non continuous sounds produced by moisture in the
tracheobronchial tree. They are heard best on inspiration.
- Ronchi and wheezes are continuous sounds produced by airflow across the passage
narrowed by secretions, mucosal swelling or tumor. They are more prominent on
expiration.
- Friction rubs are crackling, grating sounds originating in an inflamed pleura.
ABNORMAL (ADVENTITIOUS) BREATH SOUNDS
Breath Sounds Description Etiology
Crackles
Crackles in general Soft, high pitched, Secondary to fluid in the
discontinuous popping airway or alveoli or to
sounds that occur during delayed opening of
inspiration (while usually collapsed alveoli.
heard on inspiration, they Associated with heart
may also be heard on failure and pulmonary
expiration); may or may not fibrosis.
be cleard by coughing.
Coarse crackles Discontinuous popping Associated with
sounds heard in early obstructive pulmonary
inspiration; harsh, moist disease.
sound originating in the
large bronchi.
Fine crackles Discontinuous popping Associated with interstitial
sounds heard in late pneumonia, restrictive
inspiration; sounds like hair pulmonary disease (eg,
rubbing together; originates fibrosis); fine crackles in
in the alveoli. early inspiration are
associated with bronchitis
or pneumonia.
Wheezes
Wheezes in general Usually heard on expiration, Associated with bronchial
but may be heard on wall oscillation and
inspiration depending on charge in airway
the cause. diameter.
Associated with chronic
bronchitis or bronchiec-
tasis.
Sonorous wheezes Deep, low pitched Associated with
(rhonchi) rumbling sounds heard secretions or tumor.
primarily during expiration;
caused by air moving
through narrowed
tracheobroncial passages.
Sibilant wheezes Continuous, musical, high Associated with
pitched, whistlelike sounds bronchospasm, asthma,
heard during inspiration and and buildup of secretions.
expiration caused by air
passing through narrowed
or partially obstructed
airways; may clear with
coughing.
Friction Rubs
Pleural friction rub Harsh, crackling sound, like Secondary to
two pieces of leather being inflammation and loss of
rubbed together (sound lubricating pleural fluid.
imitated by rubbing thumb
and finger together near the
ear).
Heard during inspiration
alone or during both
inspiration and expiration.
May subside when patient
holds breath; coughing will
not clear sound.
Best heard over the lower
lateral anterior surface of
the thorax.
Sound can be enhanced by
applying pressure to the
chest wall with the
diaphragm of the
stethoscope.
Diagnostic Tests
A. Risk factors for respiratory disorders.
* Allergies
*Chest injury
*Crowded living conditions
*Exposure to chemicals and environmental pollutants
*Family history of infectious disease
*Frequent respiratory illnesses
*Geographical residence and travel to foreign countries
*Smoking
*Surgery
*Use of chewing tobacco
*Viral syndromes
C. Sputum specimen***
Description: Specimen obtained by expectoration or tracheal suctioning to assist in the
identification of organisms or abnormal cells.
Once the nurse has assessed the client, the nurse explains the procedure. The
client is assisted to a sitting upright position such as semi - Fowlers with the
head hyperextended (unless contraindicated). Hand hygiene is performed, and the
nurse applies appropriate protective garb, using aseptic technique. The nurse
prepares the needed suctioning equipment, turns on the suction device, and
sets it to the appropriate pressure. The nurse hyperoxygenates the client with
a resuscitation bag, increasing the oxygen flow rate, or asks the client to take
deep breaths. The nurse dons sterile gloves and lubricates the catheter with
sterile water or water soluble lubricant (per agency procedure), inserts the
catheter without the application of suction, and then applies intermittent
suction for up to 10 seconds while rotating and withdrawing the catheter.
After suctioning, the nurse hyperoxygenates the client and encourages the
client to take deep breaths if possible. During the procedure, the nurse monitors
the client for toleration of the procedure and the presence of complications.
Finally, the nurse listens to breath sounds to assist in determining effectiveness
and documents the procedure, the clients response, and effectiveness.
Reference
Ignatavicius, Workman (2016), p. 525. Perry, Potter, Ostendorf
(2014), pp. 631632, 637.
Preprocedure
a. Determine the specific purpose of collection and check institutional policy for the
appropriate method for collection.
b. Obtain an early morning sterile specimen by suctioning or expectoration after a
respiratory treatment if a treatment is prescribed.
c. Instruct the client to rinse the mouth water before collection.
d. Obtain 15 mL of sputum.
e.Instruct the client to take several deep breaths and then cough deeply to obtain
sputum.
f. Always collect the specimen before the client begins antibiotic therapy.***
Postprocedure
a. If a culture of sputum is prescribed, transport the specimen to the laboratory
immediately.***
b. Assist the client with mouth care.
!Ensure that an informed consent was obtained for any invasive procedure. Vital
signs are measured before the procedure and monitored postprocedure to detect signs of
complications.
E. Endobrochial ultrasound(EBUS)
1. Tissue samples are obtained from central lung masses and lymph nodes, using a
bronchoscope with the help of ultrasound guidance.
2. Tissue samples are used for diagnosing and staging lung cancer, detecting infections,
and identifying inflammatory diseases that affect the lungs, such as sarcoidosis.
3. Postprocedure, the client is monitored for signs of bleeding and respiratory distress.
F. Pulmonary Angiography***
Description
a. A flouroscopic procedure in which a catheter is inserted through the antecubital or
femoral vein into the pulmonary artery or 1 of its branches.
b. Involves an injection of iodines or radiopaque contrast material.
Preprocedure
a. Obtain informed consent.
b. Assess for allergies to iodine, seafood, or other radiopaque dyes.
c. Maintain NPO status of the client for 8 hours before the procedure.
d. Monitor Vital Signs
e. Assess results of coagulation studies.
f. Establish an intravenous access.
g. Administer sedation as prescribed.
h. Instruct the client to lie still during the procedure.
i. Instruct the client that he or she may feel an urge to cough, flushing, nausea, or a
salty taste following injection of the dye.***
j. Have emergency resuscitation equipment available.
Postprocedure
a. Monitor Vital Signs.
b. Avoid taking blood pressurres for 24 hours in the extremity used for the injection.
c. Monitor peripheral neurovascualr status of the affected extemity.
d. Assess insertion site for bleeding.
e. Monitor for delayed reaction to the dye.
G. Thoracentesis
Description: Removal of fluid or air from the pleural space via transthoracic aspiration.
Preprocedure
a. Obtain Informed Consent.
b. Obtain Vital Signs.
c. Prepare the client for ultrasound or chest radiograph, if prescribed, before procedure.
d. Assess results of coagulation studies.
e. Note that the client is positioned sitting upright, with the arms and shoulders supported
by a table at the bedside during the procedure.
f. If the client cannot sit up, the client is placed lying in bed toward the unaffected side,
with the head of the bed elevated.***
g. Instruct the client not to cough, breath deeply, or move during the procedure.
Postprocedure
a. Monitor Vital Signs.
b. Monitor respiratory status.
c. Apply a pressure dressing, and assess the puncture site for bleeding and crepitus.
d.Monitor for signs of pneumothorax, air embolism, and pulmonary edema.***
I. Lung Biopsy
Description:
a. A transbrochial biopsy and a transbrochial needle aspiration may be performed to
obtain tissue for analysis by culture or cytological examination.
b. An open lung biopsy is performed in the operating room.
Preprocedure
a. Obtain informed consent.
b. Maintain NPO status of the client before the procedure.
c. Inform the client that a local anesthetic will be used for a needle biopsy but a sensation
of pressure during needle insertion and aspiration may be felt.
d. Administer analgesics and sedatives as prescribed.
Postprocedure***
a. Monitor Vital Signs.
b. Apply a dressing to the biopsy site and monitor for drainage or bleeding.
c. Monitor for signs of respiratory distress, and notify the health care provider (HCP) if
they occur.
d. Monitor for signs of Pneumothorax and air emboli, and notify the health care provider if
they occur.
e. Prepare the client for the chest radioprahy if prescribed.
L. Skin Tests: A skin test uses an intradermal injection to help diagnose various
infectious diseases.
Skin Test Procedure
1. Determine hypersensitivity or previous reactions to skin test.
2. Use a skin site that is free of excessive body hair, dermatitis, and blemishes.
3. Apply the injection at the upper third of the inner surface of the left arm.
4. Circle and mark the injection test site.
5. Document the date, time and test site.
6. Advise the client not to scratch the test site to prevent infection and possible
abscess formation.
7. Instruct the client to avoid washing the test site.
8. Interpret the reaction at the injection site 24 to 72 hours after administration of
the test antigen.
9. Assess the test site for the amount of induration (hard swelling) in millimeters
and for the presence of erythema and vesiculation (small blister like elevations).
The Allens test is performed before obtaining an arterial blood specimen from the
radial artery to determine the presence of collateral circulation and the adequacy
of the ulnar artery. *Failure to determine the presence of adequate collateral
circulation could result in severe ischemic injury to the hand if damage to
the radial artery occurs with arterial puncture. The nurse first would explain the
procedure to the client. To perform the test, the nurse applies direct pressure
over the clients ulnar and radial arteries simultaneously. While applying pressure,
the nurse asks the client to open and close the hand repeatedly; the hand should
blanch. The nurse then releases pressure from the ulnar artery while compressing
the radial artery and assesses the color of the extremity distal to the pressure
point. *If pinkness fails to return within 6 to 7 seconds, the ulnar artery is
insufficient, indicating that the radial artery should not be used for obtaining a
blood specimen. Finally, the nurse documents the findings. Other sites, such as
the brachial or femoral artery, can be used if the radial artery is not deemed
adequate.
Reference: Perry, Potter, Ostendorf (2014), pp. 10911092.
4. Assess factors that may affect the accuracy of the results, such as changes in the O2
settings, suctioning within the past 20 minutes, and clients activities.
5. Provide emotional support to the client.
6. Assist with the specimen draw: prepare a heparinized syringe (if not already
prepackaged).
7. Apply pressure immediately to the puncture site following the blood draw; maintain
pressure for 5 minutes or for 10minutes if the client is taking an anticoagulant.
8. Appropriately label the specimen and transport it on ice to the laboratory.
9. On the laboratory form, record the clients temperature and the type of supplemental
O2 that the client is receiving.
!Avoid suctioning the client before drawing an ABG sample because the suctioning
procedure will deplete the clients oxygen, resulting in inaacurate ABG results.
N. Pulse oximetry***
Description
1. Pulse oximetry is a noninvasive test that registers the oxygen saturation of the clients
hemoglobin.
2. The capillary oxygen saturation (SaO2), is recorded as a percentage.
3. The normal value is 95% to 100%.***
4. After a hypoxic client uses up the readily available oxygen (measured as the arterial
oxygen pressure, PaO2 , on arterial blood gas {ABG} testing), the reserve oxygen, that
oxygen attached to the hemoglobin (SaO2), is drawn on to provide oxygen to the tissues.
5. A pulse oximeter reading can alert the nurse to hypoxemia before clinical signs occur.
6. If pulse oximetry readings are below normal, instruct the client in deep breathing
technique and recheck the pulse oximetry.
Procedure
1. A sensor is placed on the clients finger, toe, nose, earlobe, or forehead to measure
oxygen saturation, which then is displayed on a monitor.
2. Maintain the transducer at heart level.
3. Do not select an extremity with an impediment to blood flow.
! A usual pulse oximetry reading is between 95% and 100%. A pulse oximetry reading
lower than 90% necessitates HCP notification; values below 90% are acceptable only in
certain chronic conditions. Agency procedures and HCP prescriptions are followed
regarding actions to take for specific readings.
O. D dimer
1. A blood test that measures clot formation and lysis that results from the degradation of
fibrin.
2. Helps to diagnose (a positive test result) the presence of thrombus in conditions such
as deep vein thrombosis, pulmonary embolism, or stroke; it is also used to diagnose
disseminated intravascular coagulation (DIC) and to monitor the effectiveness of
treatment.
3.The normal D dimer level is less than or equal to 250ng/mL (250 mcg/L) D dimer
units (DDU); normal fibrinogen is 200 to 400 mg/dL (2 to 4 g/L).
Huff Coughing
*This is an effective coughing technique that
conserves energy, reduces fatigue, and facilitates
mobilization of secretions.
*The client should take 3 or 4 deep breaths using
pursed lip and diaphragmatic breathing. Leaning
slightly forward, the client should cough 3 or 4 times
during exhalation.
*The client may need to splint the thorax or abdomen
to achieve a maximum cough.
C. Incentive spirometry
Client Instruction for Incentive Spirometry
1. Instruct the client to assume a sitting or upright position.
2. Instruct the client to place the mouth tightly around the mouthpiece of the device.
3. Instruct the client to inhale slowly to raise and maintain the flow rate indicator between
the 600 and 900 marks.
4. Instruct the client to hold the breath for 5 seconds and then to exhale through pursed
lips.
5. Instruct the client to repeat this process 10 times every hour while awake.
IV. Oxygen
A. Supplemental oxygen delivery systems.
Device Oxygen Delivered Nursing Considerations
Nasal cannula (nasal 1 6 L/min for oxygen Easily tolerated
prongs) concentration (FiO2) of Can dislodge easily.
24% (1 L/min) to 44% (at Doesnt get in the way of
6 L/min). eating or talking.
Effective oxygen concen-
tration can be delivered.
Allows the client to breath
through the nose or
mouth.
Ensure that prongs are in
the nares with openings
facing the client
Assess nasal mucosa for
irritation from drying effect
of higher flow rates.
Assess skin integrity, as
tubing can irritate skin.
Add humidification as
prescribed and check
water levels.
Simple face mask 5 8 L/min oxygen flow Interferes with eating and
for FiO2 of 40% - 60% talking.
Minimum flow of 5L/min Can be warm and
needed to flush CO2 from confining.
mask. Ensure that mask fits
securely over nose and
mouth.
Remove saliva and
mucus from the mask.
Provide skin care to area
covered by mask.
Provide emotional
support to decrease
anxiet in the client who
feels claustrophobic.
Monitor for risk of
aapiration from inability of
client to clear mouth (i.e.,
if vomiting occurs)
Venturi mask (Ventimask) 4 10 L/min oxygen flow Keep the air entrapment
for FiO2 of 24% - 55% port for the adapter open
Delivers exact desired and uncovered to ensure
selected concentrations adequate oxygen
of O2. delivery.
Keep mask snug on the
face and ensure tubing is
free of kinks because the
FiO2 is altered if kinking
occurs or if the mask fits
poorly.
Assess nasal mucosa for
irritation; humidity or
aerosol can be added to
the system as needed.
Partial rebreather mask 6 -15 L/min oxyge flow for The client rebreathes
(mask with reservoir bag) FiO2 of 70% - 90%. one-third of the exhaled
tidal volume, which is
high in oxygen, thus
providing a high FiO2.
Adjust flow rate to keep
the reservoir bag two-
thirds full during
inspiration.
Keep mask snug on face.
Make sure the reservoir
bag does not twist or kink.
Deflation of the bag
results in decreased
oxygen delivered
and rebreathing of
exhaled air.
Tracheostomy collar and The tracheostomy collar Ensure that aerosol mist
T- bar or T-piece (face can be used to deliver escapes from the vents of
tent; face shield) the desired amount of the delivery system
oxygen to a client during inspiration and
with a tracheostomy. expiration.
Aspecial adaptor (T-bar Empty condensation from
or T-piece) can be used the tubing to prevent the
to deliver any desired client from being lavaged
FiO2 to client with trache- with water and to promote
ostomy, laryngectomy, or an adequate oxygen flow
endotracheal tube. rate (remove and clean
The face tent provides 8- the tubing at least every 4
12 L/min and the FiO2 hr).
varies due to environ- Keep the exhalation port
mental loss. in the T-piece open and
uncovered (if the port is
occluded, the client can
suffocate).
Position the T-piece so
that it does not pull on the
tracheostomy or
endotracheal tube and
cause erosion of the skin
at the tracheostomy
insertion site.
1. Nasal cannula for low flow: Used for the client with chronic airflow limitation and for
longterm oxygen use.
2. Nasal high flow (NHF) respiratory therapy: Used for hypoxemic clients in mild to
moderate respiratory distress.
3. Simple face mask: Used for short term oxygen therapy or to deliver oxygen in an
emergency.
4. Venturi mask: Used for clients at risk for or experiencing acute respiratory failure
5. Partial rebreather mask: Useful when the oxygen concentration needs to be raised; not
usually prescribed for a client with chronic obstructive pulmonary disease (COPD).
6. Nonrebreather mask: Most frequently used for the client with a deteriorating respiratory
status who might require intubation.
7. Tracheostomy collar and T bar or T piece: Tracheostomy collar is used to deliver
high humidity and the desired oxygen to the client with a tracheostomy; the T bar or T
piece is used to deliver the desired FiO2 to the client with a tracheostomy, laryngectomy,
or endotracheal tube.
8. Face tent: Used instead of a tight fitting mask for the client who has facial trauma or
burns.
B. Continuous positive airway pressure (CPAP) and bilevel positive airway pressure
(BiPAP).
1. CPAP maintains a set positive airway pressure during inspiration and expiration;
beneficial in clients who have obstructive sleep apnea or acute exacerbations of COPD.
2. BiPAP provides positive airway pressure during inspiration and ceases airway support
during expiration; there is only enough pressure provided during expiration to keep the
airways open; usually used if CPAP is ineffective.
3. Both CPAP and BiPAP improve oxygenation through airway support.
C. General interventions
1.Assess color, pulse oximetry reading, and vital signs before and during treatment.
2. Place an Oxygen in Use sign at the clients bedside.
3. Assess for the presence of chronic lung problems.
4. Humidify the oxygen if indicated.
!A client who is hypoxemic and has chronic hypercapnia requires low levels of oxygen
delivery at 1 to 2 L/minute because a low arterial oxygen level is the clients primary drive
for breathing.
V. Mechanical Ventilation
Types
1. Pressure cycled ventilator: The ventilator pushes air into the lungs until a specific
airway presure is reached; it is used for short periods, as in the postanesthesia care unit.
3. Time cycled ventilator: The ventilator pushes air int the lungs until a preset time has
elapsed; it is used for the pediatric or neonatal client.
3. Volume cycled ventilator
a. The ventilator pushes air into the lungs until a preset volume is delivered.
b. A constant tidal volume is delivered regardless of the changing compliance of the
lungs and chest wall or the airway resistance in the client or ventilator.
4. Microprocessor ventilator
a. A computer or microprocessor is built into the ventilator to allow continuous monitoring
of ventilatory functions, alarms, and client parameters.
b. This type of ventilator is more responsive to clients who have severe lung disease or
require prolonged weaning.
Mode of Ventilation
1. Noninvasive positive pressure ventilation or BiPAP.
a. Ventilatory support given without using an invasive artificial airway (endotracheal tube
or tracheostomy tube); orofacial masks and nasal masks are used instead.
b. An inspiratory positive airway pressure (IPAP) and an expiratory positive airway
pressure (EPAP) are set on a large ventilator or a small flow generator ventilator with a
desired pressure support and positive end-expiratory pressure
(PEEP) level. This allows more air to move into and out of the lungs without the
normal muscular activity needed to do so.
c. Can be used in certain situations of COPD distress, heart failure, asthma, pulmonary
edema, and hypercapnic respiratory failure
!A resuscitation bag should be available at the bedside for all clients receiving
mechanical ventilation.
2. Controlled
a. The client receives a set tidal volume at a set rate.
b. Used for clients who cannot initiate respiratory effort.
c. Least used mode; if the client attempts to initiate a breath, the ventilator locks out the
clients inspiratory effort.
3. Assist-control
a. Most commonly used mode***
b. Tidal volume and ventilatory rate are preset on the ventilator.
c. The ventilator takes over the work of breathing for the client.
d. The ventilator is programmed to respond to the clients inspiratory effort if the client
does initiate a breath.
e. The ventilator delivers the preset tidal volume when the client initiates a breath
while allowing the client to control the rate of breathing.
f. If the clients spontaneous ventilatory rate increases, the ventilator continues to deliver
a preset tidal volume with each breath,which may cause hyperventilation and respiratory
alkalosis.***
4. Synchronized intermittent mandatory ventilation (SIMV)
a. Similar to assist-control ventilation in that the tidal volume and ventilatory rate are
preset on the ventilator
b. Allows the client to breathe spontaneously at her or his own rate and tidal volume
between the ventilator breaths
c. Can be used as a primary ventilatorymode or as a weaning mode
d. When SIMV is used as a weaning mode, the number of SIMV breaths is decreased
gradually, and the client gradually resumes spontaneous breathing.
Interventions
!For a client receiving mechanical ventilation, always assess the client first and then
assess the ventilator.
1.Assess vital signs, lung sounds, respiratory status, and breathing patterns (the client
will never breathe at a rate lower than the rate set on the ventilator).
2. Monitor skin color, particularly in the lips and nailbeds.
3. Monitor the chest for bilateral expansion.
4.Obtain pulse oximetry readings.
5. Monitor ABG results.
6. Assess the need for suctioning and observe the type, color, and amount of secretions.
7. Assess ventilator settings.
8. Assess the level of water in the humidifier and the temperature of the humidification
system because extremes in temperature can damage the mucosa in the airway.
9. Ensure that the alarms are set.
10. If a cause for an alarm cannot be determined, ventilate the client manually with a
resuscitation bag until the problem is corrected.
11. Empty the ventilator tubing when moisture collects.
12. Turn the client at least every 2 hours or get the client out of bed as prescribed to
prevent complications of immobility.
13. Have resuscitation equipment available at the bedside.
Low-Pressure Alarm
Disconnection or leak in the ventilator or in the clients airway cuff occurs.
The client stops spontaneous breathing.
Complications
1. Hypotension caused by the application of positive pressure, which increases
intrathoracic pressure and inhibits blood return to the heart.
2. Respiratory complications such as pneumothorax or subcutaneous emphysema as a
result of positive pressure.
3. Gastrointestinal alterations such as stress ulcers
4. Malnutrition if nutrition is not maintained
5. Infections
6. Muscular deconditioning
7. Ventilator dependence or inability to wean
Flail chest
Description
a. Occurs from blunt chest trauma associated with accidents, which may result in
hemothorax and rib fractures.
b. The loose segment of the chest wall becomes paradoxical to the expansion and
contraction of the rest of the chest wall.
Assessment
a. Paradoxical respirations (inward movement of a segment of the thorax during
inspiration with outward movement during expiration)
b. Severe pain in the chest
c. Dyspnea
d. Cyanosis
e. Tachycardia
f. Hypotension
g. Tachypnea, shallow respirations
h. Diminished breath sounds
Interventions
a. Maintain the client in a Fowlers position.
b. Administer oxygen as prescribed.
c. Monitor for increased respiratory distress.
d. Encourage coughing and deep breathing.
e. Administer pain medication as prescribed.
f. Maintain bed rest and limit activity to reduce oxygen demands.
g. Prepare for intubation with mechanical ventilation, with PEEP for severe flail chest
associated with respiratory failure and shock.
Pulmonary contusion
Description
a. Characterized by interstitial hemorrhage associated with intraalveolar hemorrhage,
resulting in decreased pulmonary compliance.
b. The major complication is acute respiratory distress syndrome.
Assessment
a. Dyspnea
b. Restlessness
c. Increased bronchial secretions
d. Hypoxemia
e. Hemoptysis
f. Decreased breath sounds
g. Crackles and wheezes
Interventions
a. Maintain a patent airway and adequate ventilation.
b. Place the client in a Fowlers position.
c. Administer oxygen as prescribed.
d. Monitor for increased respiratory distress.
e. Maintain bed rest and limit activity to reduce oxygen demands.
f. Prepare for mechanical ventilation with PEEP if required.
Pneumothorax
Description
a. Accumulation of atmospheric air in the pleural space, which results in a rise in
intrathoracic pressure and reduced vital capacity
b. The loss of negative intrapleural pressure results in collapse of the lung.***
c. A spontaneous pneumothorax occurs with the rupture of a pulmonary bleb.
d. An open pneumothorax occurs when an opening through the chest wall allows the
entrance of positive atmospheric air pressure into the pleural space.
e. A tension pneumothorax occurs from a blunt chest injury or from mechanical
ventilation with PEEP when a buildup of positive pressure occurs in the pleural space.
f. Diagnosis of pneumothorax is made by chest x-ray.
Assessment
a. Absent breath sounds on affected side
b. Cyanosis
c. Decreased chest expansion unilaterally
d. Dyspnea
e. Hypotension
f. Sharp chest pain
g. Subcutaneous emphysema as evidenced by crepitus on palpation
h. Sucking sound with open chest wound
i. Tachycardia
j. Tachypnea
k. Tracheal deviation to the unaffected side with tension pneumothorax
Interventions
a. Apply a nonporous dressing over an open chest wound.
b. Administer oxygen as prescribed.
c. Place the client in a Fowlers position.
d. Prepare for chest tube placement, which will remain in place until the lung has
expanded fully.
e. Monitor the chest tube drainage system.
f. Monitor for subcutaneous emphysema.
!Clients with a respiratory disorder should be positioned with the head of the bed
elevated.
Asthma Triggers
Environmental Physiological Factors Medications Occupational Food
Factors Exposure Additives
Factors
*Animal danders *Gastroesophageal *Acetylsalicylic *Metal salts *Sulfites
*Cockroaches reflux disease acid (aspirin) *Wood and (bisulfites and
*Exhaust fumes (GERD) *B Adrenergic vegetables metabisulfites)
*Fireplaces *Hormonal changes blockers dusts *Beer, wine,
*Molds *Stress *Nonsteroidal *Industrial dried fruit,
*Perfumes or *Viral upper antiinflammatory chemical shrimp,
other products respiratory infection drugs and plastics processed
with aerosol potatoes
sprays. *Monosodium
*Pollens glutamate.
*Smoke, including
cigarette or cigar
smoke
*Sudden weather
changes
From Lewis S, Dirksen S, Heitkemper M, Bucher L, Camera I: Medical-surgical nursing:
assessment and management of clinical problems, ed 8, St. Louis, 2011, Mosby.
Triggers*
*Allergens *Infection
*Exercise *Irritants
IgE mast cells mediated response
*Air trapping
*Hypoxemia
*Obstruction of large and small airways
*Respiratory acidosis
FIGURE 54-10 Pathophysiology in asthma. Stems with asterisks are primary processes.
IgE, Immunoglobulin E.
Assessment
1. Restlessness
2. Wheezing or crackles***
3. Absent or diminished lung sounds
4. Hyperresonance
5. Use of accessory muscles for breathing
6. Tachypnea with hyperventilation
7. Prolonged exhalation
8. Tachycardia
9. Pulsus paradoxus
10. Diaphoresis
11. Cyanosis
12. Decreased oxygen saturation
13. Pulmonary function test results that demonstrate decreased airflow rates.
Interventions
1.Monitor vital signs.
2. Monitor pulse oximetry
3. Monitor peak flow
4. During an acute asthma episode, provide interventions to assist with breathing.
Client Education
1. On the intermittent nature of symptoms and need for long-term management.
2. To identify possible triggers and measures to prevent episodes.
3. About the management of medication and proper administration.
4. About the correct use of a peak flowmeter.
5. About developing an asthma action plan with the primary HCP and what to do if an
asthma episode occurs.
XII. Pnemonia
Description
1. Infection of the pulmonary tissue, including the interstial spaces, the alveoli, and the
brochioles.
2. The edema associated with inflammation stiffens the lung, decreases lung compliance
and vital capacity, and causes hypoxemia.
3. Pneumonia can be community acquired or hospital acquired.
4. The chest x ray film shows lobar or segmental consolidation, pulmonary
infiltrates, or pleural effusions.
5. A sputum culture identifies the organism.
6. The white blood cell count and the erythrocyte sedimentation rate are elevated.
Assessment
1. Chills
2. Elevated temperature
3. Pleuritic pain
4. Tachypnea
5. Ronchi and wheezes
6. Use of accessory muscles for breathing.
7. Mental status changes
8. Sputum production
Interventions
1. Administer oxygen as prescribed.
2. Monitor respiratory status.
3. Monitor for labored respirations, cyanosis, and cold and clammy skin.
4. Encourage coughing and deep breathing and use of the incentive spirometer.
5. Place the client in a semi-Fowlers position to facilitate breathing and lung
expansion.
6. Change the clients position frequently and ambulate as tolerated to mobilize
secretions.
7. Provide Chest Physiotherapy.
8. Perform nasotracheal suctioning if the client is unable to clear secretions.
9. Monitor pulse oximetry.
10. Monitor and record color, consistency, and amount of sputum.
11. Provide a high-calorie, high-protein diet with small frequent meals.
12. Encourage fluids, up to 3 L/day, to thin secretions unless contraindicated.
13. Provide a balance of rest and activity, increasing activity gradually.
14. Administer antibiotics as prescribed.
15. Administer antipyretics, bronchodilators, cough suppressants, mucolytic
agents, and expectorants as prescribed.
16. Prevent the spread of infection by hand washing and the proper disposal of
secretions.
Client Education
1. About the importance of rest, proper nutrition, and adequate fluid intake
2. To avoid chilling and exposure to individuals with respiratory infections or viruses
3. Regarding medications and the use of inhalants as prescribed
4. To notify the HCP if chills, fever, dyspnea, hemoptysis, or increased fatigue occurs
5. Pneumococcal vaccine as recommended by the health care provider(HCP).
!Teach clients that using proper hand washing techniques, disposing of respiratory
secretions properly; and receiving vaccines will assist in preventing the spread of
infection.
XIII. Influenza
Description
1. Also known as the flu; highly contagious acute viral respiratory infection.
2. May be caused by several viruses, usually known as type A, B, and C.
3. Yearly Vaccination is recommended to prevent the disease, especially for those
older than 50 years of age, individuals with chronic ilness or who are
immunocompromised, those living in institutions, and health care personnel providing
direct care to clients (the vaccination is contraindicated in the individual with egg
allegies).
4. Additional prevention measures include avoiding those who have developed influenza,
frequent and proper handwashing, and cleaning and disinfecting surface that have
become contaminated with secretions.
5. Avian Influenza A(H5N1)
a. Affects birds; does not usually affect humans; however, human cases have been
reported in some countries.
b. An H5N1 vaccine has been developed for use if a pandemic virus were to emerge.
c. Reported symptoms are similar to those associated with influenza types A, B, and C.
d. Prevention measures include thorough cooking of poultry products, avoiding contact
with wild animals, frequent and proper hand washing, and cleaning and disinfecting
surfaces that have become contaminated with secretions.
6. Swine (H1N1) Influenza
a. A strain of flu that consists of genetic materials from swine, avian, and human
influenza viruses.
b. Signs and symptoms are similar to those that present with seasonal flu; in addition,
vomiting and diarrhea commonly occur.
c. Prevention measures and treatment are the same as for the seasonal flu.
Assessment
1. Acute onset of fever and muscle aches.
2. Headache
3. Fatigue, weakness, anorexia.
4. Sore throat, cough, and rhinorrhea.
Interventions
1. Encourage rest.
2. Encourage fluids to prevent pulmonary complications (unless
contraindicated).
3. Monitor lung sounds.
4. Provide supportive therapy such as antipyretics or antitussives as indicated.
5. Administer antiviral medications as prescribed for the current strain of
influenza.
XVI. Empyema
Description
1. Collection of pus within the pleural cavity.
2. The fluid is thick, opaque, and foul smelling.
3. The most common cause is pulmonary infection and lung abscess caused by thoracic
surgery or chest trauma, in which bacteria are introduced directly into the pleural space.
4. Treatment focuses on treating the infection, emptying the empyema cavity,
reexpanding the lung, and controlling the infection.
Assessment
1. Recent febrile illness or trauma
2. Chest pain
3. Cough
4. Dyspnea
5. Anorexia and weight loss
6. Malaise
7. Elevated temperature and chills
8. Night sweats
9. Pleural exudate on chest x ray.
Interventions
1. Monitor breath sounds.
2. Place the client in a semi Fowlers or high Fowlers position.***
3. Encourage coughing and deep breathing.
4. Admminister antibiotics as prescribed.
5. Instruct the client to splint the chest as necessary.
6. Assist with thoracentesis or chest tube insertion to promote drainage and lung
expanasion.
7. If marked pleural thickening occurs, prepare the client for decortication, if
prescribed; this surgical procedure involves removal of the restrictive mass of fibrin
and inflammatory cells.
XVII. Pleurisy
Description
1. Inflammation of the visceral and parietal membranes; may be caused by
pulmonary infarction or pneumonia.
2. The visceral and parietal membranes rub together during respiration and cause
pain.
3. Pleurisy usually occurs on 1 side of the chest, usually in the lower lateral portions in
the chest wall.
Assessment
1. Knifelike pain aggravated on deep breathing and coughing.
2. Dyspnea
3. Pleural friction rub heard on auscultation.
Interventions
1. Identify and treat the cause.
2. Monitor lung sounds.
3. Administer analgesics as precribed.
4. Apply hot or cold applcations as prescribed.
5. Encourage coughing and deep breathing.
6. Instruct the client to lie on the affected side to splint chest.***
Laryngeal Cancer
Description
1. Laryngeal cancer is a malignant tumor of the larynx.
2. Laryngeal cancer presents as malignant ulcerations with underlying infiltration
and is spread by local extension to adjacent structures in the throat and neck,
and by the lymphatic system.
3. Diagnosis is made by laryngoscopy and biopsy showing a positive cytological
study for cancer cells.
4. Laryngoscopy allows for evaluation of the throat and biopsy of tissues; chest
radiography, CT, and MRI are used for staging.
Risk factors
1. Cigarette smoking.
2. Heavy alcohol use and the combined use of tobacco and alcohol.
3. Exposure to environmental pollutants (e.g., asbestos, wood dust).
4. Exposure to radiation
Assessment***
1. Persistent hoarseness or sore throat and ear pain.
2. Painless neck mass.
3. Feeling of lump in the throat.
4. Burning sensation in the throat.
5. Dysphagia.
6. Change in voice quality.
7. Dyspnea.
8. Weakness and weight loss
9. Hemoptysis.
10. Foul breath odor.
Interventions
1. Place in Fowlers position to promote optimal air exchange.***
2. Monitor respiratory status.
3. Monitor for signs of aspiration of food and fluid.
4. Administer oxygen as prescribed.***
5. Provide respiratory treatments as prescribed.
6. Provide activity as tolerated.
7. Provide a high calorie and high protein diet.
8. Provide nutritional support via parenteral nutrition, nasogastric tube feedings, or
gastrostomy or jejunostomy tube, as prescribed.
9. Administer analgesics as prescribed for pain.
10. Encourage clients to stop smoking and drinking alcohol to increase
effectiveness of treatments.
Nonsurgical interventions
1. Radiation therapy in specified situations
2. Chemotherapy,which maybe given in combination with radiation and surgery
Surgical interventions
1. The goal is to remove the cancer while preserving as much normal function as
possible.
2. Surgical intervention depends on the tumor size, location, and amount of tissue
to be resected.
3. Types of resection include cordal stripping, cordectomy, partial laryngectomy,
and total laryngectomy.
4. A tracheostomy is performed with a total laryngectomy; this airway opening is
permanent and is referred to as a laryngectomy stoma.
Preoperative interventions
1. Discuss self-care of the airway, alternative methods of communication, suctioning,
pain control methods, the critical care environment, and nutritional support.
2. Encourage the client to express feelings about changes in body image and loss of
voice.
3. Describe the rehabilitation program and information about the tracheostomy and
suctioning.
Postoperative interventions
1. Monitor Vital Signs.
2. Monitor respiratory status; monitor airway patency and provide frequent suctioning
to remove bloody secretions.
3. Place the client in a high Fowlers position.
4. Maintain mechanical ventilator support or a tracheostomy collar with
humidification, as prescribed.
5. Monitor pulse oximetry.
6. Maintain surgical drains in the neck area if present.
7. Observe for hemorrhage and edema in the neck.
8. Monitor IV fluids or parenteral nutrition until nutrition is administered via a
nasogastric, gastrostomy, or jejunostomy tube.
9. Provide oral hygiene.
10. Assess gag and cough reflexes and the ability to swallow.
11. Increase activity as tolerated.
12. Assess the color, amount, and consistency of sputum.
13. Provide stoma and laryngectomy care
Stoma Care Following Laryngectomy
-Protect the neck from injury.
-Instruct the client in how to clean the incision and provide stoma care.
-Instruct the client to wear a stoma guard to shield the stoma.
-Demonstrate ways to prevent debris from entering the stoma.
-Advise the client to wear loose fitting, high collared clothing to cover the stoma.
-Avoid swimming, showering, and using aerosol sprays.
-Teach the client clean suctioning technique.
-Advise the client to increase humidity in the home.
-Increase fluid intake to 3000 mL / day as prescribed.
-Avoid exposure to persons with activity.
-Alternate rest periods with activity.
-Instruct the client in range of motion exercises for the arms, shoulders, and
neck as prescribed.
-Advise the client to wear a MedicAlert bracelet.
14. Provide consultation with speech and language pathologist as prescribed.
15. Reinforce method of communication established preoperatively.
16. Prepare the client for rehabilitation and speech therapy (Box 48-16).
Speech Rehabilitation Following Laryngectomy
Esophageal Speech
-The client produces esophageal speech by burping the air swallowed.
-The voice produced is monotone, cannot be raised or lowered, and carries no pitch.
-The client must have adequate hearing because his or her mouth shapes words as
they are heard.
Mechanical Devices
-One device, the electrolarynx, is placed against the side of the neck; the air inside the
neck and pharynx is vibrated, and the client articulates.
-Another device consists of a plastic tube that is placed inside the clients mouth and
vibrates on articulation.
Tracheoesophageal Fistula
-A fistula is created surgically between the trachea and the esophagus, with
eventual placement of a prosthesis to produce speech.
-The prosthesis provides the client with a means to divert air from the trachea
into the esophagus, and out of the mouth.
-Lip and tongue movement produce the speech.
XXI. Histoplasmosis
Description
1. Pulmonary fungal infection caused by spores of Histoplasma capsulatum.
2. Transmission occurs by the inhalation of spores, which commonly are found in
contaminated soil.***
3. Spores also are usually found in bird droppings.
Assessment
1. Similar to pnuemonia: Chills, Elevated temperature, Pleuritic pain, Tachypnea,
Rhonchi and wheezes, Use of accessory muscles for breathing, Mental status
changes, Sputum production
2. Positive skin test for histoplasmosis.***
3. Positive agglutination test
4. Splenomegaly, hepatomegaly
Interverventions
1. Administer oxygen as prescribed.
2. Monitor breath sounds.
3. Administer antiemetics, antihistamines, antipyretics, and corticosteroids as
prescribed.
4. Administer fungicidal medications as prescribed.
5. Encourage coughing and deep breathing.
6. Place the client in a semi Fowlers position.
7. Monitor Vital Signs.
8. Monitor for nephrotoxicity form fungicidal medications.
9. Instruct the client to wear a mask and spray the floor with water before sweeping
barn and chicken coops.
XXII. Sarcoidosis
Description
1. Presence of epithelioid cell tubercles in the lung.
2. The cause is unknown, but a high titer of Epstein Barr virus may be noted.
3. Viral incidence is highest in African Americans and young adults.
Assessment
1. Night sweats
2. Fever
3. Weight loss
4. Cough and dyspnea
5. Skin nodules
6. Polyarthritis.
7. Kveim test: Sarcoid node antigen is injected intradermally and causes a local
nodular lesion in about 1 month.***
Interventions
1. Administer corticosteroids to control symptoms.
2. Monitor temperature.
3. Increase fluid intake.
4. Provide frequent periods of rest.
5. Encourage small, frequent, nutritious meals.
XXIII. Occupational Lung Disease
Description
1. Caused by exposure to environmental or occupational fumes, dust, vapors,
gases, bacterial or fungal antigens, and allergens; can result in acute reversible
effects or chronic lung disease.
2. Common disease classifications include occupational asthma pneumoconiosis
(silicosis or coal miners [black lung] disease), diffuse interstitial fibrosis
(asbestosis, talcosis, berylliosis), or extrinsic allergic alveolitis (farmers lung, bird
fanciers lung, or machine operators lung).
Assessment
1. Manifestations depend on the type of disease and respiratory symptoms.***
Interventions
1. Prevention through the use of respiratory protective devices.***
2. Treatment is based on the symptoms experienced by the client.
XXIV. Tuberculosis***
Description
1. Highly communicable disease caused by Mycobacterium tuberculosis.
2. M. tuberculosis is a nonmotile, nonsporulating, acid-fast rod that secretes niacin; when
the bacillus reaches a susceptible site, it multiplies freely.
3. Because M. tuberculosis is an aerobic bacterium, it primarily affects the pulmonary
system, especially the upper lobes, where the oxygen content
is highest, but also can affect other areas of the body, such as the brain, intestines,
peritoneum, kidney, joints, and liver.
4. An exudative response causes a nonspecific pneumonitis and the development of
granulomas in the lung tissue.
5. Tuberculosis has an insidious onset, and many clients are not aware of symptoms until
the disease is well advanced.
6. Improper or noncompliant use of treatment programs may cause the development of
mutations in the tubercle bacilli, resulting in a multidrugresistant
strain of tuberculosis (MDR-TB).***
7. The goal of treatment is to prevent transmission, control symptoms, and prevent
progression of the disease.
Risk factors***
1. Child younger than 5 years of age
2. Drinking unpasteurized milk if the cow is infected with bovine tuberculosis.
3. Homeless individuals or those from a lower socioeconomic group, minority group, or
refugee group.
4. Individuals in constant, frequent contact with an untreated or undiagnosed
individual.
5. Individuals living in crowded areas, such as long term care facilites, prisons, and
mental health facilities.
6. Older client.
7. Individuals with malnutrition, infection, immune dysfunction, or human
immunodeficiency virus infection; or immunosuppressed as a result of medication
therapy.
8. Individuals who abuse alcohol or are intravenous drug users.
Transmission***
1. Via the airborne route by droplet infection.
2. When an infected individual coughs, laughs, sneezes, or sings, droplet nuclei
containing tuberculosis bacteria enter the air and may be inhaled by others.
3. Identification of those in close contact with the infected individual is important so that
they can be tested and treated as necessary.
4. When contacts have been identified, these persons are assessed with a
tuberculin skin test and chest x-rays to determine infection with tuberculosis.
5. After the infected individual has received tuberculosis medication for 2 to 3 weeks,
the risk of transmission is reduced greatly.
Disease progression
1. Droplets enter the lungs, and the bacteria form a tubercle lesion.
2. The defense systems of the body encapsulate the tubercle, leaving a scar.
3. If encapsulation does not occur, bacteria may enter the lymph system, travel to the
lymph nodes, and cause an inflammatory response termed granulomatous
inflammation.
4. Primary lesions form; the primary lesions may become dormant but can be
reactivated and become a secondary infection when reexposed to the bacterium.
5. In an active phase, tuberculosis can cause necrosis and cavitation in the lesions,
leading to rupture, the spread of necrotic tissue, and damage
to various parts of the body.
Client history***
1. Past exposure to tuberculosis
2. Clients country of origin and travel to foreign countries in which the incidence of
tuberculosis is high
3. Recent historyof influenza, pneumonia, febrile illness, cough, or foul-smelling
sputum production
4. Previous tests for tuberculosis; results of the testing
5. Recent bacillus Calmette-Guerin (BCG) vaccine (a vaccine containing attenuated
tubercle bacilli that may be given to persons in foreign countries
or to persons traveling to foreign countries to produce increased resistance to
tuberculosis).
!An individual who has received a BCG vaccine will have a positive tuberculin skin
test result and should be evaluated for tuberculosis with a chest x ray.
Clinical manifestations
1. May be asymptomatic in primary infection
2. Fatigue
3. Lethargy
4. Anorexia
5. Weight loss
6. Low-grade fever
7. Chills
8. Night sweats
9. Persistent cough and the production of mucoid and mucopurulent sputum, which is
occasionally streaked with blood
10. Chest tightness and a dull, aching chest pain may accompany the cough.
Chest assessment
1. A physical examination of the chest does not provide conclusive evidence of
tuberculosis.
2. A chest x-ray is not definitive, but the presence of multinodular infiltrates with
calcification in the upper lobes suggests tuberculosis.***
3. If the disease is active, caseation and inflammation may be seen on the chest x-
ray.
4. Advanced disease
a. Dullness with percussion over involved parenchymal areas, bronchial breath
sounds, rhonchi, and crackles indicate advanced disease.
b. Partial obstruction of a bronchus caused by endobronchial disease or
compression by lymph nodes may produce localized wheezing and dyspnea.
QuantiFERON TB Gold Test***
1. A blood analysis test by an enzyme-linked immunosorbent assay
2. A sensitive and rapid test (results can be available in 24 hours) that assists in
diagnosing the client
Sputum cultures
1. Sputum specimens are obtained for an acidfast smear.***
2. A sputum culture identifying M. tuberculosis confirms the diagnosis.
3. After medications are started, sputum samples are obtained again to determine the
effectiveness of therapy.***
4. Most clientshavenegative cultures after 3 months of treatment.
Tuberculin skin test (TST)***
1. A positive reaction does not mean that active disease is present but indicates
previous exposure to tuberculosis or the presence of inactive (dormant)
disease.***
2. Once the test result is positive, it will be positive in any future tests.
3. Skin test interpretation depends on 2 factors: measurement in millimeters of the
induration, and the persons risk of being infected with tuberculosis and progression to
disease if infected.
4. Once an individuals skin test is positive, a chest x-ray is necessary to rule out
active tuberculosis or to detect old healed lesions.
C. Hypothalamus
1. Portion of the diencephalon of the brain, forming the floor and part of the lateral wall of
the third ventricle
2. Activates, controls, and integrates the peripheral autonomic nervous system,
endocrine processes, and many somatic functions, such as body temperature,
sleep, and appetite
D. Pituitary gland
1. The master gland; located at the base of the brain (cranial cavity in sella turcica of
sphenoid bone; near optic chiasm
2. Influenced by the hypothalamus; directly affects the function of the other endocrine
glands
3. Anterior lobe (adenohypophysis) and posterior lobe (neurohypophysis)
4. Promotes growth of body tissue, influences water absorption by the kidney, and
controls sexual development and function
5. Pituitary Hormes
1. Hormones secreted by anterior lobe
a. Growth hormone (GH)
(1) Promotes protein anabolism
(2) Promotes fat mobilization and catabolism
(3) Slows carbohydrate metabolism
b. Thyroid-stimulating hormone (TSH): stimulates synthesis and secretion of thyroid
hormones
c. ACTH
(1) Stimulates growth of adrenal cortex
(2) Stimulates secretion of glucocorticoids; slightly stimulates mineralocorticoid secretion
d. Follicle-stimulating hormone (FSH)
(1) Stimulates primary graafian follicle to grow and develop
(2) Stimulates follicle cells to secrete estrogen
(3) Stimulates development of seminiferous tubules and spermatogenesis
e. Luteinizing hormone (LH)
(1) Stimulates maturation of follicle and ovum; required for ovulation
(2) Forms corpus luteum in ruptured follicle following ovulation; stimulates
corpus luteum to secrete progesterone
(3) In males, LH is called interstitial cellstimulating hormone (ICSH);
stimulates testes to secrete testosterone
f. Prolactin (PRL)
(1) Promotes breast development during pregnancy
(2) Initiates milk production after delivery
(3) Stimulates progesterone secretion by corpus luteum
2. Hormones secreted by posterior lobe
a. Antidiuretic hormone (ADH, vasopressin)
(1) Increases water reabsorption by distal and collecting tubules of kidneys
(2) Stimulates vasoconstriction, raising blood pressure
b. Oxytocin
(1) Stimulates contractions by pregnant uterus
(2) Stimulates milk ejection from alveoli of lactating breasts into ducts
c. Melanocyte-stimulating hormone (MSH): stimulates synthesis and dispersion of
melanin in skin, causing darkening
E. Adrenal gland
1. One adrenal gland is on top of each kidney.
2. A Two closely associated structures, adrenal medulla and adrenal cortex, positioned
at each kidneys superior border
3. Regulates sodium and electrolyte balance; affects carbohydrate, fat, and protein
metabolism; influences the development of sexual characteristics; and sustains the fight-
or-flight response
4. Adrenal hormones
1. Adrenal cortex
a. The cortex is the outer shell of the adrenal gland.
b. The cortex synthesizes glucocorticoids and mineralocorticoids and secretes small
amounts of sex hormones (androgens, estrogens)
c. secretes the mineralocorticoid aldosterone and the glucocorticoids cortisol and
corticosterone
a. Aldosterone
(1) Markedly accelerates sodium and water reabsorption by kidney tubules
(2) Markedly accelerates potassium excretion by kidney tubules
(3) Secretion increases as sodium ions decrease or potassium ions increase
b. Cortisol and corticosterone
(1) Accelerate mobilization and catabolism of tissue protein and fats
(2) Accelerate liver gluconeogenesis (hyperglycemic effect)
(3) Decrease antibody formation (immunosuppressive, antiallergic effect)
(4) Slow proliferation of fibroblasts characteristic of inflammation
(antiinflammatory effect)
(5) Decrease adrenocorticotropic hormone (ACTH) secretion
(6) Mildly accelerate sodium and water reabsorption and potassium excretion
by kidney tubules
(7) Increase release of coagulation factors
2. Adrenal medulla
a. The medulla is the inner core of the adrenal gland.
b. The medulla works as part of the sympathetic nervous system and produces two
catecholamines, epinephrine and norepinephrine.
c. Stimulate liver and skeletal muscle to break down glycogen to produce glucose
d. Increase oxygen use and carbon dioxide production
e. Increase blood concentration of free fatty acids through stimulation of lipolysis in
adipose tissue
f. Cause constriction of most blood vessels of body, thus increasing total peripheral
resistance and arterial pressure to shunt blood to vital organs
g. Increase heart rate and force of contraction, thus increasing cardiac output
h. Inhibit contractions of gastrointestinal and uterine smooth muscle
i. Epinephrine significantly dilates bronchial smooth muscle
F. Thyroid gland
1. Located in the anterior part of the neck
2. Thyroid hormones: accelerate cellular reactions in most body cells
3. Controls the rate of body metabolism and growth and produces thyroxine (T4),
triiodothyronine (T3), and thyrocalcitonin
Thyroxine: stimulates metabolic rate; essential for physical and mental development
Triiodothyronine: inhibits anterior pituitary secretion of thyroid-stimulating hormone
Calcitonin (thyrocalcitonin): decreases loss of calcium from bone; promotes
hypocalcemia; action opposite that of parathormone
G. Parathyroid glands
1. Located on the thyroid gland
2. Small glands (2 to 12) embedded in posterior part of thyroid
3. Controls calcium and phosphorus metabolism; produces parathyroid hormone
(parathormone)
4. Parathyroid hormone (parathormone)
1. Increases blood calcium concentration
a. Breakdown of bone with release of calcium into blood (requires active form of vitamin
D)
b. Calcium absorption from intestine into blood
c. Kidney tubule reabsorption of calcium
2. Decreases blood phosphate concentration by slowing its reabsorption from
kidneys, thereby decreasing calcium loss in urine
H. Pancreas
1. Located posteriorly to the stomach (retroperitoneal in abdominal cavity)
2. Influences carbohydrate metabolism, indirectly influences fat and protein metabolism,
and produces insulin and glucagon
3. Pancreatic hormones: regulate glucose and protein homeostasis through action of
insulin and glucagon
Insulin: secreted by beta cells of islets of Langerhans
a. Promotes cellular uptake of glucose
b. Stimulates intracellular macromolecular synthesis, such as glycogen synthesis
(glyconeogenesis), fat synthesis (lipogenesis), and protein synthesis
c. Stimulates cellular uptake of sodium and potassium (latter is significant in
treatment of diabetic coma with insulin)
Glucagon: secreted by alpha cells of islets of Langerhans
a. Induces liver glycogenolysis; antagonizes glycogen synthesis stimulated by insulin
b. Inhibits hepatic protein synthesis, which makes amino acids available for
gluconeogenesis and increases urea production
c. Stimulates hepatic ketogenesis and release of glycerol and fatty acids from
adipose tissue when cellular glucose level falls
J. Negative-feedback loop
1. Regulates hormone secretion by the hypothalamus and pituitary gland
2. Increased amounts of target gland hormones in the bloodstream decrease secretion of
the same hormone and other hormones that stimulate its release.
II. Diagnostic Tests
A. Stimulation and suppression tests
1. Stimulation tests
a. In the client with suspected underactivity of an endocrine gland, a stimulus may be
provided to determine whether the gland is capable of normal hormone production.
b. Measured amounts of selected hormones or substances are administered to stimulate
the target gland to produce its hormone.
c. Hormone levels produced by the target gland are measured.
d. Failure of the hormone level to increase with stimulation indicates hypofunction.
2. Suppression tests
a. Suppression tests are used when hormone levels are high or in the upper range of
normal.
b. Agents that normally induce a suppressed response are administered to determine
whether normal negative feedback is intact.
c. Failure of hormone production to be suppressed during standardized testing indicates
hyperfunction.
D. Thyroid-stimulating hormone***
1. Blood test is used to differentiate the diagnosis of primary hypothyroidism.
2. Normal value is 210 mcU/L (210 mU/L).
3. Elevated values indicate primary hypothyroidism.
4. Decreased values indicate hyperthyroidism or secondary hypothyroidism.
E. Thyroid scan
1. A thyroid scan is performed to identify nodules or growths in the thyroid gland.
2. A radioisotope of iodine or technetium is administered before scanning the thyroid
gland.
3. Reassure the client that the level of radioactive medication is not dangerous to self or
others.***
4. Determine whether the client has received radiographic contrast agents within the past
3 months, because these may invalidate the scan.
5. Check with the health care provider (HCP) regarding discontinuing medications
containing iodine for 14 days before the test and the need to discontinue thyroid
medication before the test.***
6. Instruct the client to maintain NPO (nothing by mouth) status after midnight on the
day before the test; if iodine is used, the client will fast for an additional 45 minutes after
ingestion of the oral isotope and the scan will be performed in
24 hours.
7. If technetium is used, it is administered by the intravenous (IV) route 30 minutes
before the scan.
8. The test is contraindicated in pregnancy.
G. Glycosylated hemoglobin
1. HgbA1C is blood glucose bound to hemoglobin.
2. Hemoglobin A1c (glycosylated hemoglobin A; HbA1c) is a reflection of how well blood
glucose levels have been controlled for the past 3 to 4 months.
3. Hyperglycemia in clients with diabetes is usually a cause of an increase in HbA1c.
4. Fasting is not required before the test.
5. Normal reference intervals: 4.0%6.0% (4.0% 6.0%)
6. HgbA1C and estimated average glucose (eAG) reference intervals
!Poor glycemic control in a client with diabetes mellitus is usually the cause of an
increase in the HbA1c calue.
A. Hypopituitarism
1. Description: Hyposecretion of 1 or more of the pituitary hormones caused by tumors,
trauma, encephalitis, autoimmunity, or stroke
2. Hormones most often affected are growth hormone (GH) and gonadotropic hormones
(luteinizing hormone, follicle-stimulating hormone), but thyroid-stimulating hormone
(TSH), adrenocorticotropic hormone (ACTH), or antidiuretic hormone (ADH) may be
involved.
3. Assessment
a. Mild to moderate obesity (GH, TSH)
b. Reduced cardiac output (GH, ADH)
c. Infertility, sexual dysfunction (gonadotropins, ACTH)
d. Fatigue, low blood pressure (TSH, ADH, ACTH, GH)
e. Tumors of the pituitary also may cause headaches and visual defects (the pituitary is
located near the optic nerve).
4. Interventions***
a. Client may need hormone replacement for the specific deficient hormones.
b. Provide emotional support to the client and family.
c. Encourage the client and family to express feelings related to disturbed body image
orsexual dysfunction.
d. Client education is needed regarding the signs and symptoms of hypofunction and
hyperfunction related to insufficient or excess hormone replacement
B. Hyperpituitarism (acromegaly)
1. Description: Hypersecretion of growth hormone by the anterior pituitary gland in an
adult; caused primarily by pituitary tumors
Leads to conditions sunch as acromegaly and cushings disease
2. Assessment
a. Large hands and feet
b. Thickening and protrusion of the jaw
c. Arthritic changes and joint pain, impingement syndromes
d. Visual disturbances
e. Diaphoresis
f. Oily, rough skin
g. Organomegaly
h . Hypertension, atherosclerosis, cardiomegaly, heart failure
i. Dysphagia
j. Deepening of the voice
k. Thickening of the tongue, narrowing of the airway, sleep apnea
l. Hyperglycemia
m. Colon polyps, increased colon cancer risk
3. Interventions***
a. Provide pharmacological interventions to suppress GH or to block the action of GH
b. Prepare the client for radiation of the pituitary gland or for stereotactic radiosurgery if
prescribed.
c. Prepare the client for hypophysectomy if planned.
d. Provide pharmacological and nonpharmacological interventions for joint pain.
e. Provide emotional support to the client and family, and encourage the client and family
to express feelings related to disturbed body image.
f. Provide frequent skin care.
D. Diabetes Insipidus***
1. Description***
a. Hyposecretion of ADH caused by stroke or trauma or maybe idiopatic
b. Kidney tubules fail to reabsorb water.
c. In central diabetes insipidus there is decreased ADH production.
d. In nephrogenic diabetes insipidus, ADH production is adequate but the kidneys do
not respond appropriately to the ADH.
2. Assessment***
a. Excretion of large amounts of dilute urine
b. Polydipsia
c. Dehydration (decreased skin turgor and dry mucous membranes)
d. Inability to concentrate urine
e. Low urinary specific gravity; normal is 1.003 1.030 (1.005 1.030)
f. Fatigue
g. Muscle pain and weakness
h . Headache
i. Postural hypotension that may progress to vascular collapse without rehydration
j. Tachycardia
3. Interventions***
a. Monitor vital signs and neurological and cardiovascular status.
b. Provide a safe environment, particularly for the client with postural hypotension.
c. Monitor electrolyte values and for signs of dehydration.
d. Maintain client intake of adequate fluids; IV hypotonic saline may be prescribed to
replace urinary losses.
e. Monitor intake and output, weight, serum osmolality, and specific gravity of urine for
excessive urinary output, weight loss, and low urinary specific gravity.
f. Instruct the client to avoid foods or liquids that produce diuresis
g. Vasopressin or desmopressin acetate may be prescribed; these are used when the
ADH deficiency is severe or chronic.
h . Instruct the client in the administration of medications as prescribed; desmopressin
acetate may be administered by subcutaneous injection, intravenously, intranasally, or
orally; ***watch for signs of water intoxication indicating overtreatment.
i. Instruct the client to wear a MedicAlert bracelet.
7. Client education***
a. Need for lifelong glucocorticoid replacement and possibly lifelong
mineralocorticoid replacement.
b. Corticosteroid replacement will need to be increased during times of stress.
c. Avoid individuals with an infection.
d. Avoid strenuous exercise and stressful situations.
e. Avoid over-the-counter medications.
f. Diet should be high in protein and carbohydrates; clients taking glucocorticoids
should be prescribed calcium and vitamin D supplements to protect against
corticosteroid-induced osteoporosis; some clients taking mineralocorticoids may be
prescribed a diet high in sodium.
g. Wear a MedicAlert bracelet.
h. Report signs and symptoms of complications, such as underreplacement and
overreplacement of corticosteroid hormones.
B. Addisonian crisis
1. Description
a. A life-threatening disorder caused by acute adrenal insufficiency.
b. Precipitated by stress, infection, trauma, surgery, or abrupt withdrawal of exogenous
corticosteroid use
c. Can cause hyponatremia, hyperkalemia, hypoglycemia, and shock***
2. Assessment
a. Severe headache
b. Severe abdominal, leg, and lower back pain
c. Generalized weakness
d. Irritability and confusion
e. Severe hypotension
f. Shock
3. Interventions
a. Prepare to administer glucocorticoids intravenously as prescribed.
b. Administer IV fluids as prescribed to replace fluids and restore electrolyte balance.
c. Following resolution of the crisis, administer glucocorticoid and mineralocorticoid
orally as prescribed.
d. Monitor vital signs, particularly blood pressure.
e. Monitor neurological status, noting irritability and confusion.
f. Monitor intake and output.
g. Monitor laboratory values, particularly sodium, potassium, and blood glucose
levels.
h. Protect the client from infection.
i. Maintain bed rest and provide a quiet environment.
! Clients taking exogenous corticosteroids must establish a plan with their HCPs for
increasing their corticosteroids during times of stress.
E. Pheochromocytoma***
1. Description
a. Catecholamine-producing tumor usually found in the adrenal medulla, but
extraadrenal locations include the chest, bladder, abdomen, and brain; typically is a
benign tumor but can be malignant
b. Excessive amounts of epinephrine and norepinephrine are secreted.
c. Diagnostic test includes a 24-hour urine collection for VMA.
d. Surgical removal of the adrenal gland is the primary treatment.
e. Symptomatic treatment is initiated if surgical removal is not possible.
f. The complications associated with pheochromocytoma include hypertensive crisis;
hypertensive retinopathy and nephropathy, cardiac enlargement, and dysrhythmias; heart
failure; myocardial infarction; increased platelet aggregation; and stroke.
g. Death can occur from shock, stroke, renal failure, dysrhythmias, or dissecting aortic
aneurysm.
2. Assessment***
a. Paroxysmal or sustained hypertension
b. Severe headaches
c. Palpitations
d. Flushing and profuse diaphoresis
e. Pain in the chest or abdomen with nausea and vomiting
f. Heat intolerance
g. Weight loss
h . Tremors
i. Hyperglycemia
3. Interventions***
a. Monitor vital signs, particularly blood pressure and heart rate.
b. Monitor for hypertensive crisis; monitor for complications that can occur with
hypertensive crisis, such as stroke, cardiac dysrhythmias, and myocardial infarction.
c. Instruct the client not to smoke, drink caffeine-containing beverages, or change
position suddenly.
d. Prepare to administer -adrenergic blocking agents and -adrenergic blocking agents
as prescribed to control hypertension. - Adrenergic blocking agents are started 7 to
10 days before -adrenergic blocking agents.
e. Monitor serum glucose level.
f. Promote rest and a nonstressful environment.
g. Provide a diet high in calories, vitamins, and minerals.
h . Prepare the client for adrenalectomy.***
!For the client with pheochromocytoma, avoid stimuli that can precipitate a
hypertensive crisis, such as increased abdominal pressure and vigorous abdominal
palpation.
F. Adrenalectomy***
1. Description
a. Surgical removal of an adrenal gland.
b. Lifelong glucocorticoid and mineralocorticoid replacement is necessary with
bilateral adrenalectomy.
c. Temporary glucocorticoid replacement, *usually up to 2 years, is necessary after a
unilateral adrenalectomy.
d. Catecholamine levels drop as a result of surgery, which can result in cardiovascular
collapse, hypotension, and shock, and the client needs to be monitored closely.
e. Hemorrhage also can occur because of the high vascularity of the adrenal glands.
2. Preoperative interventions
a. Monitor electrolyte levels and correct electrolyte imbalances.
b. Assess for dysrhythmias.
c. Monitor for hyperglycemia.
d. Protect the client from infections.
e. Administer glucocorticoids as prescribed.
3. Postoperative interventions
a. Monitor vital signs.
b. Monitor intake and output; *if the urinary output is lower than 30 mL/hour, notify the
HCP, because this may result in acute kidney injury and indicate impending shock.***
c. Monitor weight daily.
d. Monitor electrolyte and serum glucose levels.
e. Monitor for signs of hemorrhage and shock, particularly during the first 24 to 48 hours.
f. Monitor for manifestations of adrenal insufficiency.
g. Assess the dressing for drainage.
h . Monitor for paralytic ileus.
i. Administer IV fluids as prescribed to maintain blood volume.
j. Administer glucocorticoids and mineralocorticoids as prescribed.
k. Administer pain medication as prescribed.
l. Provide pulmonary interventions to prevent atelectasis (coughing and deep
breathing, incentive spirometry, splinting of incision).
m. Instruct the client in the importance of hormone replacement therapy following
surgery.
n . Instruct the client regarding signs and symptoms of complications such as
underreplacement and overreplacement of hormones.
o. Instruct the client regarding the need to wear a MedicAlert bracelet.
B. Myxedema coma***
1. Description
a. This rare but serious disorder results from persistently low thyroid production.
b. Coma can be precipitated by acute illness, rapid withdrawal of thyroid medication,
anesthesia and surgery, hypothermia, or the use of sedatives and opioid analgesics.
2. Assessment
a. Hypotension
b. Bradyardia
c. Hypothermia
d. Hyponatremia
e. Hypoglycemia
f. Genrealized edema
g. Respiratory failure
h. Coma
3. Interventions
a. Maintain a patent airway.
b. Institute aspiration precautions.
c. Administer IV fluids (normal or hypertonic saline) as prescribed.
d. Administer levothyroxine sodium intravenously as prescribed.***
e. Administer glucose intravenously as prescribed.
f. Administer corticosteroids as prescribed.
g. Assess the clients temperature hourly.
h. Monitor blood pressure frequently.
i. Keep the client warm.
j. Monitor for changes in mental status.
k. Monitor electrolyte and glucose levels.
C. Hyperthyroidism
1. Description***
a. Hyperthyroid state resulting from hypersecretion of thyroid hormones
(T3 and T4).
b. Characterized by an increased rate of body metabolism.
c. A common cause is Graves disease, also known as toxic diffuse goiter.
d. Clinical manifestations are referred to as thyrotoxicosis.
e. The T3 and T4 are usually elevated and the TSH level is low.
2. Assessment***
a. Personality changes such as irritability, agitation, and mood swings.
b. Nervousness and fine tremors of the hands.
c. Heat intolerance.
d. Weight loss.
e. Smooth, soft skin and hair.
f. Palpitations, cardiac dysrhythmias, such as tachycardia or atrial fibrillation
g. Diarrhea
h. Protruding eyeballs (exophthalmos) may be present
i. Diaphoresis
j. Hypertension
k. Enlarged thyroid gland (goiter)
3. Interventions***
a. Provide adequate rest.
b. Administer sedatives as prescribed.
c. Provide a cool and quiet environment.
d. Obtain weight daily.
e. Provide a high-calorie diet.
f. Avoid the administration of stimulants.
g. Administer antithyroid medications, such as methimazole or propylthiouracil(PTU)
that block thyroid synthesis as prescribed.***
h . Administer iodine preparations that inhibit the release of thyroid hormone as
prescribed.
i. Administer propranolol(Inderal) for tachycardia as prescribed.
j. Prepare the client for radioactive iodine therapy, as prescribed, to destroy thyroid
cells.
k. Prepare the client for subtotal thyroidectomy if prescribed.
l. Elevate the head of the bed of a client experiencing exophthalmos; in addition,
instruct on low-salt diet, administer artificial tears, encourage the use of dark glasses,
and tape eyelids closed at night if necessary.***
m. Allow the client to express concerns about body image changes.
D. Thyroid storm
1. Description***
a. This acute and life-threatening condition occurs in a client with uncontrollable
hyperthyroidism.
b. It can be caused by manipulation of the thyroid gland during surgery and the release of
thyroid hormone into the bloodstream; it also can occur from severe infection and
stress.
c. Antithyroid medications, beta blockers, glucocorticoids, and iodides may be
administered to the client before thyroid surgery to prevent its occurrence.
2. Assessment
a. Elevated temperature (fever)
b. Tachycardia
c. Systolic hypertension
d. Nausea, vomiting, and diarrhea
e. Agitation, tremors, anxiety
f. Irritability, agitation, restlessness, confusion, and seizures as the condition progresses
g. Delirium and coma
3. Interventions***
a. Maintain a patent airway and adequate ventilation.
b. Administer antithyroid medications, iodides, propranolol, and glucocorticoids as
prescribed.
c. Monitor vital signs.
d. Monitor continually for cardiac dysrhythmias.
e. Administer nonsalicylate antipyretics as prescribed (salicylates increase free thyroid
hormone levels).
f. Use a cooling blanket to decrease temperature as prescribed.
E. Thyroidectomy
1. Description
a. Removal of the thyroid gland
b. Performed when persistent hyperthyroidism exists
c. Subtotal thyroidectomy, removal of a portion of the thyroid gland, is the preferred
surgical intervention.
2. Preoperative interventions
a. Obtain vital signs and weight.
b. Assess electrolyte levels.
c. Assess for hyperglycemia.
d. Instruct the client in how to perform coughing and deep-breathing exercises and how
to support the neck in the postoperative period when coughing and moving.***
e. Administer antithyroid medications, iodides, propranolol, and glucocorticoids as
prescribed to prevent the occurrence of thyroid storm.
3. Postoperative interventions***
a. Monitor for respiratory distress.
b. Have a tracheotomy set, oxygen, and suction at the bedside.
c. Limit client talking, and assess level of hoarseness.
d. Avoid neck flexion and stress on the suture line.
e. Monitor for laryngeal nerve damage, as evidenced by airway obstruction, dysphonia,
high-pitched voice, stridor, dysphagia, and restlessness.
f. Monitor for signs of hypocalcemia and tetany, which can be caused by trauma to the
parathyroid gland.
SIGNS OF TETANY
Cardiac dysrhythmias
Carpopedal spasm
Dysphagia
Muscle and abdominal cramps
Numbness and tingling of the face and extremities
Positive Chvosteks sign
Positive Trousseaus sign
Visual disturbances (photophobia)
Wheezing and dyspnea (bronchospasm, laryngospasm)
Seizures
g. Prepare to administer calcium gluconate as prescribed for tetany.
h. Monitor for thyroid storm.
! Following thyroidectomy, maintain the client in a semi-Fowlers position. Monitor the
surgical site for edema and for signs of bleeding and check the dressing anteriorly and
at the back of the neck.
B. Hyperparathyroidism
1. Description: Condition caused by hypersecretion of parathyroid hormone (PTH) by
the parathyroid gland
2. Assessment***
a. Hypercalcemia and hypophosphatemia.***
b. Fatigue and muscle weakness.
c. Skeletal pain and tenderness.
d. Bone deformities that result in pathological fractures.
e. Anorexia, nausea, vomiting, epigastric pain.
f. Weight loss.
g. Constipation.
h. Hypertension.***
i. Cardiac dysrhythmias.
j. Renal stones.
3. Interventions***
a. Monitor vital signs, particularly blood pressure.
b. Monitor for cardiac dysrhythmias.
c. Monitor intake and output and for signs of renal stones.
d. Monitor for skeletal pain; move the client slowly and carefully.
e. Encourage fluid intake.
f. Administer furosemide as prescribed to lower calcium levels.***
g. Administer NS intravenously as prescribed to maintain hydration.
h . Administer phosphates, which interfere with calcium reabsorption, as prescribed.
i. Administer calcitonin(Fortical; Miacalcin) as prescribed to decrease skeletal calcium
release and increase renal excretion of calcium.***
j. Administer IV or oral bisphosphonates to inhibit bone resorption.
k. Monitor calcium and phosphorus levels.
l. Prepare the client for parathyroidectomy as prescribed.
m. Encourage a high-fiber, moderate-calcium diet.***
n . Emphasize the importance of an exercise program and avoiding prolonged
inactivity.***
C. Parathyroidectomy
1. Description: Removal of 1 or more of the parathyroid glands.
a. Endoscopic radio guided parathyroidectomy with autotransplantation is the most
common procedure.
b. Parathyroid tissue is transplanted in the forearm or near the sternocleidomastoid
muscle, allowing PTH secretion to continue.
2. Preoperative interventions
a. Monitor electrolytes, calcium, phosphate, and magnesium levels.
b. Ensure that calcium levels are decreased to near-normal values.
c. Inform the client that talking may be painful for the first day or two after surgery.
3. Postoperative interventions***
a. Monitor for respiratory distress.
b. Place a tracheotomy set, oxygen, and suctioning equipment at the bedside.
c. Monitor vital signs.
d. Position the client in semi-Fowlers position.
e. Assess neck dressing for bleeding.
f. Monitor for hypocalcemic crisis, as evidenced by tingling and twitching in the
extremities and face.
g. Assess for positive Trousseaus sign or Chvosteks sign, which indicates tetany.
h . Monitor for changes in voice pattern and hoarseness.
i. Monitor for laryngeal nerve damage.
j. Instruct the client in the administration of calcium and vitamin D supplements as
prescribed.
C. Insulin administration***
1. Subcutaneous injections and mixing insulin.
2. Insulin pumps
a. Continuous subcutaneous insulin infusion is administered by an externally worn
device that contains a syringe attached to a long, thin, narrow-lumen tube with a
needle or Teflon catheter attached to the end.
b. The client inserts the needle or Teflon catheter into the subcutaneous tissue (usually
on the abdomen or upper arm) and secures it with tape or a transparent dressing; the
pump is worn on a belt or in a pocket; the needle or Teflon catheter is changed at least
every 2 to 3 days.
c. A continuous basal rate of insulin infuses; in addition, on the basis of the blood glucose
level, the anticipated food intake, and the activity level, the client delivers a bolus of
insulin before each meal.
d. Both rapid-acting and regular short-acting insulin (buffered to prevent the
precipitation of insulin crystals within the catheter) are appropriate for use in
these pumps.
3. Insulin pump and skin sensor
a. A skin sensor device can be used that monitors the clients blood glucose
continuously; the information is transmitted to the pump, determines the need for
insulin, and then the insulin is injected.
b. The pump holds up to a 3-day supply of insulin and can be disconnected easily for
activities such as bathing.
4. Pancreas transplants
a. The goal of pancreatic transplantation is to halt or reverse the complications of
diabetes mellitus.
b. Transplantations are performed on a limited number of clients (in general, these are
clients who are undergoing kidney transplantation simultaneously).
c. Immunosuppressive therapy is prescribed to prevent and treat rejection.
E. Urine testing
1. Urine testing for glucose is not a reliable indicator of the blood glucose level and is
not used for monitoring purposes.***
2. Instruct the client in the procedure for testing for urine ketones.
3. The presence of ketones may indicate impending ketoacidosis.
4. Urine ketone testing should be performed during illness and whenever the client with
type 1 diabetes mellitus has persistently elevated blood glucose levels (higher than
240 mg/dL [13.7 mmol/L] or as prescribed for 2 consecutive testing periods).
In the event of a suspected hypoglycemic reaction, the nurse should first check
the clients blood glucose level. If a blood glucose monitor is not available and the
client is experiencing the signs and symptoms of hypoglycemia, hypoglycemic reaction
should be suspected. If the blood glucose level is below 70 mg/dL (4.0 mmol/L), the
nurse should treat accordingly with 15 g of carbohydrate and recheck the level in 15
minutes. If the level is still below 70 mg/ dL (4.0 mmol/L), the nurse should treat with
an additional 15 g of carbohydrate. One more 15 g of carbohydrate if given if the level
remains below 70 mg/dL (4.0 mmol/L). The nurse then rechecks the blood glucose
level in another 15 minutes; if still below 70 mg/ dL(4.0 mmol/L), the nurse should treat
with an injectable form of glucose. The nurse should then have the client consume a
snack, document the occurrence, and explore the reasons the reaction occurred. If at
any point the client becomes unconscious, the nurse should administer an injectable
form of glucose to raise the blood glucose level.
Reference: Ignatavicius, Workman (2016), pp. 13301331. American Diabetes
Association. The 15/ 15rule.
B. Diabetic ketoacidosis (DKA)***
1. Description
a. Diabetic ketoacidosis is a life-threatening complication of type 1 diabetes mellitus
that develops when a severe insulin deficiency occurs.
b. The main clinical manifestations include hyperglycemia, dehydration, ketosis, and
acidosis.
2. Assessment***
-Differences between Diabetic Ketoacidosis and Hyperglycemia Hyperosmolar
Nonketotic Syndrome
3. Interventions***
a. Restore circulating blood volume and protect against cerebral, coronary, and renal
hypoperfusion.
b. Treat dehydration with rapid IV infusons of 0.9% or 0.45% NS as prescribed; dextrose
is added to IV fluids when the blood glucose level reaches 250 to 300 mg/dL (14.2 to
17.1 mmol/L). Too rapid administration of IV fluids; use of the incorrect types of IV
fluids, particularly hypotonic solutions; and correcting the blood glucose level too
rapidly can lead to cerebral edema.
c. Treat hyperglycemia with insulin administered intravenously as prescribed.
d. Correct electrolyte imbalances (potassium level may be elevated as a result of
dehydration and acidosis).
e. Monitor potassium level closely because when the client receives treatment for the
dehydration and acidosis, the serum potassium level will decrease and potassium
replacement may be required.
f. Cardiacmonitoring should be in place for the client with DKA due to risks associated
with abnormal serum potassium levels.
4. Insulin IV administration***
a. Use short-duration insulin only.
b. An IV bolus dose of short-duration regular U - 100 insulin (usually 5 to 10 units) may
be prescribed before a continuous infusion is begun.
c. The prescribed IV dose of insulin for continuous infusion is prepared in 0.9% or 0.45%
NS as prescribed.
d. Always place the insulin infusion on an IV infusion controller.
e. Insulin is infused continuously until subcutaneous administration resumes, to prevent a
rebound of the blood glucose level.
f. Monitor vital signs.
g. Monitor urinary output and monitor for signs of fluid overload.
h. Monitor potassium and glucose levels and for signs of increased intracranial pressure.
i. The potassium level will fall rapidly within the first hour of treatment as the dehydration
and the acidosis are treated.
j. Potassium is administered intravenously in a diluted solution as prescribed; ensure
adequate renal function before administering potassium.
5. Client education: Guidelines during Illness
*Take insulin or oral antidiabetic medications as prescribed.
*Determine the blood glucose level and test the urine for ketones every 3 to 4 hours.
*If the usual meal plan cannot be followed, substitute soft foods 6 to 8 times a day.
*If vomiting, diarrhea, or fever occurs, consume liquids every 30 to 60minutes to
prevent dehydration and to provide calories.
*Notify the health care provider if vomiting, diarrhea, or fever persists; if blood
glucose levels are higher than 250 to 300 mg/ dL (14.2 to 17.1 mmol/L); when
ketonuria is present for more than 24 hours; when unable to take food
or fluids for a period of 4 hours; or when illness persists for more than 2 days.
!Monitor the client being treated for DKA closely for signs of increased intracranial
pressure. If the blood glucose level falls too far or too fast before the brain has time to
equilibrate, water is pulled from the blood to the cerebrospinal fluid and the brain, causing
cerebral edema and increased intracranial pressure.
BLOOD SUPPLY
- GIT recieves blood from arteries that originate along the entire length of the
thoracic and abdominal aorta
- The portal venous system is composed of 5 large veins: superior mesenteric,
inferior mesenteric, gastric, splenic, and cystic veins w/c form the vena portae
that enters the liver
- Oxygen and nutrients are supplied to the stomach by the gastric artery and to
the intestines by the mesenteric arteries.
Physiology
- Sympathetic
Generally INHIBITORY!
Decreased gastric secretions
Decreased GIT motility
Sphincters and blood vessels constrict
- Parasympathetic
Generally EXCITATORY!
Increased gastric secretions
Increased gastric motility
Sphincters relax
Terms
Digestion: phase of the digestive process that occurs when enzymes mix with
ingested food and when proteins, fats, and sugars are broken down into their
component molecules
Absorption: phase of the digestive process that occurs when small molecules,
vitamins, and minerals pass through the walls of the small and large intestine and
into the bloodstream
Elimination: phase of the digestive process that occurs after digestion and
absorption, when waste products are eliminated from the body
Digestive Processes
Chewing
- 1.5ml of saliva is secreted daily from the parotid, submaxillary and sublingual
glands
- PTYALIN or SALIVARY AMYLASE is an enzyme that begins the digestion of
starches
Gastric Function
- stomach-secretes a highly acidic fluid in response to the presence of ingested
food
- fluid can total as 2.4L/day can have a ph as low as 1 and derives its acidity from
hydrochloric acid (HCl)
a. to breakdown food into more absorbable components
b. to aid in the destruction of ingested bacteria
Gastric Enzymes
Secreted by zymogens or chief cells
Amylase=for starch digestion
Lipase=for fat digestion
Pepsin=for protein digestion
Rennin=for milk and protein digestion
Colonic Function
- bacteria make up a major component of the contents of the large intestine, assist
in completing the breakdown of waste material especially undigested and
unabsorbed proteins and bile salts
Paracentesis is the transabdominal removal of fluid from the peritoneal cavity. The
nurse first ensures that the client understands the procedure and that informed consent
has been obtained, because the procedure is invasive. The nurse next obtains
preprocedure vital signs, including weight, so that a baseline is obtained. Weight is taken
before and after the procedure to provide an indication of the effectiveness of the
procedure in fluid removal. The client is assisted to void to emptythe bladder and to move
the bladder out of the wayof the paracentesis needle. The client is positioned upright on
the edge of a bed with the back supported and the feet resting on a stool, or in a Fowlers
position in bed. The nurse assists the HCP,monitors vital signs per protocol, and provides
comfort and support to the client during the procedure. Once the procedure is complete,
the nurse applies a dressing to the site of puncture and monitors for leakage or bleeding.
The client is placed in a position of comfort, bed rest is maintained as prescribed, and
vital signs are monitored to assess for complications. The fluid removed from the client is
measured, labeled, and sent to the laboratory for analysis. The nurse documents the
event, the clients response, the appearance and amount of fluid removed, and any
additional pertinent data.
Reference Ignatavicius, Workman (2016), p. 1199.
!The rapid removal of fluid from the abdominal cavity during paracentesis leads to
decreased abdominal pressure, which can cause vasodilation and resultant shock;
therefore, heart rate and blood pressure must be monitored closely.
K. Liver biopsy***
1. Description: A needle is inserted through the abdominal wall to the liver to obtain a
tissue sample for biopsy and microscopic examination.
2. Preprocedure***
a. Assess results of coagulation tests (prothrombin time, partial thromboplastin time,
platelet count).***
b. Administer a sedative as prescribed.***
c. Note that the client is placed in the supine or left lateral position during the
procedure to expose the right side of the upper abdomen.
3. Postprocedure
a. Assess vital signs.
b. Assess biopsy site for bleeding.***
c. Monitor for peritonitis
Signs of Bowel Perforation and Peritonitis
Guarding of the abdomen
Increased temperature and chills
Pallor
Progressive abdominal distention and abdominal pain
Restlessness
Tachycardia and tachypnea
d. Maintain bed rest for several hours as prescribed.***
e. Place the client on the right side with a pillow under the costal margin for 2 hours
to decrease the risk of bleeding, and instruct the client to avoid coughing and
straining.***
f. Instruct the client to avoid heavy lifting and strenuous exercise for 1 week.
L. Stool specimens
1. Testing of stool specimens includes inspecting the specimen for consistency and color
and testing for occult blood.
2. Tests for fecal urobilinogen, fat, nitrogen, parasites, pathogens, food substances, and
other substances may be performed; these tests require that the specimen be sent to
the laboratory.
3. Random specimens are sent promptly to the laboratory.
4. Quantitative 24- to 72-hour collections must be kept refrigerated until they are taken to
the laboratory.
5. Some specimens require that a certain diet be followed or that certain medications be
withheld; check agency guidelines regarding specific procedures.
M. Urea breath test
1. The urea breath test detects the presence of Helicobacter pylori, the bacteria that
cause peptic ulcer disease.
2. The client consumes a capsule of carbon-labeled urea and provides a breath sample
10 to 20 minutes later.
3. Certain medications may need to be avoided before testing. These may include
antibiotics or bismuth subsalicylate for 1 month before the test; sucralfate and
omeprazole for 1 week before the test; and cimetidine, famotidine, ranitidine, and
nizatidine for 24 hours before breath testing.
4. H. pylori can also be detected by assessing serum antibody levels.
N. Liver and pancreas laboratory studies***
1. Liver enzyme levels (alkaline phosphatase [ALP], aspartate aminotransferase [AST],
and alanine aminotransferase [ALT]) are elevated with liver damage or bilary
obstruction. Normal reference intervals: ALP, 0.5 to 2.0 mckat/L(35 to 120 U/L); AST,
0 to 35 U/L(0 to 35 U/L);ALT, 4 to 36 U/L(4 to 36 U/L).
2. Prothrombin time is prolonged with liver damage. Normal reference interval:11 to
12.5 seconds.
3. The serum ammonia level assesses the ability of the liver to deaminate protein
byproducts. Normal reference interval: 10 to 80 mcg/dL (6 to 47 mcmol/L).
4. An increase in cholesterol level indicates pancreatitis or biliary obstruction. Normal
reference interval: < 200 mg/dL (< 5.0 mmol/L).
5. An increase in bilirubin level indicates liver damage or biliary obstruction. Normal
reference intervals: Total, 0.3 to 1.0 mg/dL (5.1 to 17 mcmol/L); indirect, 0.2 to 0.8
mg/dL (3.4 to 12 mcmol/L); direct, 0.1 to 0.3 mg/dL (1.7 to 5.1 mcmol/L).
6. Increased values for amylase and lipase levels indicate pancreatitis. Normal
reference intervals: amylase, 60 to 120 Somogyi units/dL (30 to 220 U/L); lipase, 0 to
160 U/L (0 to 160 U/L).
III. Assessment PG 693
A. Abdomen
1. Subjective data: Changes in appetite or weight, difficulty swallowing, dietary intake,
intolerance to certain foods, nausea or vomiting, pain, bowel habits, medications
currently being taken, history of abdominal problems or abdominal surgery.***
2. Objective data***
a. Ask the client to empty the bladder.
b. Be sure to warm the hands and the endpiece of the stethoscope.
c. Examine painful areas last.
!When performing an abdominal assessment, the specific order for assessment
techniques is inspection, auscultation, percussion, and palpation.
3. Inspection
a. Contour: Look down at the abdomen and then across the abdomen from the rib
margin to the pubic bone; describe as flat, rounded, concave, or protuberant.
b. Symmetry: Note any bulging or masses.
c. Umbilicus: Should be midline and inverted
d. Skin surface: Should be smooth and even
e. Pulsations from the aorta may be noted in the epigastric area, and peristaltic waves
may be noted across the abdomen.
4. Auscultation
a. Performed before percussion and palpation, which can increase peristalsis.
b. Hold the stethoscope lightly against the skin and listen for bowel sounds in all 4
quadrants; begin in the right lower quadrant (bowel sounds are normally heard here).
c. Note the character and frequency of normal bowel sounds: high-pitched gurgling
sounds occurring irregularly from 5 to 30 times a minute.
d. Identify as normal, hypoactive, or hyperactive (borborygmus).
e. Absent sounds: Auscultate for 5 minutes before determining that sounds are absent.
f. Auscultate over the aorta, renal arteries, iliac arteries, and femoral arteries for vascular
sounds or bruits.
5. Percussion
a. All 4 quadrants are percussed lightly.
b. Borders of the liver and spleen are percussed.
c. Tympany should predominate over the abdomen, with dullness over the liver and
spleen.
d. Percussion over the kidney at the 12th rib (costovertebral angle) should produce
no pain.
6. Palpation
a. Begin with light palpation of all 4 quadrants, using the fingers to depress the skin about
1 cm; next perform deep palpation, depressing 5 to 8 cm.
b. Palpate the liver and spleen (spleen may not be palpable).
c. Palpate the aortic pulsation in the upper abdomen slightly to the left of midline;
normally it pulsates in a forward direction (pulsation expands laterally if an aneurysm is
present).
7. diagnostic tests related to the gastrointestinal system.
8. Client teaching***
a. Encourage the client to consume a balanced diet; obesity needs to be prevented.
b. Substances that can cause gastric irritation should be avoided.
c. The regular use of laxatives is discouraged.
d. Lifestyle behaviors that can cause gastric irritation (e.g., spicy foods) should be
modified.
e. Regular physical examinations are important.
f. The client should report gastrointestinal problems to the HCP.
IV. Gastrointestinal Tubes (see chapter 20 pg. 239 of nclex rn saunders 7th edition)
Care of client with tube
VI. Gastritis
A. Description
1. Inflammation of the stomach or gastric mucosa
2. Acute gastritis is caused by the ingestion of food contaminated with disease-causing
microorganisms or food that is irritating or too highly seasoned, the overuse of aspirin
or other NSAIDs, excessive alcohol intake, bile reflux, or radiation therapy.
3. Chronic gastritis is caused bybenign ormalignant ulcers or by the bacteria H. pylori,
and also may becaused by autoimmune diseases, dietary factors, medications,
alcohol, smoking, or reflux.
B. Assessment
Assessment Finding in Acute and Chronic
Gastritis
Acute Chronic
Abdominal discomfort Anorexia, nausea, and
Anorexia, nausea, and vomiting
vomiting Belching
Headache Heartburn after eating
Hiccupping Sour taste in the mouth
Reflux Vitamin B12 deficiency
C. Interventions***
1. Acute gastritis: Food and fluids may be withheld until symptoms subside; afterward,
and as prescribed, ice chips can be given, followed by clear liquids, and then solid
food.
2. Monitor for signs of hemorrhagic gastritis such as hematemesis, tachycardia, and
hypotension, and notify the HCP if these signs occur.
3. Instruct the client to avoid irritating foods, fluids, and other substances, such as spicy
and highly seasoned foods, caffeine, alcohol, and nicotine.
4. Instruct the client in the use of prescribed medications, such as antibiotics to treat H.
pylori, and antacids.
5. Provide the client with information about the importance of vitamin B12 injections if a
deficiency is present.
VII.Peptic Ulcer Disease
A. Description
1. A peptic ulcer is an ulceration in the mucosal wall of the stomach, pylorus, duodenum,
or esophagus in portions accessible to gastric secretions; erosion may extend through
the muscle.
2. The ulcer may be referred to as gastric, duodenal, or esophageal, depending on its
location.
3. The most common peptic ulcers are gastric ulcers and duodenal ulcers.
*B. Gastric ulcers
1. Description
a. A gastric ulcer involves ulceration of the mucosal lining that extends to the submucosal
layer of the stomach.
b. Predisposing factors include stress, smoking, the use of corticosteroids, NSAIDs,
alcohol, history of gastritis, family history of gastric ulcers, or infection with H. pylori.
c. Complications include hemorrhage, perforation, and pyloric obstruction.
2. Assessment***
Assessment of Gastric and Duodenal Ulcers
***Gastric
*Gnawing, sharp pain in or to the left of the mid-epigastric region occurs 30 to 60
minutes after a meal (food ingestion accentuates the pain{Ingestion of food
does not relieve pain}).
*Hematemesis is more common than melena.
***Duodenal
*Burning pain occurs in the mid-epigastric area 11/2 to 3 hours after a meal and during
the night (often awakens the client).
*Melena is more common than hematemesis.
*Pain is often relieved by the ingestion of food.
3. Interventions***
a. Monitor vital signs and for signs of bleeding.
b. Administer small, frequent bland feedings during the active phase.
c. Administer H2-receptor antagonists or proton pump inhibitors as prescribed to
decrease the secretion of gastric acid.
d. Administer antacids as prescribed to neutralize gastric secretions.
e. Administer anticholinergics as prescribed to reduce gastric motility.
f. Administer mucosal barrier protectants as prescribed 1 hour before each meal.
g. Administer prostaglandins as prescribed for their protective and antisecretory actions.
4. Client education***
a. Avoid consuming alcohol and substances that contain caffeine or chocolate.
b. Avoid smoking.
c. Avoid aspirin or NSAIDs.
d. Obtain adequate rest and reduce stress.
5. Interventions during active bleeding
a. Monitor vital signs closely.
b. Assess for signs of dehydration, hypovolemic shock, sepsis, and respiratory
insufficiency.
c. Maintain NPO status and administer intravenous (IV) fluid replacement as
prescribed; monitor intake and output.
d. Monitor hemoglobin and hematocrit.
e. Administer blood transfusions as prescribed.
f. Prepare to assist with administering medications as prescribed to induce
vasoconstriction and reduce bleeding.
6. Surgical interventions
a. Total gastrectomy: Removal of the stomach with attachment of the esophagus to the
jejunum or duodenum; also called esophagojejunostomy or esophagoduodenostomy
b. Vagotomy: Surgical division of the vagus nerve to eliminate the vagal impulses that
stimulate hydrochloric acid secretion in the stomach
c. Gastric resection: Removal of the lower half of the stomach and usually includes a
vagotomy; also called antrectomy
d. Gastroduodenostomy: Partial gastrectomy, with the remaining segment
anastomosed to the duodenum; also called Billroth I.
*The distal portion of the stomach is removed, and the remainder is anastomosed to
the duodenum.
e. Gastrojejunostomy: Partial gastrectomy, with the remaining segment anastomosed to
the jejunum; also called Billroth II.
*The lower portion of the stomach is removed, and the remainder is anastomosed
to the jejunum.
f. Pyloroplasty: Enlargement of the pylorus to prevent or decrease pyloric obstruction,
thereby enhancing gastric emptying
7. Postoperative interventions
a. Monitor vital signs.
b. Place in a Fowlers position for comfort and to promote drainage.***
c. Administer fluids and electrolyte replacements intravenously as prescribed;
monitor intake and output.
d. Assess bowel sounds.
e. Monitor NG suction as prescribed.
f. Maintain NPO status as prescribed for 1 to 3 days until peristalsis returns.
g. Progress the diet from NPO to sips of clear water to 6 small bland meals a day,
as prescribed when bowel sounds return.
h . Monitor for postoperative complications of hemorrhage, dumping syndrome,
diarrhea, hypoglycemia, and vitamin B12 deficiency.***
! Following gastric surgery, do not irrigate or remove the NG tube unless specifically
prescribed because of the risk for disruption of the gastric sutures. Monitor closely to
ensure proper functioning of the NG tube to prevent strain on the anastomosis site.
Contact the HCP if the tube is not functioning properly.
C. Duodenal ulcers
1. Description
a. A duodenal ulcer is a break in the mucosa of the duodenum.
b. Risk factors and causes include infection with H. pylori; alcohol intake; smoking;
stress; caffeine; and the use of aspirin, corticosteroids, and NSAIDs.
c. Complications include bleeding, perforation, gastric outlet obstruction, and intractable
disease.
2. Assessment***
Assessment of Gastric and Duodenal Ulcers
***Gastric
*Gnawing, sharp pain in or to the left of the mid-epigastric region occurs 30 to 60 minutes
after a meal (food ingestion accentuates the pain).
*Hematemesis is more common than melena.
***Duodenal
*Burning pain occurs in the mid-epigastric area 11/2 to 3 hours after a meal and during
the night (often awakens the client).
*Melena is more common than hematemesis.
*Pain is often relieved by the ingestion of food.**
3. Interventions
a. Monitor vital signs.
b. Instruct the client about a bland diet, with small, frequent meals.
c. Provide for adequate rest.
d. Encourage the cessation of smoking.
e. Instruct the client to avoid alcohol intake; caffeine; and the use of aspirin,
corticosteroids, and NSAIDs.
f. Administer medications to treat H. pylori and antacids to neutralize acid secretions
as prescribed.
g. Administer H2-receptor antagonists or proton pump inhibitors as prescribed to
block the secretion of acid.
4. Surgical interventions: Surgery is performed only if the ulcer is unresponsive to
medications or if hemorrhage, obstruction, or perforation occurs.
D. Dumping syndrome
1. Description: The rapid emptying of the gastric contents into the small intestine that
occurs following gastric resection
2. Assessment***
a. Symptoms occurring 30 minutes after eating
b. Nausea and vomiting
c. Feelings of abdominal fullness and abdominal cramping
d. Diarrhea
e. Palpitations and tachycardia
f. Perspiration
g. Weakness and dizziness
h. Borborygmi (loud gurgling sounds resulting from bowel hypermotility)
3. Client education***
Client Education: Preventing Dumping Syndrome
*Avoid sugar, salt, and milk.
*Eat a high-protein, high-fat, low-carbohydrate diet.***
*Eat small meals and avoid consuming fluids with meals.
*Lie down after meals.
*Take antispasmodic medications as prescribed to delay gastric emptying.
X. Gastric Cancer
A. Description
1. Gastric cancer is a malignant growth of the mucosal cells in the inner lining of the
stomach, with invasion to the muscle and beyond in advanced disease.
2. No single causative agent has been identified but it is believed that H. pylori infection
and a diet of smoked, highly salted, processed, or spiced foods have carcinogenic
effects; other risk factors include smoking, alcohol and nitrate ingestion, and a history
of gastric ulcers.
3. Complications include hemorrhage, obstruction, metastasis, and dumping syndrome.
4. The goal of treatment is to remove the tumor and provide a nutritional program.
B. Assessment
1. Early:
a. Indigestion
b. Abdominal discomfort
c. Full feeling
d. Epigastric, back, or retrosternal pain
2. Late:
a. Weakness and fatigue
b. Anorexia and weight loss
c. Nausea and vomiting
d. A sensation of pressure in the stomach
e. Dysphagia and obstructive symptoms
f. Iron deficiency anemia
g. Ascites
h . Palpable epigastric mass
C. Interventions
1. Monitor vital signs.
2. Monitor hemoglobin and hematocrit and administer blood transfusions as prescribed.
3. Monitor weight.
4. Assess nutritional status; encourage small, bland, easily digestible meals with vitamin
and mineral supplements.
5. Administer pain medication as prescribed.
6. Prepare the client for chemotherapy or radiation therapy as prescribed.
7. Prepare the client for surgical resection of the tumor as prescribed.
**Surgical Interventions for Gastric Cancer**
Subtotal Gastrectomy
Billroth I
Also called gastroduodenostomy
Partial gastrectomy, with remaining segment anastomosed to the duodenum
Billroth II
Also called gastrojejunostomy
Partial gastrectomy, with remaining segment anastomosed to the jejunum
Total Gastrectomy
Also called esophagojejunostomy
Removal of the stomach, with attachment of the esophagus to the jejunum or
duodenum
D. Postoperative interventions
1. Monitor vital signs.
2. Place in Fowlers position for comfort.
3. Administer analgesics and antiemetics, as prescribed.
4. Monitor intake and output; administer fluids and electrolyte replacement by IV as
prescribed; administer parenteral nutrition as indicated.
5. Maintain NPO (nothing bymouth) status as prescribed for 1 to 3 days until peristalsis
returns; assess for bowel sounds.
6. Monitor nasogastric suction. Following gastrectomy, drainage from the nasogastric
tube is normally bloody for 24 hours postoperatively, changes to brown-tinged,
and is then yellow or clear.
7. Do not irrigate or remove the nasogastric tube (follow agency procedures); assist the
HCP with irrigation or removal.
8. Advance the diet from NPO to sips of clear water to 6 small bland meals a day, as
prescribed.
9. Monitor for complications such as hemorrhage, dumping syndrome, diarrhea,
hypoglycemia, and vitamin B12 deficiency.
XII. Cholecystitis
A. Description
1. Inflammation of the gallbladder that may occur as an acute or chronic process***
2. Acute inflammation is associated with gallstones (cholelithiasis).
3. Chronic cholecystitis results when inefficient bile emptying and gallbladder
muscle wall disease cause a fibrotic and contracted gallbladder.
4. Acalculous cholecystitis occurs in the absence of gallstones and is caused by
bacterial invasion via the lymphatic or vascular system.
B. Assessment
1. Nausea and vomiting
2. Indigestion
3. Belching
4. Flatulence
5. Epigastric pain that radiates to the right shoulder or scapula***
6. Pain localized in right upper quadrant and triggered by high-fat or high-volume meal
7. Guarding, rigidity, and rebound tenderness
8. Mass palpated in the right upper quadrant***
9. Murphys sign (cannot take a deep breath when the examiners fingers are passed
below the hepatic margin because of pain)***
10. Elevated temperature
11. Tachycardia
12. Signs of dehydration
C. Biliary obstruction
1. Jaundice***
2. Dark orange and foamy urine***
3. Steatorrhea and clay-colored feces***
4. Pruritus***
D. Interventions
1. Maintain NPO status during nausea and vomiting episodes.
2. Maintain NG decompression as prescribed for severe vomiting.
3. Administer antiemetics as prescribed for nausea and vomiting.
4. Administer analgesics as prescribed to relieve pain and reduce spasm.
5. Administer antispasmodics (anticholinergics) as prescribed to relax smooth muscle.
6. Instruct the client with chronic cholecystitis to eat small, low-fat meals.***
7. Instruct the client to avoid gas-forming foods.
8. Prepare the client for nonsurgical and surgical procedures as prescribed.
E. Surgical interventions
1. Cholecystectomy is the removal of the gallbladder.
2. Choledocholithotomy requires incision into the common bile duct to remove the
stone.
3. Surgical procedures may be performed by laparoscopy.
F. Postoperative interventions
1. Monitor for respiratory complications caused by pain at the incisional site.***
2. Encourage coughing and deep breathing.***
3. Encourage early ambulation.
4. Instruct the client about splinting the abdomen to prevent discomfort during coughing*
5. Administer antiemetics as prescribed for nausea and vomiting.
6. Administer analgesics as prescribed for pain relief.
7. Maintain NPO status and NG tube suction as prescribed.***
8. Advance diet from clear liquids to solids when prescribed and as tolerated by the
client.
9. Maintain and monitor drainage from the T-tube, if present
**Care of a T Tube**
Purpose and Description
A T-tube is placed after surgical exploration of the common bile duct. The tube preserves
the patency of the duct and ensures drainage of bile until edema resolves and bile is
effectively draining into the duodenum. A gravity drainage bag is attached to the T-tube
to collect the drainage.
Interventions***
*Place the client in semi-Fowlers position to facilitate drainage.
*Monitor the output, amount and the color, consistency, and odor of the drainage.
*Report sudden increases in bile output to the health care provider (HCP).
*Monitor for inflammation and protect the skin from irritation.
*Keep the drainage system below the level of the gallbladder.
*Monitor for foul odor and purulent drainage and report its presence to the HCP.
*Avoid irrigation, aspiration, or clamping of the T-tube without an HCPs prescription.
*As prescribed, clamp the tube before a meal and observe for abdominal discomfort
and distention, nausea, chills, or fever; unclamp the tube if nausea or vomiting occurs.
XIII. Cirrhosis
A. Description
1. A chronic, progressive disease of the liver characterized by diffuse degeneration and
destruction of hepatocytes
2. Repeated destruction of hepatic cells causes the formation of scar tissue.
3. Cirrhosis has many causes and is due to chronic damage and injury to liver cells; the
most common are chronic hepatitis C, alcoholism, nonalcoholic fatty liver disease
(NAFLD), and nonalcoholic steatohepatitis (NASH).
B. Complications
1. Portal hypertension: A persistent increase in pressure in the portal vein that develops
as a result of obstruction to flow
2. Ascites
a. Accumulation of fluid in the peritoneal cavity that results from venous congestion of the
hepatic capillaries
b. Capillary congestion leads to plasma leaking directly from the liver surface and portal
vein.
3. Bleeding esophageal varices: Fragile, thin-walled, distended esophageal veins that
become irritated and rupture
4. Coagulation defects
a. Decreased synthesis of bile fats in the liver prevents the absorption of fat-soluble
vitamins.
b. Without vitamin K and clotting factors II, VII, IX, and X, the client is prone to bleeding.
5. Jaundice: Occurs because the liver is unable to metabolize bilirubin and because the
edema, fibrosis, and scarring of the hepatic bile ducts interfere with normal bile and
bilirubin secretion
6. Portal systemic encephalopathy: End-stage hepatic failure characterized by altered
level of consciousness, neurological symptoms, impaired thinking, and neuromuscular
disturbances; caused by failure of the diseased liver to detoxify neurotoxic agents such
as ammonia
7. Hepatorenal syndrome
a. Progressive renal failure associated with hepatic failure
b. Characterized by a sudden decrease in urinary output, elevated blood urea nitrogen
and creatinine levels, decreased urine sodium excretion, and increased urine
osmolarity
C. Assessment
Dermatological Findings
Axillary and pubic hair changes
Caput medusae (dilated abdominal veins )*
Ecchymosis; petechiae*
Increased skin pigmentation
Jaundice
Palmar erythema*
Pruritus
Spider angioma s (chest and thorax)*
Endocrine Findings
Increased aldosterone
Increased antidiuretic hormone
Increased circulating estrogens
Increased glucocorticoids
Gyne comastia
Immune System Disturbance
Increased susceptibility to infection
Leukopenia
Neurological Findings
Asterixis
Paresthesias of feet
Peripheral nerve degeneration
Portal-systemic encephalopathy
Reversal of sleep-wake pattern
Sensory disturbances
Pulmonary Findings
Dyspne a
Hydrothorax
Hyperventilation
Hypoxemia
Gastrointestinal (GI)Findings
Abdominal pain
Anorexia
Ascites
Clay-colored s tools
Diarrhea
Esophageal varices
Hiatal hernia
Hypersplenism
Malnutrition
Nausea
Small nodular liver
Vomiting
Fetor hepaticus
Galls tones
Gastritis
Gastrointestinal ble eding
Hemorrhoidal varices
Hepatomegaly
Hematological Findings
Anemia
Disseminated intravascular coagulation
Impaired coagulation
Splenomegaly
Thrombocytopenia
Cardiovascular Findings
Cardiac dysrhythmias
Development of collateral circulation
Fatigue
Hyperkinetic circulation
Peripheral edema
Portal hypertension
Spider angiomas
Fluid and Electrolyte Disturbances
Ascites
Decreased effective blood volume
Hypokalemia
Peripheral edema
Water retention
Hypocalcemia
Dilutional hyponatremia or hypernatremia
Renal Findings
Hepatorenal syndrome
Incre ased urine bilirubin
D. Interventions***
1. Elevate the head of the bed to minimize shortness of breath.
2. If ascites and edema are absent and the client does not exhibit signs of impending
coma, a high-protein diet supplemented with vitamins is prescribed.
3. Provide supplemental vitamins (B complex; vitamins A, C, and K; folic acid; and
thiamine) as prescribed.
4. Restrict sodium intake and fluid intake as prescribed.
5. Initiate enteral feedings or parenteral nutrition as prescribed.
6. Administer diuretics asprescribed to treat ascites.
7. Monitor intake and output and electrolyte balance.
8. Weigh client and measure abdominal girth daily
*How to measure abdominal girth. With the client supine, bring the tape measure
around the client and take a measurement at the level of the umbilicus. Before
removing the tape, mark the clients abdomen along the sides of tape on the clients
flanks (sides) and midline to ensure that later measurements are taken at the same
place.
9. Monitor level of consciousness; assess for precoma state (tremors, delirium).
10. Monitor for asterixis, a coarse tremor characterized by rapid, nonrhythmic extensions
and flexions in the wrist and fingers
***Eliciting asterixis (flapping tremor). Have the client extend the arm, dorsiflexthe wrist,
and extend the fingers.Observe for rapid, nonrhythmic extensions and flexions.
11. Monitor for fetor hepaticus, the fruity, musty breath odor of severe chronic liver
disease.
12. Maintain gastric intubation to assess bleeding or esophagogastric balloon tamponade
to control bleeding varices if prescribed.
13. Administer blood products as prescribed.
14. Monitor coagulation laboratory results; administer vitamin K if prescribed.
15. Administer antacids as prescribed.
16. Administer lactulose as prescribed, which decreases the pH of the bowel, decreases
production of ammonia by bacteria in the bowel, and facilitates the excretion of
ammonia.
17. Administer antibiotics as prescribed to inhibit protein synthesis in bacteria and
decrease the production of ammonia.
18. Avoid medications such as opioids, sedatives, and barbiturates and any hepatotoxic
medications or substances.
19. Instruct the client about the importance of abstinence of alcohol intake.
20. Prepare the client for paracentesis to remove abdominal fluid.
21. Prepare the client for surgical shunting procedures if prescribed to divert fluid from
ascites into the venous system.
XV. Hepatitis
A. Description
1. Inflammation of the liver caused by a virus, bacteria, or exposure to medications or
hepatotoxins
2. The goals of treatment include resting the inflamed liver to reduce metabolic demands
and increasing the blood supply, thus promoting cellular regeneration and preventing
complications.
B. Types of Hepatitis
1. Hepatitis A virus (HAV)
2. Hepatitis B virus (HBV)
3. Hepatitis C virus (HCV)
4. Hepatitis D virus (HDV)
5. Hepatitis E virus (HEV)
C. Stages of Viral Hepatitis
Preicteric Stage
The first stage of hepatitis, preceding the appearance of jaundice; includes flulike
symptomsmalaise, fatigue; anorexia, nausea, vomiting, diarrhea; painheadache,
muscle aches, polyarthritis; and elevated serum bilirubin and enzyme levels.
Icteric Stage
The second stage of hepatitis; includes the appearance of jaundice and associated
symptoms such as elevated bilirubin levels, dark or tea-colored urine, and clay-colored
stools; pruritus; and a decrease in preicteric-phase symptoms.
Posticteric Stage
The convalescent stage of hepatitis, in which the jaundice decreases and the color of the
urine and stool returns to normal; energy increases, pain subsides, there is minimal to
absent gastrointestinal symptoms, and bilirubin and enzyme levels return to normal.
D. Assesment
1. Preicteric Stage
a. Flulike symptoms malaise, fatigue
b. Anorexia, nausea, vomiting, diarrhea
c. Pain headache, muscle aches, polyarthritis
d. Serum bilirubin and enzyme levels are elevated
2. Icteric Stage
a. Jaundice
b. Pruritus
c. Dark or tea colored urine
d. Clay colored stool
e. Decrease in preicteric phase symptoms
3. Posticteric Stage
a. Increased energy levels
b. Subsiding of pain
c. Minimal to absent gastrointestinal symptoms
d. Serum bilirubin and enzyme levels return to normal
E. Laboratory assessment
1. Alanine aminotransferase (ALT) level: Elevated into the thousands (normal, 10 to 40
units/L)
2. Aspartate aminotransferase (AST) level: Elevated into the thousands (normal 10 to
30 units/L)
3. Ammonia: Elevated levels may lead to encephalopathy (normal, 10 to 80 mcg/dL)
4. Total bilirubin levels: Elevated in the serum and urine (normal, lower than 1.5
mg/dL)
XVI. Hepatitis A
A. Description:
1.Formerly known as infectious hepatitis
2. Commonly seen during the fall and early winter
B. Individuals at increased risk
1. Commonly seen in young children
2. Individuals in institutionalized settings
3. Health care personnel
4. Crowded conditions (e.g., day care, nursin home)
5. Exposure to poor sanitation
C. Transmission***
1. Fecal-oral route
2. Person-to-person contact
3. Parenteral
4. Contaminated fruits or vegetables, or uncooked shellfish
5. Contaminated water or milk
6. Poorly washed utensils
D. Incubation and infectious period
1. Incubation period is 2 to 6 weeks.*
2. Infectious period is 2 to 3 weeks before and 1 week after development of jaundice.
E. Testing
1. Infection is established by the presence of HAV antibodies (anti-HAV) in the blood.
2. ImmunoglobulinM(IgM) and immunoglobulin G (IgG) are normally present in the blood,
and increased levels indicate infection and inflammation.
3. Ongoing inflammation of the liver is evidenced by the presence of elevated levels of
IgM antibodies, which persist in the blood for 4 to 6 weeks.
4. Previous infection is indicated by the presence of elevated levels of IgG antibodies.
F. Complication: Fulminant (severe acute and often fatal) hepatitis
G. Prevention***
1. Strict hand washing
2. Stool and needle precautions
3. Treatment of municipal water supplies
4. Serological screening of food handlers
5. Hepatitis A vaccine: Two doses are needed at least 6 months apart for lasting
protection.
6. Immuneglobulin: For individuals exposed toHAV who have never received the
hepatitis A vaccine; administer immune globulin during the period of incubation and
within 2 weeks of exposure.
7. Immune globulin and hepatitis A vaccine are recommended for household
members and sexual contacts of individuals with hepatitis A.
8. Preexposure prophylaxis with immune globulin is recommended to individuals traveling
to countrieswith poor or uncertain sanitation conditions.
!Strict and frequent hand washing is key to preventing the spread of all types of
hepatitis.
XVII. Hepatitis B
A. Description
1. Hepatitis B is nonseasonal.
2. All age groups can be affected.
B. Individuals at increased risk
1. IV drug users
2. Clients undergoing long-term hemodialysis
3. Health care personnel
C. Transmission***
1. Blood or body fluid contact***
2. Infected blood products***
3. Infected saliva or semen***
4. Contaminated needles***
5. Sexual contact***
6. Parenteral***
7. Perinatal period***
8. Blood or body fluid contact at birth***
D. Incubation Period: 6 to 24 weeks*
E. Testing
1. Infection is established by the presence of hepatitis B antigenantibody systems in the
blood.
2. The presence of hepatitis B surface antigen (HBsAg) is the serological marker
establishing the diagnosis of hepatitis B.
3. The client is considered infectious if these antigens are present in the blood.
4. If the serological marker (HBsAg) is present after 6 months, it indicates a carrier
state or chronic hepatitis.
5. Normally, the serological marker (HBsAg) level declines and disappears after the
acute hepatitis B episode.
6. The presence of antibodies to HBsAg (anti-HBs) indicates recovery and immunity to
hepatitis B.
7. Hepatitis B early antigen (HBeAg) is detected in the blood about 1 week after the
appearance of HBsAg, and its presence determines the infective state of the client.
F. Complication
1. Fulminant hepatitis
2. Chronic liver disease
3. Cirrhosis
4. Primary hepatocellular carcinoma
G. Prevention***
1. Strict hand washing
2. Screening blood donors
3. Testing of all pregnant women
4. Needle precautions
5. Avoiding intimate sexual contact and contact with body fluids if test for HBsAg is
positive.***
6. Hepatitis B vaccine: Adult and pediatric forms; there is also an adult vaccine that
protects against hepatitis A and B.
7. Hepatitis B immune globulin is for individuals exposed to HBV through sexual
contact or through the percutaneous or transmucosal routes who have never had
hepatitis B and have never received hepatitis B vaccine.
XVIII. Hepatitis C
A. Description
1. HCV infection occurs year-round.
2. Infection can occur in any age group.
3. Infection with HCV is common among IV drug users and is the major cause of
posttransfusion hepatitis.
4. Risk factors are similar to those for HBV because hepatitis C is also transmitted
parenterally.
B. Individuals at increased risk
1. Parenteral drug users
2. Clients receiving frequent transfusions
3. Health care personnel
C. Transmission: Same as for HBV, primarily through blood***
D. Incubation period: 5 to 10 weeks*
E. Testing: Anti-HCV is the antibody to HCV and is measured to detect chronic states of
hepatitis C.
F. Complications
1. Chronic liver disease
2. Cirrhosis
3. Primary hepatocellular carcinoma
G. Prevention
1. Strict hand washing
2. Needle precautions
3. Screening of blood donors
XIX. Hepatitis D
A. Description
1. Hepatitis D is common in the Mediterranean and Middle Eastern areas.***
2. Hepatitis D occurs with hepatitis B and causes infection only in the presence of
active HBV infection.
3. Coinfection with the delta agent (HDV) intensifies the acute symptoms of hepatitis B.
4. Transmission and risk of infection are the same as for HBV, via contact with blood
and blood products.***
5. Prevention of HBV infection with vaccine also prevents HDV infection, because
HDV depends on HBV for replication.
B. High-risk individuals
1. Drug users
2. Clients receiving hemodialysis***
3. Clients receiving frequent blood transfusions***
C. Transmission: Same as for HBV
D. Incubation period: 7 to 8 weeks***
E. Testing: Serological HDV determination is made by detection of the hepatitis D
antigen (HDAg) early in the course of the infection and by detection of anti-HDV
antibody in the later disease stages.
F. Complications
1. Chronic liver disease
2. Fulminant hepatitis
G. Prevention: Because hepatitis D must coexist with hepatitis B, the precautions that
help to prevent hepatitis B are also useful in preventing delta hepatitis.***
XX. Hepatitis E
A. Description
1. Hepatitis E is a waterborne virus.***
2. Hepatitis E is prevalent in areas where sewage disposal is inadequate or where
communal bathing in contaminated rivers is practiced.***
3. Risk of infection is the same as for HAV.
4. Infection with HEV presents as a mild disease except in infected women in the third
trimester of pregnancy, who have a high mortality rate.
B. Individuals with increased risk
1. Travelers to countries that have a high incidence of hepatitis E, such as India,
Burma (Myanmar), Afghanistan, Algeria, and Mexico
2. Eating or drinking of food or water contaminated with the virus
C. Transmission: Same as for HAV
D. Incubation period: 2 to 9 weeks***
E. Testing: Specific serological tests for HEV include detection of IgM and IgG
antibodies to hepatitis E (anti-HEV).
F. Complications
1. High mortality rate in pregnant women***
2. Fetal demise
G. Prevention
1. Strict hand washing
2. Treatment of water supplies and sanitation measures***
XXII. Pancreatitis
A. Description
1. Acute or chronic inflammation of the pancreas, with associated escape of pancreatic
enzymes into surrounding tissue
2. Acute pancreatitis occurs suddenly as 1 attack or can be recurrent, with
resolutions.***
3. Chronic pancreatitis is a continual inflammation and destruction of the pancreas, with
scar tissue replacing pancreatic tissue.***
4. Precipitating factors include trauma, the use of alcohol, biliary tract disease, viral or
bacterial disease, hyperlipidemia, hypercalcemia, cholelithiasis, hyperparathyroidism,
ischemic vascular disease, and peptic ulcer disease.
B. Acute pancreatitis
1. Assessment
a. Abdominal pain, including a sudden onset at a mid-epigastric or left upper quadrant
location with radiation to the back***
b. Pain aggravated by a fatty meal, alcohol, or lying in a recumbent position***
c. Abdominal tenderness and guarding***
d. Nausea and vomiting***
e. Weight loss***
f. Absent or decreased bowel sounds***
g. Elevated white blood cell count, and elevated glucose, bilirubin, alkaline phosphatase,
and urinary amylase levels
h . Elevated serum lipase and amylase levels
i. Cullens sign
j. Turners sign
!Cullens sign is the discoloration of the abdomen and periumbilicalarea.
Turners sign is the bluish discoloration of the flanks. Both signs are indicative of
pancreatitis.
2. Interventions
a. Maintain (NPO) status/Withhold food and fluid during the acute period and maintain
hydration with IV fluids as prescribed.***
b. Administer parenteral nutrition for severe nutritional depletion.***
c. Administer supplemental preparations and vitamins and minerals to increase caloric
intake if prescribed.***
d. An NG tube may be inserted if the client is vomiting or has biliary obstruction or
paralytic ileus.***
e. Administer opiates as prescribed for pain.
f. Administer H2-receptor antagonists or proton pump inhibitors as prescribed to
decrease hydrochloric acid production and prevent activation of pancreatic enzymes.
g. Instruct the client in the importance of avoiding alcohol.***
h . Instruct the client in the importance of follow-up visits with the HCP.
i. Instruct the client to notify the HCP if acute abdominal pain, jaundice, clay-colored
stools, or dark-colored urine develops.***
C. Chronic Pancreatitis
1. Assessment***
a. Abdominal pain and tenderness
b. Left upper quadrant mass
c. Steatorrhea and foul-smelling stools that may increase in volume as pancreatic
insufficiency increases
d. Weight loss
e. Muscle wasting
f. Jaundice
g. Signs and symptoms of diabetes mellitus***
2. Interventions***
a. Instruct the client in the prescribed dietary measures (fat and protein intake may be
limited).
b. Instruct the client to avoid heavy meals.
c. Instruct the client about the importance of avoiding alcohol.
d. Provide supplemental preparations and vitamins and minerals to increase caloric
intake.
e. Administer pancreatic enzymes as prescribed to aid in the digestion and absorption of
fat and protein.
f. Administer insulin or oral hypoglycemic medications as prescribed to control diabetes
mellitus, if present.
g. Instruct the client in the use of pancreatic enzyme medications.
h. Instruct the client in the treatment plan for glucose management.
i. Instruct the client to notify the HCP if increased steatorrhea, abdominal distention
or cramping, or skin breakdown develops.
j. Instruct the client in the importance of follow-up visits. Pg 705
B. TEST IV
1. Alterations in Human Functioning
a. Disturbances in Fluids and Electrolytes
b. Inflammatory and Infectious Disturbances
c. Disturbances in Immunologic functioning
d. Disturbances in Cellular functioning
2. Client Biologic Crisis
3. Emergency and Disaster Nursing
C. TEST V
1. Disturbances in Perception and Coordination
a. Neurologic Disorders
b. Sensory Disorders
c. Musculo-skeletal Disorders
d. Degenerative Disorders
2. Maladaptive Patterns of Behavior
a. Anxiety Response and Anxiety Related Disorders
b. Psycho-physiologic Responses, Somatoform, and Sleep Disorders
c. Abuse and Violence
d. Emotional Responses and Mood Disorders
e. Schizophrenia and Other Psychotic and Mood Disorders
f. Social Responses and Personality Disorders
g. Substance related Disorders
h. Eating Disorders
i. Sexual Disorders
j. Emotional Disorders of Infants, Children and Adolescents.