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NCM 107
RLE MODULE RLE UNIT WEEK
1 1 7
MEDICAL – SURGICAL NURSING
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
1. Discuss the disease process of chronic obstructive pulmonary disease and its contributing
factors.
2. Map out the course of the disease based on the given clinical scenario.
3. Formulate a care plan based on identified priority problems of the patient.
4. Explain the nursing responsibilities relative to the drugs prescribed.
Berman, Snyder & Frandsen. (2016). Kozier & Erb’s Fundamentals of Nursing. (10 th ed.).
Pearson
Lewis & Bucher. ((2017). Medical-Surgical Nursing: Assessment and management of Clinical
Problems. (10th ed.). C & E
Linton. (2020). Medical-Surgical Nursing. (7 th ed.). ELSMoore. (2018). Brunner & Suddarth’s
Textbook of Medical-Surgical Nursing.(14th ed.). Wolters Kluwer
Silvestri, L.A. (2018). Saunders Q & A Review for the NCLEX-RN Examination, 7 th ed.
Missouri: Elsevier
https://www.slideshare.net/rsmehta/3-monitoring-amp-devices-used-in-icu-ccu-53533107
https://www.slideshare.net/rsmehta/1-critical-care-53532785
Medical – Surgical Nursing is specialized and skilled branch of nursing. It can be considered
to be the foundation of nursing because it has several interdisciplinary advanced specialization
in several vital area of nursing, such as: Cardiology, Neurology, Oncology etc.
DEFINITION
Medical surgical nursing is a specialized branch of nursing that involve the nursing care of
adult patients, whose disease condition are treated medically, surgically and
pharmacologically. - Sharon L Lewis
Medical- surgical clinical nurses are specialist who are involved in the direct clinical practices
and play a vital role at several stages of treatment of the patient.
They served the responsibility of caring for the patient before, during as well as after the
surgical intervention for the treatment of the disease.
Respiratory Disorders
Respiratory disorder, or respiratory disease, is a term that encompasses a variety of
pathogenic conditions that affect respiration. Respiration makes gas exchange that involves
taking oxygen into the body and expelling carbon dioxide. Respiratory disease occurs in the
respiratory tract, which includes the alveoli, bronchi, bronchioles, pleura, pleural cavity, trachea
and the nerves as well as muscles of breathing.
There are three main types of respiratory disease: airway diseases, lung tissue diseases and
lung circulation diseases. Airway diseases affect the tubes that carry oxygen and other gases
into and out of the lungs. Airway diseases usually result in narrowing or blocking of the
passageways. Lung tissue diseases affect the structure of lung tissue and result in scarring or
inflammation of the lung tissue. This, in turn, makes breathing difficult. Lung circulation
diseases occur when the blood vessels in the lungs become clotted, inflamed or scarred.
These diseases affect the ability of the lungs to receive oxygen and produce carbon dioxide,
and they may affect the functioning of the heart.
Common Manifestations:
o Cough: although cough is a reflex that protects the lungs form the accumulation of
secretions or the inhalation of foreign bodies, it can also be a symptom of a number of
disorders of the pulmonary system or it can be suppressed in other disorders. It results from
the irritation of the mucous membranes anywhere in the respiratory tract. The stimulus that
produces a cough may arise form an infectious process or from an air bone irritant such as
smoke, smog, dust, or a gas. A dry, irritative cough is characteristic of an upper respiratory
tract infection or viral origin. Coughing at night time may herald the onset of left-sided heart
failure or bronchial asthma. A cough in the morning with sputum production may indicate
bronchitis. A persistent cough may affect a patient’s quality of life and may produce
embarrassment, exhaustion, inability to sleep, and pain. Cough suppressants must be used
with caution, because they may relieve the cough but do no address the cause of the cough.
o Sputum production: a patient who coughs long enough almost invariably produces sputum.
Violent coughing causes bronchial spasm, obstruction, and further irritation of the bronchi and
may result in syncope (fainting).
Bacterial infection: a profuse amount of purulent sputum thick and yellow, green, or rust-
colored.
Viral bronchitis: thin, mucoid sputum
Chronic bronchitis: gradual increase of sputum over time
Cancer: pink-tinged mucoid sputum
Pulmonary edema: profuse, frothy, pink material, often welling up into the throat
Infection: foul-smelling sputum and bad breath point to the presence of a lung abscess,
bronchiectasis and infection caused by fusospirochetal or other anaerobic organisms.
Relief measures: if the sputum is too thick for the patient to expectorate, is necessary to
increase water content through adequate hydration and inhalation of aerosolized solutions.
Smoking is contraindicated because it interferes with ciliary action, increases bronchial
secretions causes inflammation. The nurse encourages adequate oral hygiene and wise
selection of food. Also, encourage the patient and family to remove sputum cups, emesis
basins and soiled tissues properly
o Chest pain: chest pain associated with pulmonary conditions may be sharp, stabbing, and
intermittent. Chest pain may occur with pneumonia, pulmonary embolism and pleurisy. The
nurse assesses the quality, intensity, and radiation of pain and identifies and explores
precipitating factors and their relationship to the patient’s position. Analgesic medications may
be effective in relieving chest pain.
o Clubbing of the fingers: is a sing of lung disease that is found in patients with chronic
hypoxic conditions, chronic lung infections, or malignancies of the lung.
o Cyanosis: a bluish coloring of the skin is a very late indication of hypoxia. The presence or
absence of cyanosis is determined by the amount of unoxygenated hemoglobin in the blood. In
the presence of a pulmonary condition, observing the color of the tongue and lips assesses
central cyanosis. Peripheral cyanosis results from decreased blood flow to a certain area of
body, as in vasoconstriction of the nail beds or earlobes from exposure to cold.
RESPIRATORY TREATMENT MODALITIES
Numerous treatment modalities are used when caring for clients with various respiratory
conditions. The choice of treatment modalities is based on the oxygenation disorder and
whether there is a problem with gas ventilation, diffusion or both.
INDICATIONS OF SPIROMETRY
Incentive spirometry is used after surgery, especially Thoracic and abdominal surgery,
to promote the expansion of the alveoli and to prevent or trat atelectasis.
ENDOTRACHEAL INTUBATION
Endotracheal intubation involves passing an endotracheal tube through the mouth or
nose into the trachea.
Endotracheal intubation provides a patent airway when the patient is having respiratory
distress that cannot be treated with simpler methods and is the method of choice in
emergency care.
TRACHEOSTOMY
A tracheostomy is a surgical procedure in which an opening is made into the trachea.
The indwelling tube inserted into the trachea is called a tracheostomy tube.
A tracheostomy either Temporary or permanent.
COMPLICATIONS OF TRACHEOSTOMY
Complications may occur early or late in the course of tracheostomy tube management.
They may even occur after the tube has been removed.
EARLY COMPLICATIONS INCLUDING
Bleeding
Pneumothorax
Air embolism
Aspiration
Subcutaneous or mediastinal emphysema
Recurrent laryngeal nerve damage
MECHANICAL VENTILATION
Mechanical ventilation may be required for a variety of reasons.
To control the patient Respiration during surgery or during treatment of severe head
injury, to oxygenate the blood when the patient ventilatory efforts are inadequate
MECHANICAL VENTILATION
A mechanical ventilator is a Positive or negative pressure breathing device that can
maintain ventilation and oxygen delivery for a prolonged period
INDICATIONS:
Continues decrease in oxygenation (PaO2), an increase in arterial carbon dioxide levels
( PaCO2) and persistent acidosis ( decreased pH) mechanical ventilation may be
necessary. ( Any dramatic alterations in ABGs valves)
Conditions such as Thoracic or abdominal surgery
Drugs over dose
Neuromuscular injury and inhalation injury
COPD , multiple trauma, shock, multisystem failure and coma.
CLASSIFICATION OF VENTILATORS
Negative- pressure ventilators
Positive- pressure ventilators
COMPLICATIONS
Alterations in cardiac function
Barotrauma ( trauma to the trachea or alveoli secondary to Positive pressure)
Ventilator associated pneumonia
Pulmonary infection
Sepsis
POSTURAL DRAINAGE
use of the gravity
NURSING CARE
Position the client
Best time – A.M. upon arising, 1 hr before meals, 2-3 hrs after meals
Stop if cyanosis or exhaustion occurs
Maintain position 5-20 mins after
Provide mouth care after the procedure
Pre procedure
a. Remove all jewelry and other metal objects from the chest area.
b. Assess the client’s ability to inhale and hold breath.
c. Question females regarding pregnancy or the possibility of pregnancy.
Post procedure:
Assist the client to dress.
2. SPUTUM SPECIMEN
Description
a specimen obtained by expectoration or tracheal suctioning to assist in the
identification of organisms or abnormal cells.
Pre procedure
a. Determine specific purpose of collection and check with institutional policy for appropriate
collection of specimen.
b. Obtain an early morning sterile specimen from suctioning or expectoration after a respiratory
treatment, if a treatment is prescribed.
c. Obtain 15 ml of sputum.
d. Instruct the client to rinse the mouth with water before collection.
e. Instruct the client to take several deep breaths and then cough deeply to obtain sputum.
f. Always collect the specimen before client begins antibiotic therapy.
Post procedure
a. Transport specimen to laboratory STAT.
b. Assist the client with mouth care.
4.BRONCHOSCOPY
Description
direct visual examination of the larynx, trachea, and bronchi with a fiberoptic
bronchoscope
Pre procedure
a. Obtain informed consent.
b. Maintain NPO status for client from midnight before the procedure.
c. Obtain vital signs.
d. Assess the result of coagulation studies.
e. Remove dentures or eyeglasses.
f. Prepare suction equipment.
g. Administer medication for sedation as prescribed.
h. Have emergency resuscitation equipment readily available.
Post procedure
a. Monitor vital signs.
b. Maintain client in semi-Fowler position.
c. Assess for the return of the gag reflex.
d. Maintain NPO status until gag reflex returns.
e. Have an emesis basin readily available for client to expectorate sputum.
f. Monitor for bloody sputum.
g. Monitor respiratory status, particularly if sedation was administered
h. Monitor for complications, such as bronchospasm, bronchial perforation indicated by facial
or neck crepitus, dysrhythmias, fever, bacteremia, hemorrhage, hypoxemia, and
pneumothorax.
i. Notify the physician if fever, difficulty in breathing, or other signs of complications occur
following the procedure.
5.PULMONARY ANGIOGRAPHY
Description
a. Pulmonary angiography is an invasive fluoroscopic procedure in which a catheter is inserted
through the antecubital or femoral vein into the pulmonary artery or one of its branches.
b. Pulmonary angiography involves an injection of iodine or radiopaque or contrast material.
Pre procedure
a. Obtain informed consent
b. Assess for allergies to iodine, seafood, or other radiopaque dyes.
c. Maintain NPO status of client for 8 hours before procedure.
d. Monitor vital signs
e. Assess results of coagulation studies
f. Establish and 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 salty taste
following injection of the dye
j. Have emergency resuscitation equipment available
Post procedure
a. Monitor vital signs
b. Avoid taking blood pressures for 24 hours in the extremity used for injection
c. Monitor peripheral neurovascular status of the affected extremity
d. Assess insertion site for bleeding
e. Monitor for delayed reaction to the dye
6.THORACENTESIS (thoracocentesis)
Description
removal of fluid or air from the pleural space via a transthoracic aspiration for diagnostic
or therapeutic purposes.
Pre procedure
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 head supported by a table
at the bedside during the procedure.
f. If the client cannot sit up, the client is placed lying in bed on the unaffected side with the
head of the bed elevated 45 degrees
g. Instruct the client not to cough, breath deeply, or move during the procedure.
Post procedure
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
7.LUNG BIOPSY
Description
a. A percutaneous lung biopsy is performed to obtain tissue for analysis by culture or
cytological examination
b. A needle biopsy is done to identify pulmonary lesions, changes in lung tissue, and the cause
Pre procedure
a. Obtain informed consent
b. Maintain NPO status.
c. Inform the client that a local anesthetic will be used but that sensation of pressure during
needle insertion and aspiration may be felt.
d. Administer analgesics and sedatives as prescribed
Post procedure
a. Monitor vital signs
b. Apply dressing to the biopsy site and monitor for drainage or bleeding
c. Monitor for signs of respiratory distress, and notify physician if they occur
d. Monitor for signs of pneumothorax and air emboli, and notify physician if they occur
e. Prepare the client for chest radiography if prescribed
Pre procedure
a. Obtain informed consent
b. Assess client for allergies to dye, iodine, or seafood
c. Remove jewelry around the chest area
d. Review breathing methods that may be required during testing.
e. Establish an intravenous access
f. Administer sedation if prescribed
g. Have emergency resuscitation equipment available.
Post procedure
a. Monitor client for reaction to nucleotide
b. Instruct client to wash hands carefully with soap and water for 24 hours following the
procedure.
9. SKIN TEST
Description
A skin test is an intradermal injection used to assist in diagnosing various infectious
diseases
Pre procedure:
Determine hypersensitivity or previous reactions to skin tests
Procedure
a. Use test injection test that is free of excessive body hair, dermatitis, and blemishes.
b. Apply the injection at the upper one third of inner surface of the left arm
c. Circle and mark the test site
d. Document the date, time, and test site
Post procedure
a. Advise the client not to scratch the test site so as to prevent infection and abscess formation
b. Instruct the client to avoid washing the test site.
c. Interpret the reaction at the injection site 48 to72 hours after administration of the test
antigen
d. Assess the test site for the amount of induration (hard swelling) in millimeters and for the
presence of erythema and vesiculation (small blisterlike elevations)
Pre procedure
a. Perform Allen’s test before drawing radial artery specimens.
b. Have the client rest for 30 minutes before specimen collection.
c. Avoid suctioning before drawing ABG sample.
d. Do not turn off oxygen unless the ABG sample is ordered to be drawn with client breathing
room air.
Post procedure
a. Place the specimen on ice.
b. Note the client’s temperature on laboratory form.
c. Note the oxygen and type of ventilation that the client is receiving on the laboratory form.
d. Apply pressure to the puncture site for 5 to 10 minutes and longer if the client is taking
anticoagulant therapy or has a bleeding disorder.
e. Transport the specimen to the laboratory within 15 minutes.
11.PULSE OXIMETRY
Description
a. Pulse oximetry is a noninvasive test that registers the oxygen saturation of the client’s
hemoglobin.
b. This arterial oxygen saturation (SaO 2 ) is recorded as a percentage.
c. The normal value is 95% to 100%.
d. After a hypoxic client uses up the readily available oxygen (measured as the arterial oxygen
pressure, PaO 2 , on ABG testing), the reserve oxygen, that oxygen attached to the
hemoglobin (SaO 2 ), is drawn on to provide oxygen to the tissues.
e. A pulse oximeter reading can alert the nurse to hypoxemia before clinical signs occur.
Procedure
a. A sensor is placed on the client’s finger, toe, nose, ear lobe, or forehead to measure oxygen
saturation, which then is displayed on a monitor.
b. Maintain the transducer at heart level.
c. Do not select an extremity with an impediment to blood flow.
d. Results lower than 91% necessitate immediate treatment.
e. If the SaO 2 is less than 85%, the tissues of the body have a difficult time becoming
oxygenated; an SaO 2 of less than 70% is life threatening.
Spirometry is a physiological test that measures how an individual inhales or exhales volumes
of air as a function of time.
Spirometry assesses the integrated mechanical function of the lung, chest wall, and respiratory
muscles by measuring the total volume of air exhaled from a full lung (total lung capacity
[TLC]) to maximal expiration (residual volume [RV]).
The severity of reductions in the FEV1% can be characterized by the following scheme:
•Mild - Greater than 70% of predicted
•Moderate - 60-69% of predicted
•Moderately severe - 50-59%
•Severe - 35-49% of predicted
•Very severe - Less than 35% of predicted
Peak Expiratory Flow Rate (PEFR) Normal Values: Normal values vary based on a
person's age, sex, and height. Peak flow measurements are most useful when a person
compares the number on a given day to his or her "personal best."
Normal Values: Normal values are related to the patient's height as follows: An easy to
remember approximation is: PEFR (L/min) = [Height (cm) - 80] x 5
The "personal best" peak flow rate is the highest peak flow rate you can reach over a
two- to three-week period when you feel good and have no asthma symptoms.
This flow rate serves as a benchmark in the daily self-management plan.
SURGICAL MANAGEMENT
1.Chest Tube Thoracotomy
Chest Tubes/Water seal drainage
Insertion of a catheter into the intrapleural space to maintain constant negative pressure
when air/fluid have accumulated
Chest tube is inserted to underwater drainage to allow for the space of air/fluid and
prevent reflux of air into the chest
For evacuation of air, chest tube is placed in the second or third intercostal space,
anterior or midaxillary line (air rises to upper chest)
For drainage of fluid, chest tube is place in the eight or ninth intercostal space,
midaxillary line.
Chest tube is connected to tubing for the collection system; the distal end of the
collection tubing must be placed below the water level in order to prevent atmospheric
air from entering the pleural space.
Drainage system: water-seal drainage system can be set up using one, two, or three
bottles; or a commercial, disposable device (e.g., Pleur-evac) may be used.
One-Bottle System
Two-bottle system
a. One bottle serves as a drainage collection chamber, the other as a water seal.
b. The first bottle is the drainage collection and has two short tubes in the rubber stopper. One
of these tubes is attached to the drainage tubing coming from the client; the other is attached
to the underwater tube of the second bottle (the water-seal bottle). The air vent of the water-
seal bottle must be left open to the atmospheric air. If suction is used, the first bottle serves as
drainage collection and water-seal chamber, and the second bottle serves as the suction
chamber
Three-Bottle System
a. This system has a drainage collection, a water seal, and a suction-control bottle.
b. The third bottle controls the amount of pressure in the system. The suction control bottle has
three tubes inserted in the stopper, two short and one long. One short tube is joined with the
tubing to former air vent of the water-seal; the second short tube is connected to suction. The
third (long) tube (or suction-control tube) is located between the short tubes and has one end
open to the atmosphere and other below the water level.
MEDICAL MANAGEMENT
1. Antibiotics for bacterial infection and as supportive treatment for viral infections, considered
to for respiratory support measures . like Penicillin, Tetracycline, Microlides (Zethromax)
Azethromycin (Side Effect: Ototoxicity) Broad Spectrum Antibiotic is given for patients with
MRSA like vaconmycin is used.
3. Diuretics is used to decrease the fluids retained on the lungs, example is Furosemide
(Lasix)
4.Corticosteroids used to decrease inflammation of the alveoli. This is the most potent and
effective anti inflammatory medications, example is Budesonide, Mometasone (Nebulized}
6. Antipyretics - Paracetamol
8. Anticholinergic – ipratropium
12. Beta adrenergic agonist - Long acting medications example is Albuterol (Ventolin) to
control asthma symptoms at night
13. Leukotriene modifiers are potent bronchoconstrictors that also dilate blood vessels and
alter permeability, example is Montelukast sodium (Singulair)
CLINICAL SCENARIO:
A. Patient’s Profile
Name: Patient TOS
Birthday: March 25, 1946
Age: 74 years old
Sex: Male
Nationality: Filipino
Religion: Roman Catholic
Marital Status: Married
Address: Obando, Bulacan
Date of Admission: August 20, 2020
Time of Admission: 5:00 PM
One (1) day prior to admission, the patient was unable to speak in full sentences as verbalized
by the wife, he had a productive cough but unknown color of the sputum, (+) audible wheezing
since last night. Five (5) hours prior to admission his wife has noted no change in his alertness,
the patient complaint of mild chest tightness, shortness of breath, cough worsen in the
morning, productive of gray sputum which prompted to seek consultation at Valenzuela
Medical Center and was admitted.
Family History
(+) Hypertension
(+) Diabetes Mellitus
(+) Heart failure
1. Father died of myocardial infarction at age of 59 years (diabetes, hypertension, smoker)
2. Mother alive (atrial fibrillation, heart failure)
3. Healthy siblings
Admission Order
The patient was admitted on August 15, 2020, at 5:00 pm with a chief complaint of shortness
of breath, he was hooked to NM 1L to run for 12 hrs. The patient was subjected to the
following laboratory procedures: CBC, Serum Na, K, Creatinine, ABG. The patient was given
Lisinopril 20 mg BID PO, Metoprolol 50 BID PO, Spironolactone 25 mg OD PO , Furosemide
40 mg OD PO, Salmeterol/ fluticasone 50/500 dry powdered inhaler (PDI) one puff inhaled
twice daily, Albuterol/ ipratropium metered-dose inhaler (MDI) or solution for nebulization every
6 hours as needed, Levalbuterol MDI two puffs every 4 to 6 hours as needed. The chest x-ray
shows hyperinflation and right lower lobe pneumonia. Doxycycline 100mg OD for one week,
Prednisone 35 mg OD for one week was started. The ABG result was Ph 7.24, PO2- 35 mm
Hg, PCO2 60 mmHg , HCO3 30, O2 sat – 70. Spirometry with FEV1 35% predicted that does
not change significantly after inhaled bronchodilators. ECG was ordered.
Bedside care is implemented to the patient that includes proper positioning, bedrest was
encouraged. The vital signs were monitored including the level of consciousness, neurologic
status, and fever. Continue observation for hypotension and difficulty of breathing. Crackles
were also monitored including respiratory distress. Intake and Output monitoring.
The patient was also provided oxygen therapy via nasal cannula. A cardiac monitor and pulse
oximeter was attached to the patient, Nebulization every 6 hours followed by chest
physiotherapy was done and physical examinations were conducted.
Care of clients:
Pharma
Drug 1 - Lisinopril
Drug 2 - Salmeterol
Drug 3 - Albuterol
Drug 4 - Doxycycline
To facilitate the practice of students’ web navigation skills, the following rules must be
implemented:
Berman, Snyder & Frandsen. (2016). Kozier & Erb’s Fundamentals of Nursing. (10 th ed.).
Pearson
Lewis & Bucher. ((2017). Medical-Surgical Nursing: Assessment and management of Clinical
Problems. (10th ed.). C & E
Linton. (2020). Medical-Surgical Nursing. (7 th ed.). ELSMoore. (2018). Brunner & Suddarth’s
Textbook of Medical-Surgical Nursing.(14th ed.). Wolters Kluwer
Silvestri, L.A. (2018). Saunders Q & A Review for the NCLEX-RN Examination, 7 th ed.
Missouri: Elsevier
https://www.slideshare.net/rsmehta/3-monitoring-amp-devices-used-in-icu-ccu-53533107
https://www.slideshare.net/rsmehta/1-critical-care-53532785
https://www.slideshare.net/AnilKumarGowda/nursing-management-of-critically-ill-patient-in-
intensive-care-units