MEDICAL SURGICAL I

PERI – OPERATIVE NURSING

❖ AREAS IN WHICH PERIOPERATIVE
DEFINITION: NURSING IS PRACTICED:
– Refers to the nursing care provided in the total surgical • Hospital operating rooms
experience of the patient. • Interventional radiology suites
• Cardiac cath labs
– The provision of nursing care by an RN Pre-operatively, • Endoscopy suites
Intra-operatively, and Post-operatively to a patient • Ambulatory surgery centers
undergoing an operative or invasive procedure. • Trauma centers
• Pediatric specialty hospitals
• Physician offices
GOALS:
❖ FUNCTIONS OF THE
• PROVIDE SAFE PATIENT CARE
– Knowledge of procedure PERIOPERATIVE NURSE
- Advocate - Change agent
– Ensure the correct patient, correct site, correct level, and - Protector - Manager of patient
correct procedure care
– Knowledge of positioning - Teacher
– Adhere to safe medication administration guidelines ❖ NURSING ROLES IN THE OR
– Perform surgical counts • Circulating Nurse
• Scrub person
• PROVIDE A SAFE ENVIRONMENT • RN first assistant (RNFA)
– Adhere to asepsis • Perioperative educator
– Promote coordinated and effective communication • Specialty team leader
• Perioperative manager
PHASES OF PERIOPERATIVE PERIOD ❖ SURGICAL ATTIRE
o PRE – OPERATIVE PHASE - Gowns - Hair covering
o INTRA – OPERATIVE PHASE - Gloves - Protective eyewear
- Masks
o POST – OPERATIVE PHASE

PRE–OPERATIVE PHASE INTRA–OPERATIVE PHASE POST–OPERATIVE PHASE

– Begins when the decision – Begins when the client is – Begins with the admission of the
to have surgery is made transferred to the operating client to the PACU and ends when
and ends when the client is table and ends when the client healing is complete
transferred to the is admitted to the post-
operating table anesthesia unit
GOAL OF NURSING CARE: GOAL OF NURSING CARE: GOAL OF NURSING CARE:
Prepare the patient mentally To maintain client safety To promote healing and comfort,
and physically restore the highest possible wellness
and prevent associated risk.

TYPES of SURGERY ACCORDING TO PURPOSE

o According to PURPOSE DIAGNOSTIC Establishes a diagnosis
o According to degree of URGENCY e.g Biopsy, Laparoscopy
PALLIATIVE Relieves or reduces pain or
o According to degree of RISK corrects a problem
e.g. Gastrostomy tube insertion
CLASSIFICATION ACCDG TO URGENCY ABLATIVE Removes a diseased body part
CLASSIFICATION INDICATION EXAMPLES e.g appendectomy
FOR SURGERY
CONSTRUCTIVE Restores function or appearance
I. EMERGENT Without delay Trauma, e.g. Face lift
life threatening intestinal TRANSPLANT Replaces malfunctioning
obstruction
II. URGENT 24-30 hrs AP, structures e.g. Kidney transplant
Prompt Attention Cholecystitis ACCORDING TO DEGREE OF RISK
III. REQUIRED, Plan within Cataracts,
Pt need to have weeks or thyroid Major Involves high degree of risk
surgery month disorder Surgery Complicated or prolonged large
IV. ELECTIVE, Failure to Repair for amount of blood loss
Pt should have have Sx is not scars, hernia Minor Involves low risk
Sx catastrophic Surgery Produces few complications
V. OPTIONAL Personal Cosmetic Sx Performed as day surgery
preference

–1–
HEALTH FACTORS THAT ACTIVITIES IN THE POST-OP
AFFECT PREOPERATIVELY SURGICAL RISK • Maintain patient’s airway
• Nutritional status • Extremes of age • Monitor VS
• Drug or alcohol abuse • Malnutrition • Assessing responses to surgery
• Respiratory status • Obesity and anesthesia
• Cardiovascular status • Co-morbid conditions • Performing interventions to
• Hepatic and renal Factors • Concurrent medications promote healing
• Endocrine Function • Prevent complications
• Immune function • Planning for home-care
• Previous medication use • Assist the client to achieve optimal
• Psychosocial factors recovery
• Spiritual and cultural beliefs
•

PRE – OPERATIVE PHASE

ACTIVITIES IN THE PRE-OP CONSENT
✓ Assessing the clients: Nursing history, physical • The surgeon is responsible for obtaining the
and emotional assessment, medication history consent for surgery
✓ Identifying potential or actual health problems • No sedation should be administered before
(comorbidities) SIGNING the consent
✓ Ensure necessary test were done including • The nurse may serve as witness
proper referrals and consultation • Minors may need a parent or legal guardian to
✓ Educate about recovery from anesthesia and sign the consent form.
postoperative care
• Older clients may need a legal guardian to sign
✓ Providing pre-operative teaching the consent form.
✓ Ensure consent is signed
• The nurse needs to document the witnessing of
✓ Start an IV infusion the signing of the consent form, after the client
✓ Address questions of the patient and family acknowledges understanding the procedure.
PRE – OP NUTRITION Consent For Surgery
• Assess order for NPO I hereby authorize Dr. ________________ and the
• Solid foods are withheld for about 8 hours staff of the hospital to perform _____________, and as such
before general anesthesia. additional operation(s) or procedure(s) as are considered
necessary on the basis of their being a threat to life found
during the course of the said operation.
PRE – OP ELIMINATION The nature and purpose of the operation, the risk
- Laxatives, enemas or both may be prescribed involved, and the possibility of complication have been
the night before surgery explained to me, in my dialect or in a language which I
understand. I acknowledge that no guarantee has been made
- Have the client void immediately BEFORE as to the results that may be obtained.
transferring them to the OR _________________ __________________
- Foley catheter may be inserted as ordered Signature of Patient Signature of Witness
_________________
Date and time
PRE – OP HYGIENE
• Bathe the night before surgery with antiseptic (Continuation of the CONSENT form…)
soap This authorization must be signed by the next of kin of the
• Shaving of the skin is usually done in the OR patient in case the patient is a minor or physically or mentally
incompetent.
• Removal of jewelry and nail polish Patient is a minor. _____ years
Patient is unable to sign because________________________.
PRE-OP PSYCHOLOGICAL PREPARATION -----------------------------------------------------------------------------
- Be alert to the client’s anxiety level I, _____________________ being the next of kin of _________
- Answer questions or concerns (Name in Print and Signature) (Name of Patient)
hereby authorize Dr. _____________________ and the staff of
- Allow time for privacy the said hospital to perform the said surgery.
_______________ ________________
• Preparing the skin Signature of Witness Signature of Next of Kin
• Administering Preanesthetic medications _______________ __________________
• Transporting the patient to the presurgical Date and Time Relationship to Patient
area
–2–
 SKIN PREPARATION
- Done after patient has been anesthetized and The SURGICAL PREPARATION SITES FOLLOW,
positioned on the operating table; skin of the depending on the type of surgery to be
operating site and extensive area surrounding it is performed.
mechanically cleansed again with an antiseptic The site extends from above the
agent immediately prior to draping eyebrows, over the top of the
HEAD & NECK head, and includes the ears and
1. Assess the client for sensitivity or allergies to both anterior and posterior areas
scrub solution, skin integrity, level of mobility of the neck. The face and eyebrows
and existing appliances, catheters or other are not shaved.
instrumentation. Clean the external auditory canal
2. Review the chart for the surgery to be with a cotton swab. Anteriorly,
performed and review the exact area to be LATERAL NECK prepare the side of the face, from
prepped. above the ear to the upper thorax
to just below the clavicle.
3. Assess the client’s level of consciousness and Posteriorly, prepare from the neck
mobility. to the supine including the area
4. Explain procedure to client and assess level above the scapula
of understanding. The site extends from the neck to
5. Be sure that hairpins, jewellery, nail polish, CHEST SURGERY the bottom of the rib cage and to
contact lenses, prostheses and dentures were the lateral midline. The shoulder
removed. and arm of the operative side
6. Assist client with the transfer from the should be included.
wheelchair or bed to the surgical table. The preparation site extends from
7. Position the client for optimal access to the ABDOMINAL the axilla to the pubis, extending
SURGERY bilaterally to the lateral midline. All
surgical site according to institutional visible pubic hair should be shaved.
protocol. Shave all pubic hair and the inner
8. Cover with a blanket; used warmed covers, PERINEAL thighs to the mid-thigh. The area
cover the hair if required. SURGERY starts above the pubic bone
9. Assemble the equipment needed. anteriorly and extends beyond the
10. Remove rings and watch and wash hands anus posteriorly
and apply clean gloves. Posteriorly from the top of the ears
CERVICAL SPINE to the waist. The area extends on
11. Arrange for adequate light on the area to SURGERY
be prepared. each side to the mid-axillary line.
12. Using warm water, hold the skin taut and Posteriorly from the axilla down to
LUMBAR SPINE the mid-gluteal level of the
hold the razor at a 45-degree angle. Shave SURGERY buttocks. The area extends on each
the area carefully by stroking in the side to the mid-axillary line.
direction of hair growth. Rinse the razor Shave the buttocks from the iliac
carefully to remove accumulated hair from RECTAL SURGERY crest down to the upper third of the
the blade. thighs, including the anal region.
13. Dry the client’s skin with a sterile towel. The area extends to the midline on
14. Clear the shaving supplies from the each side.
preparation area. Extends anteriorly from the axilla,
15. Apply sterile gloves and gown. FLANK SURGERY down to the upper thigh, including
16. Scrub the surgical site with an antibacterial the external genital area.
Posteriorly the area extends from
cleaner. Using a rotary movement to clean the mid-scapular to the mid-gluteal
the skin, begin in the center and gradually regions.
enlarge the area with each rotation. The area includes the full
17. Continue this process for 3-10 minutes as HAND & circumference of the affected arm,
prescribed by institutional policy, FOREARM from the axilla to the fingertips.
18. Clean any hidden areas in the surgical site SURGERY
(the ear canals, under the fingernails, the The area includes the entire leg,
LOWER toes, and foot of the affected leg
umbilicus) using cotton swabs, EXTREMITY
19. Rinse the area with sterile water. Wait for from the umbilicus anteriorly and
SURGERY the top of the buttocks posteriorly.
the site to dry or pat dry with a sterile
The area to be prepared includes
towel. LOWER LEG the circumference of the entire
20. Cover the area with sterile drapes, leaving SURGERY region from mid-thigh to the distal
the surgical site exposed. toes of the affected leg.
21. Evaluate and document.
–3–
PREPARATION OF THE HEAD FOR CRANIOTOMY SURGICAL PREPARATION OF UPPER EXTREMITIES
AND TRUNK FOR SURGERY

PREPARATION OF THE
NECK FOR OTOLOGICAL
SURGERY

PREPARATION OF THE NECK & THORAX

FOR THYROIDECTOMY

PRE-OP MEDICATIONS PRE-OP SCREENING TEST

PRE-OP EXAMPLE PURPOSE CBC Determine Hgb and Hct, infection
DRUGS BLOOD TYPE Determined in case of blood
Anti- Diazepam -To decrease transfusion
anxiety nervousness SERUM Evaluates the fluid and
- Promote ELECTROLYTES electrolyte status
relaxation FBS Evaluates diabetes mellitus
Anti- Atropine -Decrease BUN, Assess the renal function
cholinergic secretions CREATININE
- Prevent ALT, AST, Evaluates the liver function
bradycardia
Muscle Succinylcholine To promote BILIRUBIN
relaxant muscle relaxation SERUM Evaluates nutritional status
Anti- Promethazine To prevent ALBUMINA
emetic nausea and CXR and ECG Respiratory and Cardiac status
vomiting
Antibiotic Cephalosporin To prevent
infection
Analgesics Meperidine To decrease pain PRE-OP TEACHING
and decrease To stimulate blood circulation in
anesthetic dose LEG EXERCISES the extremities to prevent
Anti- Diphenhydramine To decrease thrombophlebitis
Histamine occurrence of To facilitate lung aeration and
allergy DEEP
H-2 Cimetidine To decrease secretion mobilization to prevent
antagonist gastric fluid and BREATHING & atelectasis and hypostatic
acidity EXERCISES pneumonia
Done every two to four hours
POSITIONING To improve circulation and
& pulmonary function, prevent
AMBULATION venous stasis, prevent adhesion

–4–
 • Assisting o Assisting patient to a semi-Fowler’s position with
patient knees bent.
to semi- o Raising patient’s right foot and keeping it elevated
Fowler’s for a few seconds.
o Extending the lower portion of the leg.
position, o Lowering the entire leg to the bed. This exercise is
leaning repeated five times with each leg.
forward o Patient pointing toes of both feet toward the foot
of the bed, with both legs extended.
• Having patient splint o Patient pulling toes toward chin, as if a string were
a chest or abdominal attached to them
incision by holding a o Having patient make circles with both ankles, first
folded bath blanket one way and then the other.
or pillow against the
incision.

• Telling patient to take a deep breath and hold it

for three seconds.
• Encouraging patient to "hack" out three short
coughs after holding breath.
• With mouth open, patient should take a quick
breath.
• Encouraging
patient to
cough deeply
once or twice
and then take
another deep
breath.

• An incentive spirometer
helps increase lung volume
and promotes inflation of
the alveoli.

• Assisting patient to
semi-Fowler’s
position.

• Setting the volume goal o Instructing patient to raise one knee and reach
indicator on the across to grasp the side rail on the side of the bed
spirometer. toward which he or she will be turning.
o Helping patient to rollover while he or she pushes
• Patient holding the with the bent leg and pulls on the side rail.
device and placing lips o Showing patient how to use a small pillow to splint
around the mouthpiece a chest or abdominal incision while turning.
to create a seal, then o After patient is turned, providing support with
taking a deep breath in. pillows behind the patients back.

The patient can observe progress toward the goal

by watching the balls or diaphragm of spirometer
elevate or lights go on (depending on equipment
used). Have patient PSYCHOSOCIAL PREPARATION
repeat exercise 5 • Be alert to the client’s level of anxiety.
to 10 times every 1 • Answer any questions or concerns the client may
to 2 hours while have regarding surgery.
awake • Allow time for privacy for the client to prepare
for surgery psychologically.
• Provide support and assistance as needed.
–5–
 INTRA – OPERATIVE PHASE
ACTIVITIES DURING THE INTRA-OP INTRA-OPERATIVE PHASE INTERVENTIONS
➢ Provide patient safety, maintain an aseptic • Determine the type of surgery and anesthesia
environment, ensure proper function of the used
equipment, position the client, emotional • Position client appropriately for surgery
support, assisting the surgeon as scrub nurse, • Assist the surgeon as circulating or scrub nurse
circulating nurse, nurse assistant • Maintain the sterility of the surgical field
• Monitor for developing complications
OPERATING ROOM TEAM
Direct Patient Care Team PRINCIPLES of STERILE TECHNIQUE
• The team is likely a symphony orchestra BASIC GUIDELINE IN SURGICAL ASEPSIS
• Each person is an integral entity in harmony with – All materials in contact with the surgical wound
his colleagues and used within the sterile field must be sterile.
1. THE STERILE TEAM – Gowns are considered sterile in front from the
2. THE UNSTERILE TEAM chest to the level of the sterile field.
– Sterile drapes are used to create a sterile field
The Sterile Team – Items should be dispensed to a sterile field by
– Operating surgeon methods that preserve the sterility
– Assistants to the surgeon: Another surgeon (1st – Movement of the surgical team are from sterile
assist), surgical resident doctor (2nd assist), RN to sterile and from unsterile to unsterile area.
assist (3rd assist) – Movement around a sterile field must not cause
– Scrub Nurse contamination of the field
– They: – When a sterile barrier is breached, the area,
• scrub their hands and arms must be considered contaminated
• Don sterile gloves and gown
• Enter the sterile field (all items for the
surgical procedure are sterilized)
The Unsterile Team
– Anesthesiologist or anesthetist
– Circulating nurse
– Technicians
– They:
• Don’t enter the sterile field
• Function outside of it
• Maintain sterile technique

FUNCTIONS of the NURSE DURING

OR PROCEDURE
◦ Assists the surgeon
◦ Maintains sterility
◦ Set up sterile tables, Prepares
SCRUB and Handles instruments,
NURSE sutures
◦ Drapes patient
◦ Counts sponges, needles,
instruments
◦ Wears sterile gown, gloves
◦ Assists the Scrub nurse
◦ Positions the patient for surgery
◦ Positions any equipment
◦ Monitors/coordinates all
CIRCULATING activities
NURSE ◦ Controls the physical and
emotional atmosphere in the
room
◦ Protects the pt’s safety and
health
–6–
OPERATING ROOM ATTIRE LEVELS OF SEDATION
PURPOSE: To provide effective barriers that
prevent the dissemination of microorganisms to the
 MINIMAL SEDATION
patient and to protect personnel from infected – drug induced state in which a patient can
patients respond normally in verbal commands
• Scrub dress/ suit – cognitive function and coordination may be
• Head cover impaired
• Mask
• Sterile gown  MODERATE SEDATION
• Sterile gloves – depressed level of consciousness that does not
• Shoe cover impair ability to maintain a patent airway
• Surgical glasses/ Visor
– calm, sedate a patient combined with analgesic
• The SCRUB NURSE then prepares the sterile – Midazolam/Diazepam
table and all the equipment to be used
 DEEP SEDATION
• The CIRCULATING NURSE assist other members – a drug induced state in which a patient cannot
of the sterile team dress be easily aroused but can respond purposefully
after repeated stimulation
ANESTHESIA – Inhaled or Intravenous
- a state of narcosis, analgesia, relaxation – Volatile Anesthetic (halothane, Isoflurane)
and reflex loss – Gas Anesthetic (Nitrous oxide)
• GENERAL ANESTHESIA
– Loss of all sensation and consciousness;
METHODS OF ANESTHESIA ADMINISTRATION
cardiovascular and ventilator functions are
impaired o Inhalation
o Intravenous
• REGIONAL OR LOCAL ANESTHESIA
o Regional Anesthesia: Epidural & Spinal
– Loss of sensation in ONE area with
consciousness present o Local Conduction Blocks: Local

STAGES OF GENERAL ANESTHESIA Inhaled Anesthetic Agents

STAGE I (BEGINNING ANESTHESIA) • VOLATILE LIQUID AGENTS
◦ Patient feels warm, dizzy with a feeling of - produce anesthesia when the vapors are
detachment inhaled
◦ Patient may have ringing, buzzing in the ear,
still conscious, sense inability to move • INHALED GASEOUS AGENTS
extremities - usually combined with oxygen eg. Nitrous
◦ Noises are exaggerated oxide
◦ Avoid unnecessary noises or motions ⎯ Anesthetic enters the blood through the
STAGE II: EXCITEMENT pulmonary capillaries and act on the cerebral
◦ TIME: loss of consciousness to loss of reflexes centers to produce loss of consciousness and
◦ Characterized by struggling, shouting, talking, sensation
crying.
◦ pupils dilate, rapid pulse and irregular RR TYPES OF ANESTHESIA
◦ restrain the patient
STAGE III: SURGICAL ANESTHESIA 1. GENERAL ANESTHESIA
◦ Surgical anesthesia is reached • Pain is controlled by general insensibility
◦ Patient unconscious and lies quietly • Loss of consciousness, Loss of reflexes
◦ Respirations are regular and CR may be
maintained for hours if properly given • Closely monitor respiratory, CNS, circulatory
depression!
STAGE IV: MEDULLARY DEPRESSION • Level of Anesthesia: light, moderate, deep
◦ stage is reached when too much anesthesia is • 3 methods:
given 1. Inhalation
◦ RR becomes shallow, pulse is weak and thready, 2. IV injection (TIVA- total intravenous
pupils widely dilated and becomes unresponsive anesthesia)
to light, cyanosis 3. Rectal installation (obsolete) indicated in
◦ Without proper treatment death will follow pedia
◦ Discontinue anesthetic abruptly,
cardiopulmonary support is initiated INHALATION:
a. Volatile Liquids
b. Gases
–7–
 INHALATION: INTRAVENOUS ANESTHESIA
VOLATILE LIQUIDS ◦ used to induce or maintain surgical anesthesia &
Examples: hypnosis with use of barbiturates, benzodiazepines,
1. HALOTHANE (Fluothane) hypnotics and opioid agents
- Non flammable ◦ nonexplosive, require little equipment and easy to
- Widely used, rapid induction, low administer
incidence of post-op nausea & vomiting
◦ useful for short procedures
- Causes hypotension and liver damage
◦ DISADVANTAGE: respiratory depressants
2.ENFLURANE Example:
- Rapid induction and recovery 1. Brevital, Surital, Pentothal Na
- Potent analgesic, but causes respiratory - causes rapid & smooth induction of
depression anesthesia.
- Hepatotoxicity is not a problem4
3. ISOFLURANE MISCELLANEOUS GENERAL ANESTHESIA:
- rapid induction and recovery a. DISSOCIATIVE ANESTHESIA
- muscle relaxants are markedly • Ex. KETAMINE (Ketalar)
potentiated • used for short diagnostic procedures in
- profound respiratory depress combination with other anesthetics
• has no analgesic or muscle relaxing properties
GASES b. NEUROLEPTICS
1. NITROUS OXIDE – (laughing gas) = • Ex. INNOVAR (Fentanyl)
induction agent • causes psychological apathy & tranquilization
- used alone for short procedures without inducing sleep or analgesia
- always given in combination with O2 • used for patients undergoing surgery & dx
- may produce hypoxia, weak anesthetic, procedures when cooperation & responsiveness
poor relaxant are necessary

COMMONLY USED IV MEDICATION

MEDICATION USAGE ADVANTAGE DISADVANTAGE
MUSCLE RELAXANT Intubation Rapid onset Myalgias, fasciculation, tissue
SUCCINYLCHOLINE Short cases Short duration trauma, paralysis
(ANECTINE)
ANXIOLYTIC/SEDATIVE Amnesia, Good sedation Prolonged duration, residual effects
DIAZEPAM Hypnotic
BARBITURATES Induction Induction Cause laryngospasm
THIOPENTAL
DISSOCIATIVE ANESTHESIA Induction Patient maintains Large doses may cause
KETAMINE (KETALAR) Short cases airway hallucination, respiratory depression
OPIOID ANALGESIC Perioperative Inexpensive, good Decrease in BP and RR
MORPHINE pain CV stability
OPIOID ANALGESIC Postoperative Good CV stability
FENTANYL (SUBLIMAZE) pain

2. REGIONAL ANESTHESIA Potential adverse effects of

anesthesia
◦ A form of local anesthesia ◦ Myocardial depression, bradycardia
◦ The patient is awake ◦ Nausea and vomiting
Applied directly on the ◦ anaphylaxis
TOPICAL skin ◦ CNS agitation, seizures, respiratory
Injected into a specific arrest
INFILTRATION area of the skin ◦ Over-sedation or under sedation
NERVE BLOCK Injected around nerve ◦ Agitation and disorientation
SPINAL Subarachnoid Low spinal anesthesia ◦ Hypothermia
Epidural space injected ◦ Hypotension
EPIDURAL with anesthesia
◦ Malignant hyperthermia

–8–
Patient Positioning
• Provides optimal visualization
• Provides optimal access for assessing and
maintaining anesthesia and function
• Protects patient from harm

Position Patient during Surgery

ABDOMINAL SURGERIES Supine
BLADDER SURGERY Slightly trendelenburg
PERINEAL SURGERY Lithotomy
BRAIN SURGERY Semi-fowler’s
SPINAL CORD Prone mostly
SURGERIES
LUMBAR PUNCTURE Side lying, flexed body

INCISION LOCATION ORGAN

a. STERNAL SPLIT Begins at the top of the sternum and Heart
extends downward to the sternal notch
b. OBLIQUE SUBCOSTAL Begins in the epigastric area and extends Right side: Gallbladder, Biliary
laterally and obliquely below the lower Left side: Spleen
costal margin
c. UPPER VERTICAL Begins below the sternal notch and Stomach, Duodenum, Pancreas
MIDLINE distally around the umbilicus
d. THORACOABDOMINAL Begins midway between the xiphoid Thorax, Heart
process and the umbilicus and extends
across the seventh or eighth ICS, to the
midscapular line
e. McBurney Begins below the umbilicus, goes through Appendix
McBurney’s point, and extends toward the
night flank
f. LOWER VERTICAL Begins below the umbilicus, downward Bladder, Uterus
MIDLINE toward the symphysis pubis
g. PFANNENSTIEL Begins 1.5 inches above the symphysis Uterus, Fallopian tubes,
pubis Ovaries

–9–
 POST – OPERATIVE PHASE
Post-operative Interventions continuation….
POST OPERATIVE INTERVENTIONS
◦ Deep breathing and coughing exercises Q2-4
◦ Transfer the postoperative patient to the PACU:
hours → to remove secretions
anesthesiologist/anesthetist
◦ Leg exercises Q 2 hours → to promote circulation
◦ NURSING OBJECTIVE:
• Provide care until the patient recovers from ◦ Ambulation ASAP→ prevents respiratory,
the effects of anesthesia, is oriented, has circulatory, urinary and gastrointestinal
stable VS and shows no evidence of complications
hemorrhage or other complications ◦ Hydration after NPO→ to maintain fluid balance
ASSESS YOUR PATIENT ◦ Suction, either gastro or respiratory→ to relieve
◦ Maintain patent airway distention, to remove respiratory secretions
◦ Maintain cardiovascular stability ◦ Diet→ progressive, usually given when bowel
◦ Monitor vital signs and note for early sounds and gag reflex return
manifestations of complications
WOUND CARE
◦ Monitor level of consciousness – Inspect dressing hourly
◦ Maintain on PROPER position – Change dressing daily
◦ NPO until fully awake, with passage of flatus and – Inspect for signs of infection→ redness,
(+) gag reflex swelling, purulent exudate
◦ Monitor the patency of the drainage – Maintain wound drainage
◦ Maintain intake and output monitoring HEMOVAC
◦ Care of the tubes, drains and wound
◦ Ensure safety by side rails up
◦ Pain medication given as ordered
◦ Measures to PREVENT post-op Complications

ACTIVITIES IN THE POST-OP

– Assessing responses to surgery and anesthesia JACKSON-PRATT PENROSE DRAIN
– Performing interventions to promote healing
– Prevent complications
– Planning for home-care
– Assist the client to achieve optimal recovery
PAIN MANAGEMENT
• Pain is usually greatest during the 12-36 hours
after surgery
• Narcotic analgesics and NSAIDS may be T-TUBE SALEM SUMP TUBE
prescribed together for the early period of
surgery
• Provide back rub, massage, diversional
activities, position changes
POSITIONING
– Clients who have spinal anesthesia is usually
placed FLAT on bed for 8-12 hours
– Unconscious client is placed side lying to drain
secretions
– Other positions are utilized BASED on the type
of surgery

SOME EXAMPLES OF POSITION POST-OP

MASTECTOMY Semi-fowler’s, affected AMPUTATION of Flat, with stump elevated
arm elevated Lower Extremities with pillow
THYROIDECTOMY Semi-fowler’s, head SUPRATENTORIAL Fowler’s
midline CRANIOTOMY
HEMORRHOIDECTOMY Semi-prone, Side-lying ANEURYSMAL REPAIR Fowler’s 45 degrees
LARYNGECTOMY Fowler’s CATARACT SURGERY Fowler’s 45 degrees
PNEUMONECTOMY Lateral, affected side INFRANTENTIONAL Flat on bed, supine
LOBECTOMY Lateral, unaffected side SPINA BIFIDA REPAIR Prone

– 10 –
DIET POST – OPERATIVE COMPLICATIONS
• NPO usually immediately after surgery ◦ Determine
• Progressive diet HYPOVOLEMIC Loss of
cause and
• Assess the return of the bowel sounds SHOCK circulatory prevent
fluid volume bleeding
LIQUID DIET vs SOFT DIET
CLEAR LIQUID FULL LIQUID SOFT DIET ◦ O2, IVF
◦ Coffee tea Clear liquid ALL CL and ◦ Encourage
PLUS: FL PLUS: URINARY Involuntary ambulation
◦ Carbonated
◦ Milk/Milk prod ◦ Meat RETENTION accumulation ◦ Provide privacy
drink
◦ Bouillon ◦ Vegetable Vegetables of urine ◦ Pour warm
◦ Clear fruit juices ◦ Fruits water
juice ◦ Cream, butter ◦ Breads and ◦ Catheterize
◦ Popsicle ◦ Yogurt cereals Embolus ◦ Notify
Puddings ◦ Pureed PULMONARY blocking the physician
◦ Gelatin
◦ Custard foods EMBOLISM lung blood ◦ Administer O2
◦ Hard candy
◦ Ice cream and flow
sherbet
CONSTIPA- Infrequent - High fiber diet
TION passage of - Increased fluid
URINARY ELIMINATION stool - Ambulation
• Offer bedpans ◦ Encourage
• Allow patient to stand at the bedside PARALYTIC Absent ambulation
commode if allowed ILEUS bowel sound ◦ NPO until
• Report to surgeon if NO URINE output noted peristalsis
within 8 hours post-op returns
CPT CHEST PHYSIOTHERAPY Occurs - Daily wound
WOUND about 3 dressing
– Chest physiotherapy is based on the fact that
INFECTION days after - Antibiotics
mucus can be knocked or shaken form the walls
surgery - Maintain drain
of the airways and helped to drain from the
lungs. ◦ Cover the
– The usual PVD SEQUENCE is as follows Separation wound with
POSITIONING, Percussion, Vibration, and WOUND of wound sterile normal
removal of secretions by SUCTIONING or DEHISCENCE edges at the saline dressing
Coughing followed lastly by oral hygiene suture line ◦ Place in low-
Fowler’s
◦ Notify MD
Protrusion of - Cover the
WOUND the internal wound with
EVISCERATION organs and saline pad
tissues - Place in low-
fowler’s
through
- Notify MD
wound
INCENTIVE SPIROMETRY
• This operates on the principle that spontaneous
sustained maximal inspiration is most beneficial
to the lungs and has virtually no adverse effects.
• The incentive spirometer measures roughly the
inspired volume and offers the “incentive” of
measuring progress

– 11 –
 MEDICAL SURGICAL I

RESPIRATORY SYSTEM
PRIMARY FUNCTIONS
• Provides O2 for metabolism in the tissues
• Removes CO2, the waste product of
metabolism
SECONDARY FUNCTIONS
• Facilitates sense of smell
• Produces speech
• Maintains acid-base balance

UPPER RESPIRATORY TRACT

NOSE
• Humidifies, warms & filters inspired air
SINUSES
• Air-filled cavities within the hollow bones
that surround the nasal passages
• Provide resonance during speech
PHARYNX
• Located behind the oral & nasal cavities
• Divided into the nasopharynx, oropharynx &
laryngopharynx
• Passageway for both the respiratory & digestive
tracts BRONCHIOLES
• Branch from the secondary bronchi & subdivide
LARYNX into small terminal & respiratory bronchioles
• Located above the trachea & just below the • Contain no cartilage & depend on the elastic
pharynx at the root of the tongue recoil of the lung for patency
• Commonly called the “VOICE BOX” • Terminal bronchioles contain no cilia & don’t
• Contains 2 pairs of vocal cords, the false & true participate in gas exchange
cords
• The opening between the true vocal cords is the ALVEOLAR DUCTS & ALVEOLI
GLOTTIS • used to indicate all structures distal to the
GLOTTIS - Valsalva Maneuver terminal bronchiole
EPIGLOTTIS • Alveolar ducts branch from the respiratory
• Leaf-shaped elastic structure that is attached bronchioles
along one end to the top of the larynx • Alveolar sacs which arise from the ducts contain
• Prevents the food from entering the trachea- clusters of alveoli which are basic units of gas
bronchial tree by closing over the glottis during exchange
swallowing. • Cells in the walls of the alveoli secrete surfactant
− phospholipid CHON the reduces the surface
tension in the alveoli
LOWER REZPIRATORY TRACT − without surfactant the alveoli would collapse
TRACHEA
• Located in front of the esophagus
• Branches into the right & left main stem bronchi at
the carina
MAINSTREAM BRONCHI
• RIGHT BRONCHUS is slightly wider, shorter, &
more vertical than the left bronchus
• Mainstream bronchi divide into 5 secondary or
lobar bronchi that enter each of the 5 lobes of
the lung
• The bronchi are lined with cilia which propel
mucus up & away from the lower airway to the
trachea where it can be expectorated or
swallowed
– 12 –
LUNGS – Dullness over the lung field is indicative of the
• Located in the pleural cavity in the thorax following conditions: Pneumonia (consolidation),
• Extend from just above the clavicles to the hemothorax, and lung tumor
diaphragm – the diaphragm is the major muscle
of respiration AUSCULTATION
• RIGHT LUNG - is larger than the left; divided – The client should breathe through his open mouth
into 3 lobes: the upper, middle & lower lobes slowly
• LEFT LUNG - somewhat narrower than the right – If abnormal sound is heard, have the client cough
lung to accommodate the heart; divided into 2 and listen again
lobes – Location, change in breath sound after coughing,
• Innervation of the respiratory structures is and heard on inspiration or expiration should be
accomplished by the PHRENIC NERVE, VAGUS noted
NERVE & THORACIC NERVES
• PARIETAL PLEURA - lines the inside of the NORMAL BREATH SOUNDS
thoracic cavity including the upper surface of the
diaphragm • heard over trachea and
BRONCHIAL bronchi.
• VISCERAL PLEURA - covers the pulmonary
SOUND -result of air passing the large
surfaces
• A thin fluid layer produced by the cells lining the passage.
pleura, lubricates the visceral & parietal pleura -loud, harsh, high pitch
• CHEST WALL - includes the rib cage, intercostal VESICULAR • heard over the entire lung field
muscles and diaphragm SOUND except the large airways
- result of air moving in and out
ACCESSORY MUSCLES OF of the alveoli
RESPIRATION - heard longer in the inspiratory
SCALENE MUSCLES phase, quiet, low pitch
• Elevate the first 2 ribs BROCHIO- • heard near the main stem
STERNOCLEIDOMASTOID MUSCLES VASCULAR bronchus
• Raises the sternum SOUND - result of air moving through
smaller airways
TRAPEZIUS & PECTORALIS MUSCLES
- moderately pitch
• Fix the shoulders
CHEST WALL DEFORMITIES
• KYPHOSIS – curvature of the spine – ABNORMAL/ADVENTITIOUS
anterior-posterior
• SCOLIOSIS - curvature of the spine-lateral BREATH SOUNDS
• BARREL-CHEST - chest wall increased 1. RALES – cracking sound, indicates vibration of
anterior-posterior, normal in children, fluid in the lungs.
typical of hyperinflation seen in COPD → result of air passing through the
fluid in small airways of alveoli
SIGNS OF RESPIRATORY DISTRESS 2. WHEEZES – amount of air passing through
• Cyanosis – persons turns’ blue narrowed small airways
• Pursed-lip breathing → high pitch, musical
• Accessory muscles used → heard during expiration and
• Intercostal in drawing inspiration
3. STRIDOR – a high pitch with loud and harsh
PALPATION sound.
– Subcutaneous structures and muscles for → Heard in patient with laryngitis,
texture, temperature and degree of croup, partially obstructed airways
development, the presence or absence of 4. RONCHI – air passing through narrow large
masses edema or tenderness should be noted airways
– Tracheal position, respiratory excursion → low pitch, snore, associated with
(symmetrical movement of chest and for wheezes
fremitus (Ninety-nine) 5. SIGH - deep inspiration followed by a
prolonged expiration occasionally
PERCUSSION fluctuating the regular breathing
– Lung fields should find: RESONANCE over pattern
the normal lung Emphysematous lungs have 6. PLEURAL – result of roughened pleural surfaces
loud low, booming sound (hyperresonance) FRICTION rubbing across each other.
RUB → sounds are described to be
crackling, GRATING
– 13 –
 PULMONARY FUNCTION NURSING CARE:
TEST/STUDIES a. carefully explaining procedure will help allay
• Evaluation of lung volume and capacities by anxiety and ensure cooperation
spirometry b. perform test before meals
• Involves the use of spirometer to diagram c. withhold medication that may alter respiratory
movement of air as client performs various function unless otherwise ordered
respiratory maneuvers. Shows restrictions or d. after procedure assess pulse and provide for
rest periods
obstruction to air flows or both.

DIAGNOSTIC TESTS
PULMONARY VOLUME
◦ Pulmonary Function Test 3. EXPIRATORY RESERVE VOLUME (ERV)
◦ Arterial Blood Gases – amount of air that can forcefully exhaled
◦ Sputum Culture and Sensitivity after a normal tidal volume inhalation
◦ Skin Test ➢ N= 1200 ml
◦ Pulse Oximeter 4. RESIDUAL VOLUME – amount of air remaining
◦ Chest X-Ray/Radiography in the lungs after a forced exhalation
◦ Bronchoscopy ➢ N= 1200 ml
◦ Pulmonary Angiography
◦ Thoracentesis II. PULMONARY CAPACITIES:
◦ Lung Biopsy 1. TOTAL LUNG CAPACITY – maximum amount of
air combined in lungs after a maximum
PULMONARY FUNCTION TEST inspiratory efforts
(PFTs) ➢ TLC= TV+IRV+ERV+RV
– include a number of different tests used to ➢ N=6000 ml
evaluate lung mechanics, gas exchange, & 2. VITAL CAPACITY – maximum amount of air that
acid-base disturbance thru spirometric can be expired after a maximum inspiratory
measurements, lung volumes, and arterial effort.
blood gases ➢ VC= TV+IRV+ERV
PRE-PROCEDURE NURSING CARE ➢ N= 4800 ml
• Determine if an analgesic that may depress the 3. INSPIRATORY CAPACITY – maximum amount
respiratory function is of air that can be inspired after a normal
• being administered expiration
• Consult with MD regarding holding ➢ IC= TV+IRV
bronchodilators prior to testing ➢ N=3600 ml
• Instruct the client to void prior to procedure and 4. FUNCTIONAL RESIDUAL CAPACITY – volume
to wear loose clothing of air remaining in the lungs after a normal tidal
• Remove dentures volume expiration
• Instruct the client to refrain from smoking or
eating a heavy meal for 4-6 hours prior to the ➢ FRC=ERV+RV
test ➢ N=2400 ml
5. DEAD SPACE – the air that fills the respiratory
POST-PROCEDURE NURSING CARE passages with each breath
• Resume normal diet and any bronchodilators & ➢ N=150 ml
respiratory treatments that were held prior to
the procedure
ARTERIAL BLOOD GASES (ABGs)
I. PULMONARY VOLUMES – measure the dissolved O2 & CO2 in the arterial
• Volume to which the lungs expand during blood and renal acid-base state & how well the
ventilation, depends on whether breathing is O2 is being carried to the body
normal – the ventilation scan determines the patency of
1. TIDAL VOLUME (TV) the pulmonary airways and detects
– amount of air in and out of the lungs with each abnormalities in ventilation
Normal breath. PRE-PROCEDURE NURSING CARE
➢ Normal volume of air with each inspiration
➢ N = 7-8ml/kg body weight • Have the client rest for 30 mins prior to specimen
➢ N = 500 ml collection
2. INSPIRATORY RESERVE VOLUME (IRV) • Avoid suctioning prior to drawing ABGs
– amount of air that can be forcefully inhaled • Don’t turn off O2 unless the ABGs are ordered
after a normal tidal volume inhalation to be drawn at room air
➢ N= 3100 ml
– 14 –
 ARTERIAL BLOOD GAS SUCTIONING PROCEDURE IN OBTAINING
POST-PROCEDURE NURSING CARE
SPUTUM SPECIMEN
• Place the specimen on ice ◦ Aseptic technique
• Note the client’s temperature on the laboratory ◦ Hyperoxygenate
form ◦ Lubricate the catheter with sterile water
• Note the O2 & type of ventilation that the client ◦ Tracheal suctioning: 4 inches
is receiving on the laboratory form ◦ Nasotracheal suctioning: insert to induce cough
• Apply pressure on the puncture site for 5-10 reflex
mins & longer if the client is on anticoagulant ◦ Don’t apply suction while inserting
therapy or has bleeding disorder ◦ Suction intermittently for 10-15 seconds
◦ Rotate and withdraw
• Transport the specimen to the laboratory within ◦ Hyperoxygenate & deep breaths
15 mins
POST-PROCEDURE NURSING CARE
SITE: Radial Artery • Transport specimen to lab stat
Ph - ⇓ acidosis ⇑ alkalosis • Mouth care
PCO2 - ⇓ alkalosis ⇑ acidosis
HCO3 - ⇓ acidosis ⇑ alkalosis SKIN TEST
PRE-PROCEDURE NURSING CARE
1. Assess ph, PCO2 & HCO3 ◦ Determine hypersensitivity or previous reactions to
2. Identify imbalance. If ph is normal use 7.4 skin tests
⇓ 7.4 – acidosis PROCEDURE:
⇑ 7.4 – alkalosis • Should be of excessive body hair & dermatitis
3. Identify if compensated or uncompensated • Upper 1/3 of inner surface
• uncompensated - if one component is • Circle, document the date, time and test site
normal & the other is abnormal
POST-PROCEDURE NURSING CARE
• compensated – if both PCO2 & HCO3
◦ Do not to scratch
are abnormal in opposite directions ◦ Do not wash
4. If compensated, identify if partially or fully ◦ Assess for induration (hard swelling), erythema
• partially – if ph is abnormal and vesiculation (small blister-like elevations)
• fully - if ph is normal
TUBERCULIN SKIN TEST
INTRADERMAL TEST:
SPUTUM CULTURE AND SENSITIVITY • Done to detect tuberculosis infection
1. CULTURE • PPD - tuberculin administered to determine any
– isolation and identification of specific previous sensitization to tubercle bacillus
microorganism from a specimen • Mantoux test -48-72 hours,
2. SENSITIVITY • 10 mm induration
– determination of antibiotic agent effective
against organism
SPUTUM EXAM:
1. AFB staining
2. Cytologic exam

DIAGNOSTIC TESTS PULSE OXIMETRY

SPUTUM SPECIMEN – a non-invasive test that registers arterial O2
– obtained by expectoration or tracheal suctioning saturation (SaO2)
– identify organisms or abnormal cells – NORMAL VALUE: 95%-100%
– alert hypoxemia before clinical signs occurs
PRE-PROCEDURE NURSING CARE PROCEDURE:
• Determine specific purpose • A sensor is placed: finger, toe, nose, earlobe or
• Early morning sterile specimen forehead
• 5 ml of sputum • Don’t select an extremity with an impediment to
• Rinse the mouth with water prior to collection blood flow
• Take several deep breaths and then cough ◦ Results lower than ⇓91% - Immediate Treatment
forcefully ◦ If the SaO2 is ⇓85% - Hypo-Oxegenation
• Collect the specimen before antibiotics ◦ If the SaO2 is ⇓70% - Life-Threatening Situation

– 15 –
 CHEST X-RAY /RADIOGRAPH PULMONARY ANGIOGRAPHY
CXR – insertion of a flouroscopy via the antecubital or
femoral vein into the pulmonary artery
– information on the anatomic location & – it involves iodine or radiopaque or contrast
appearance material
PRE-PROCEDURE NURSING CARE PRE-PROCEDURE NURSING CARE
• Remove all jewelry & other metal objects • Informed consent
• Assess ability to inhale & hold the breath • Assess for allergies to iodine, seafood & dyes
• Question regarding pregnancy of possibility of • NPO prior to procedure
pregnancy • V/S
• Assess coagulation studies
• Establish an IV
• Administer sedation
• Client must lie still during the procedure
PRE-PROCEDURE NURSING CARE
• Urge to cough, flushing, nausea, or a salty taste
• Emergency equipment available
BRONCHOSCOPY POST-PROCEDURE NURSING CARE
– visual examination of the larynx, trachea & • V/S
bronchi with a fiber-optic bronchoscope • No BP for 24 hrs in the affected extremity
PRE-PROCEDURE NURSING CARE • Monitor peripheral neurovascular status
• Informed consent • Assess for bleeding
• NPO prior • Monitor dye reaction
• Assess coagulation studies
• Remove dentures or eyeglasses
• Prepare suction
• Sedatives as Rx
• Have resuscitation equipment available
POST-PROCEDURE NURSING CARE
• V/S
• ⇑Fowler’s position
• Assess gag reflex THORACENTESIS
• NPO until gag reflex returns PRE-PROCEDURE NURSING CARE
• Monitor for bloody sputum • Informed consent
• Monitor respiratory status • V/S
• Monitor for complications: bronchospasm, • CXR or U/S prior to the procedure
bronchial perforation, crepitus, dysrhythmia, • Assess coagulation studies
fever, hemorrhage, hypoxemia, and • Upright
pneumothorax • Do not to cough, breathe deeply, or move during
• Notify the MD if complications occur the procedure
POST-PROCEDURE NURSING CARE
• V/S
• Monitor respiratory status
• Pressure dressing
• Assess site for bleeding and crepitus
• Monitor for signs of PNEUMOTHORAX, AIR
EMBOLISM & PULMONARY EDEMA

– 16 –
 • Memory problems and slowed thinking
LUNG BIOPSY
– a percutaneous lung biopsy - culture or cytologic examination
– a needle biopsy - pulmonary lesions, changes POST-PROCEDURE NURSING CARE
in lung tissue and the cause of pleural effusion
• V/S
PRE-PROCEDURE NURSING CARE • Pressure dressing
• Informed consent • Monitor for bleeding
• NPO prior • Monitor for respiratory distress
• Local anesthetic • Monitor for complications:
• Pressure during insertion and aspiration pneumothorax and air emboli
• Administer analgesics & sedatives as Rx • Prepare for CXR

UPPER RESPIRATORY
RHINITIS – inflammation and swelling of the mucous membrane of the
nose, characterized by a runny nose and stuffiness

ALLERGIC RHINITIS
– An allergic inflammation of the nasal airways
– Symptoms of allergic rhinitis may develop within
minutes after you breathe in an allergen
WHAT HAPPENS DURING AN ALLERGIC
REACTION?
• During an allergic reaction
antibodies cause histamines to
be released from certain cells.
TREATMENTS FOR ALLERGIES
1. Avoidance of material –
especially food.
2. Epinephrine – “epi – pen”
3. Antihistamines -- benadryl
Histamines cause:
a. Swelling of tissues
b. Release of fluids (runny noses and eyes) EXAMS AND TESTS:
c. muscle spasms (some cases) a. Immunoglobulin E (IgE) - measure levels of specific
allergy subs
Anaphylaxis or anaphylactic shock: b. Skin test (dilute solutions of various allergens)
– This is the sudden and severe allergic reaction to
a substance that can cause death. TREATMENT:
✓ Corticosteroids and nasal spray - congestion
EARLIER SYMPTOMS ✓ Antihistamines otc
• Itchy nose, mouth, eyes, throat, skin or any area ✓ Cromolyn sodium - aerosl nasalcrom
• Problems with smell ✓ Mucus membrane less sensitive to allergens
• Runny nose ✓ Decongestants pseudoepedrine
• Sneezing ✓ immunotherapy
• Tearing eyes
LATER SYMPTOMS
• Stuffy nose (nasal congestion)
• Coughing
• Clogged ears and decreased sense of smell
• Sore throat
• Dark circles under the eyes
• Puffiness under the eyes
• Fatigue and irritability
• Headache
– 17 –
 NON-ALLERGIC RHINITIS ACUTE NASOPHARYNGITIS
(CORYZA)
– commonly known as a runny nose, is the
medical term describing irritation and – Most frequent infectious disease in children &
inflammation of some internal areas of the adults
nose. – Average of 10-12 colds per year (adults - 4-6x)
– Caused by rhinovirus – Incubation period - 2-3 days
– Swelling-dilatation of b.vessels-mucus glands- – The COMMON COLDS
gets stimulated-congestion ETIOLOGIC AGENT:
PRECIPITATING FACTORS: o Rhinovirus-most common cause
o Parainfluenza virus
1. Environmental or Occupational irritants o Respiratory syncitial virus
2. Weather changes o Adenovirus
3. Infections o Influenza virus
4. Foods and beverages o Coxsackie virus
6. Certain medications
7. Hormone changes
SIGNS AND SYMPTOMS:
• Nasal congestion
8. Stress • Watery rhinitis
SIGNS AND SYMPTOMS: • Low grade fever
• Stuffy nose • Mucus membrane is edematous
• Runny nose • Cervical lymph node may be swollen and
• Mucus in the throat palpable
• Body malaise
• Fever
TREATMENT:
TEST AND DIAGNOSIS: ✓ Common colds are self-limiting
NASAL ENDOSCOPY ✓ Supportive care
– a test which involves looking at the inside of ✓ Relief of nasal obstruction - use of isotonic saline
your nasal passages drops and aspiration
TREATMENT & DRUGS: ✓ Antipyretic or analgesic agents
1. Oral decongestant ✓ Antitussive is used SPARINGLY
− pseudoephedrine-containing drugs
− Phenylephrine
2. Saline nasal sprays
SINUSITIS
3. Antihistamine nasal sprays – the sinuses are cavities, or air-filled pockets,
− Azelastine (Astelin, Optivar) near the nasal passage
4. Corticosteroid nasal sprays – refers to inflammation of the sinus cavities,
− Fluticasone (Flonase) which are moist, hollow spaces in the bones of
− Mometasone (Nasonex) the skull
5. Decongestant nasal sprays – most commonly caused by a viral or bacterial
− oxymetazoline (Afrin) infection or by an allergy
TIPS TO RELIEVE VIRAL RHINITIS FUNCTIONS:
✓ Rinse your nasal passages (squeeze 1. Reduce the weight of the facial bones and skull
bottle bulb syringe) while maintaining bone strength and shape.
✓ Blow your nose 2. Producing mucus for the nasal cavity
✓ Humidify 3. Adds timbre and resonance to the voice.
✓ Stay hydrated TYPES
Located inside the face, around
PREVENTION: ETHMOID the area of the bridge of the
a. Avoid your triggers SINUS nose.
b. Don’t overuse nasal decongestants MAXILLARY Located inside the face, around
SINUS the area of the cheeks.
c. Get treatment that works
Located inside the face, in the
NURSING MANAGEMENT: area of the forehead.
• Instruct patient to avoid pollutants or factors FRONTAL
This sinus does not develop until
causing allergies. SINUS around 7 years of age
• In case DOB, maintain patient on high back rest SPHENOID located deep in the face,
• Increase fluid intake SINUS behind the nose. This sinus
does not develop until
• nasal spray may be use for 3-4 days adolescence
– 18 –
 SINUSISTIS SYMPTOMS:
• Fever
• Nasal obstruction
• Raspy voice
• Pus-like nasal discharge
• Loss of sense of smell
• Facial pain or headache
CHRONIC:
• A dull ache or pressure across the midface,
especially between or deep into the eyes
• A headache that occurs daily for weeks at a
time
• Nasal congestion
• Postnasal drip
DIAGNOSTIC TEST:
o Physical examination
o Nasal and sinus cultures
o Nasal endoscopy
o CT scan of the sinuses
TREATMENT AND DRUGS
GOAL
✓ Reduce sinus inflammation
ETIOLOGY ✓ Keep your nasal passages draining
o 70% of bacterial sinusitis is caused by: ✓ Eliminate the underlying cause
✓ Streptococcus pneumoniae
✓ Haemophilus influenzae ✓ Reduce the number of sinusitis
✓ Moraxella catarrhalis MANAGEMENT
o Other causative organisms are:
✓ Staphylococcus aureus a. Promote drainage
✓ Streptococcus pyogenes b. Thin the mucus
✓ Gram-negative bacilli c. Relieve pain
✓ Respiratory viruses d. Nasal saline irrigation
CAUSES: TO REDUCE CONGESTION:
• Infection • Apply a warm, moist washcloth to your face
• Allergies several times a day
• Immunological/structural problems • Drink plenty of fluids to thin the mucus
TYPES: • Inhale stem 2-4 times per day
– Sinusitis is defined as acute if it is • Spray with nasal saline several times per day
ACUTE • Use a humidifier
totally resolved in less than 30
SINISITIS
days.
PREVENTION
– Results from undetermined sources
a. Avoid allergens
CHRONIC in many cases.
b. Eat plenty of fruits and vegetables which are
SINUSITIS – Sinusitis is defined as chronic if it
rich in oxidants
has been ongoing for more than
c. Avoid contracting upper respiratory tract
8 to 12 weeks.
infections
PATHOPHYSIOLOGY d. Sleep with the head of the bed elevated
e. Use decongestants with precaution

– 19 –
 EPISTAXIS
– A nosebleed is loss of blood from the tissue
lining the nose.
– Bleeding most commonly occurs in one nostril
only
o ANTERIOR
− Bleed fairly slowly
− Self-limiting and resolve quickly
o POSTERIOR
− More severe
− Often cause blood to drain into the throat,
causing nausea and vomiting
SIGNS AND SYMPTOMS: OTHER MEASURES:
• Supplemental vitamin K
• Bright red blood or bright dark red
• Blood transfusion
DIAGNOSTIC TEST
o Complete blood count ❖ TO CONTROL EPISTAXIS:
o Nasal endoscopy (examination of the nose using 1. Have the patient sit upright with his head tilted
a camera) 2. Compress the soft portion of the nostrils
o Partial thromboplastin time measurements against the septum
o Prothrombin (PT) 3. Apply an ice collar or cold, wet compress to
the nose
PREVENTION AND TREATMENT 4. Administer oxygen as needed
✓ Avoid picking the nose. 5. Monitor v/s and skin color
✓ Humidifying the air during the winter. 6. Tell the patient to breathe through his mouth
✓ Bleeding usually can be controlled at home by
pinching the sides of the nose together for 10
minutes. ❖ TO PREVENT RECURRENCE OF EPISTAXIS:
1. Instruct patient not to pick his nose or insert
✓ Avoid nose blowing during and after episodes
foreign bodies into it
✓ Sit upright and lean forward
2. Suggest a humidifier
✓ If the pinch technique does not stop the
3. Caution the patient against inserting cotton or
bleeding:
tissues into the nose
− Nasal packing with a piece of cotton 4. Instruct the patient to sneeze with his mouth
saturated w/ a drug such as open
(phenylephrine).
ASSESSMENT AND MANAGEMENT:
a. Place a non-trauma patient in a sitting position, NASAL FRACTURE
and pinch nostrils together.
b. Direct the patient not to sniff or blow his or her – a break in the bone over the bridge of
nose. the nose
c. If the pinch technique does not stop the bleeding:
– Nasal packing with a piece of cotton COMMON CAUSE:
saturated w/ a drug such as o Blunt injury as a result of fight or sports injury
(phenylephrine). o Facial trauma from falls and accidents
d. Seek medical care immediately if: o Traction and torsion injuries
– The bleeding lasts for more than 20 minutes SIGN AND SYMPTOMS:
– The nosebleed follows an accident • Bruising
e. For more severe or recurring bleeding: • septal hematoma
– Electrocautery (cauterization using an • Swelling
electrical current to produce heat) • Tenderness
– Another treatment is to place a long • Pain
absorbent sponge in the nostril. • Deformity e.g Septal deviation
– The sponge swells in contact with moisture • Epistaxis
and compresses the bleeding site. The
sponge is removed after 2 to 4 days
f. Provide continuous assessment.
– 20 –
 NASAL FRACTURE
DIAGNOSIS NASAL POLYPS
o History and physical examination
- Crepitus, Indentation, or Irregularity of the – Nasal polyps are soft, noncancerous growths
nasal bone and epistaxis on the lining of your nose or sinuses.
- Edema and Ecchymosis – They often occur in groups, like grapes on a
- Knowledge of the shape and appearance of stem.
the patient's nose before the injury will aid in
comprehending the severity of the nasal injury RISK FACTORS
o X-rays or CT scans • Asthma
• Cystic fibrosis,
TREATMENT: • Family history
✓ Stop bleeding as an initial mngt.
✓ Minor nasal fractures are allowed to heal on SYMPTOMS:
their own • A runny nose
✓ Close reduction • Persistent stuffiness
✓ ORIF • Postnasal drip
O PREVENTIONS: • Decreased or no sense of smell
− Avoid injuries • Loss of sense of taste
− Wear helmets • Facial pain or headache
• Snoring
• Itching around your eyes
❖ FIRST AID
• Reassure the patient and try to keep the TEST AND DIAGNOSIS:
patient calm. o Nasal endoscopy
• Have the patient breathe through the o Allergy tests
mouth and lean forward in a sitting o Computerized tomography (CT) scan
position in order to keep blood from going GOAL OF TREATMENT:
down the back of the throat. ✓ Decrease the size of polyps
• Apply cold compresses to the nose to ✓ Eliminate polyps and to treat disorders,
reduce swelling. If possible, the patient
should hold the compress so that there isn't MEDICATIONS
too much pressure on • Nasal corticosteroids.
• the nose. • Other corticosteroids.
• To help relieve pain, acetaminophen • Other medications
(Tylenol) is recommended • Polypectomy
• Endoscopic sinus surgery
❖ DON’TS
• Do NOT try to straighten a broken nose. PREVENTION
• Do NOT move the person if there is a. Manage allergies and asthma.
reason to suspect a head or neck injury. b. Avoid irritants.
c. Practice good hygiene
d. Humidify your home
e. Use a nasal rinse, or nasal lavage

– 21 –
 DISORDER OF THE THROAT
TONSILITIS
– TONSILLITIS is when the tonsils — fleshy pads
on each side of the back of the throat —
become infected with a virus or bacteria
– Swelling and inflammation of the tonsils
– Usually caused by viral infections
- Can also be
caused by
bacteria
ETIOLOGIC FACTORS
• Epstein-Barr virus
• bacterial infection
RISK FACTORS
• Being a child
• Contact with others ❖ TONSILLECTOMY IS DONE IF:
1. Seven or more serious throat infections in one
SIGNS AND SYMPTOMS year
• Difficulty of swallowing (dysphagia) 2. Five or more serious throat infections every
• Painful swallowing (odynophagia) year over a two-year period
• Fever 3. Three or more serious throat infections every
• Lethargy year over a three-year period
• Mouth breathing 4. to treat an abscess that doesn't improve with
• Difficulty hearing (eustachian tube) antibiotic treatment, or if
5. swollen tonsils are blocking breathing
• Halitosis
6. Done in OPD basis
• Sleep apnea
POST –OP CARE:
❖ WHEN TO SEEK MEDICAL ADVICE • Observe for, & report unusual bleeding (frequent
1. Your sore throat lasts more than 48 hours swallowing)
2. You have a fever above 103 F (39 C) • Help prevent bleeding by discouraging the client
3. You can't swallow because your tonsils are so from coughing & clearing the throat.
swollen or painful • Position the client on the side to facilitate
4. Your sore throat is accompanied by abdominal drainage from the throat
pain, especially if you're vomiting • Provide appropriate teaching.
5. You have a stiff neck or feel weak
6. Seek emergency care if you or your child is: PREVENTION:
7. Drooling ✓ Frequent handwashing
8. Unable to swallow because of pain or swelling ✓ Common-sense precautions
− Cough/sneeze in the tissue
TEST AND DIAGNOSIS
− Don’t share drinking glass/eating utensils
o Throat and Swab
o Complete Blood Cell Count − Avoid close contact with anyone who is sick
MANAGEMENT:
TREATMENT a. Drink more fluids
✓ ANTIPYRETIC b. Gargle with warm salt water
✓ ANALGESICS c. Use honey and lemon
✓ ANTIBIOTICS (10 days course – usually d. Suck on a throat lozenge or hard candy
Penicillin but may be Erythromycin if allergic to e. Humidify the air
penicillin) is prescribed for bacterial infections f. Avoid smoke and other air pollutants
to prevent the complication of rheumatic fever. g. Rest your voice
✓ SURGICAL – tonsillectomy with adenoidectomy
COMPLICATIONS:
TREATMENT AND DRUGS • Airway Obstruction
• Virus → Self care • Abscess
• Bacteria → Antibiotics • Heart Problems
• Nephritis

– 22 –
 EPIGLOTTITIS LARYNGITIS
– is a life-threatening condition that occurs – inflammation of your voice box (larynx) due
when the epiglottis swells, blocking the flow to overuse, irritation or infection.
of air into your lungs. ACUTE LARYNGITIS
• Viral infections such as those that cause a cold
CAUSES: • Vocal strain, caused by yelling or overusing your
◦ Infection voice
◦ Haemophilus Influenza type B (Hib) • Viruses such as measles or mumps
◦ Streptococcus pneumoniae • Bacterial infections such as diphtheria
◦ Streptococcus A, B and C
◦ Candida albicans CHRONIC LARYNGITIS
◦ Varicella zoster • that lasts more than three weeks
◦ Physical injury
CAUSES:
RISK FACTORS ◦ Inhaled irritants, such as chemical fumes, allergens
◦ Children age 2 to 6 or smoking
◦ Crowded conditions
◦ Weak immune system ◦ Acid reflux, also called GastroEsophageal
Reflux Disease (GERD)
SYMPTOMS: ◦ Chronic sinusitis
• Fever
• Severe sore throat ◦ Excessive alcohol use
• Difficult and painful swallowing ◦ Habitual overuse of your voice (such as with
• Drooling singers or cheerleaders)
• A muffled or hoarse voice ◦ Smoking
• Harsh, raspy breathing
• Difficulty breathing RISK FACTORS
• Blue skin or lips • Respiratory Infection
TEST AND DIAGNOSIS: • Exposure to irritating substances
PRIORITY: • Overusing your voice
o the first priority is to ensure your airways are SIGNS AND SYMPTOMS
open and you're receiving enough oxygen.
o Chest or neck X-ray • Gradual onset from upper respiratory tract
o Blood test infection which progresses to signs of distress.
o Throat culture • Hoarseness
TREATMENT AND DRUGS: • Low grade fever
✓ Epiglottitis → infection → IV antibiotics • Barking cough at night
✓ tracheotomy • Inspiratory stridor
• Retractions
PREVENTION: • Severe respiratory distress
a. Hib Vaccine • Restlessness& Irritability
b. Vaccine side effects X • Wheezing, rales, rhonchi, & localized areas of
− Don't share personal items. diminished breath sounds
− Wash your hands frequently.
− Use an alcohol-based hand sanitizer if soap TEST AND DIAGNOSIS:
and water aren't available. o Physical History
COMPLICATIONS: o Laryngoscopy
o Biopsy
• Respiratory Failure
• Blood infection MANAGEMENT:
• Pulmonary Edema a. Assess for airway obstruction by evaluating
respiratory status. Note color, respiratory effort,
evidence of fatigue, & VS.
b. Provide warm, moist environment-give O2 to
alleviate hypoxia
c. Keep emergency equipment (tracheostomy &
intubation tray) near the bedside.
d. Give corticosteroids & epinephrine (nebulizer) -
reduce inflammation and bronchodilation,
antibiotics.
e. Intravenous hydration

– 23 –
TREATMENT:
LARYNGITIS
PHARYNGITIS
– Inflammation of the pharynx
HOME TREATMENT:
✓ Breathe moist air – Often due to a rapid onset of sore throat
✓ Rest your voice as much as possible. - Without discomfort or pain with swallowing
✓ Drink plenty of fluids – Assessment and Management
✓ Treat the underlying cause of laryngitis o Symptoms may include:
✓ Suck lozenges, gargle salt water or chew a • Discomfort or pain on swallowing
piece of gum • Pharyngeal erythema
• Purulent patchy yellow, gray, or white
PREVENTION: exudate
• To prevent dryness or irritation to your vocal • Ulcers on the soft palate
cords: – A dry, scratchy or swollen throat
− Don't smoke, and avoid secondhand smoke – Pain when swallowing, breathing or talking
− Drink plenty of water
− Avoid clearing your throat ❖ VIRAL PHARYNGITIS
− Avoid upper respiratory infections • Manifestations are generally mild
MANAGEMENT: SYMPTOMS:
a. Use a humidifier. • Sore throat
b. Inhale steam. • Fever & general malaise
c. Moisten your throat. • Enlarged lymph nodes
d. Avoid talking or singing too loudly or for too • Erythema of the pharynx
long.
e. Avoid decongestants TREATMENT:
f. Rest your voice ✓ Antipyretic
✓ Gargle with warm water- (school age)
✓ Provide liquid foods - (+) difficulty of
swallowing
NURSING DIAGNOSIS:
Risk for fluid volume deficit

❖ STREPTOCOCCAL PHARYNGITIS
• Cause by group A beta-hemolytic
streptococcus
• Can lead to cardiac and kidney damage
(autoimmune diseases)
• More severe than viral infection
SIGN AND SYMPTOMS
• Marked erythema of the back of throat and
palatine tonsils
• Tonsils are enlarged and white exudates in the
PHARYNGITIS tonsillar crypts
• High grade fever
• Difficulty swallowing
DIAGNOSIS: throat swab and culture
TREATMENT
✓ ANTIBIOTICS- 10 day-course of oral antibiotics
(Pen G or Erythromycin)
✓ High fluid intake
✓ Relief of pain

COMPLICATIONS:
• Rheumatic fever – Rheumatic Heart Disease
• Glomerulonephritis

– 24 –
 RESPIRATORY DISORDERS
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
(COPD)
• a group of diseases that includes:
– EMPHYSEMA
– ASTHMA
– BRONCHIECTASIS
– CHRONIC BRONCHITIS
• COPD leads to pulmonary insufficiency,
pulmonary hypertension & cor
pulmonale

EMPHYSEMA COPD – EMPHYSEMA

• Alveoli enlarge as adjacent chambers break
through
• Chronic inflammation promotes lung fibrosis
• Airways collapse during expiration
• Patients use a large amount of energy to
exhale
• Overinflation of the lungs leads to a
permanently expanded barrel chest (AP
diameter is INCREASED)
• Cyanosis appears late in the disease
PULMONARY EMPHYSEMA
• NEW NAME: C.A.L. (CHRONIC AIRWAY
LIMITATION)
• Chief characteristics:
− Chronic airway obstruction
− Poor entry of O2
− Poor removal of CO2
− Air trapping
− Overstretching of alveolar walls
 CO2  O2

– 25 –
PATHOPHYSIOLOGY: PUL. EMPHYSEMA

• CAN BE INHERITED:
– ALPHA1-ANTITRYPSIN DEFICIENCY ASTHMA
results in the destruction of the alveolar
walls
• AGING PROCESS • Chronic inflammatory disease that causes
ASSESSMENT: airway hyper-responsiveness, mucosal edema
• pink puffer: and hyper-mucus production.
⇑ mucus speaks in short & jerky sentence • REVERSIBLE WITH TREATMENT OR
coughing anxious SPONTANEOUSLY
orthopneic pos. Frequently develop URTI
barreled chest Prolonged expiratory time • Responds to irritants: dyspnea, coughing, and
SOB wheezing
wheezing digital clubbing • Characterized by recurring episodes of
1. Exertional Dyspnea paroxysmal dyspnea, wheezing on
2. Barreled chest inspiration/expiration caused by constriction
3. Hyper resonance of the bronchi and viscous mucus secretions.
4. Spontaneous pneumothorax
BRONCHIAL ASTHMA

CHRONIC BRONCHITIS
• Mucosa of the lower respiratory passages
becomes severely inflamed
• Mucus production increases: 2-3 months
productive cough for at least 2 consecutive
years
• Pooled mucus impairs ventilation and gas
exchange
• Risk of lung infection increases PHATOPHYSIOLOGY
• Pneumonia is common
• Hypoxia and cyanosis occur early
BRONCHIAL INFLAMATION ⇒ ⇑ MUCUS ⇒
⇓ CILIA ⇒ R. ACIDOSIS
CAUSES:
• Smoking
• Pollution
• Allergens
ASSESSMENT:
a. Chronic Cough
b. Blue Bloater:
- Cyanotic Edema
- Chronic cough Exertional dyspnea, ⇑RR
- Hypoxia Polycythemia- ⇑RBC
- Hypercapnia Cor pulmonale-RVH &
- Resp. Acidosis dilatation
- ⇑ incidence in heavy cigarette smokers – 26 –
 TYPES: SIGNS AND SYMPTOMS: ASTHMA
– r/t external allergens such as: • Successive episodes of coughing: dry, hacking,
EXTRINSIC • CONTACTANTS: non-productive cough
or ATOPIC dust, chemicals, soaps, • Increased respiratory secretions: whitish,
ASTHMA perfumes, lotions, make-up stringy
• INHALANTS: • Wheezing on expiration
dust, hay, scents, smoke, sprays • Prolonged expiration
• INGESTANTS: • Dry lips and mucous membranes (mouth)
food, milk, chicken, beef, pork, • Dyspnea, Tachypnea, Tachycardia
eggs, etc. • Apprehension and restlessness
• SUDDEN CHANGES IN
TEMPERATURE NCP: BRONCHIAL ASTHMA
INTRINSIC – not r/t external allergens a. Nsg. Dx.#1: Ineffective Airway Clearance
• Stress r/t Secretions, Spasms and Swelling of
or NON • Fatigue
ATOPIC • Lack of Sleep airway associated w/ allergy of the LRT
ASTHMA • Anxiety • GOALS:
– both types present − Long-term Goal: Patient will achieve an
MIXED • STATUS ASTHMATICUS open airway and adequate ventilation as
TYPE OF - severe form of constriction & manifested by normal VS and relief of
ASTHMA inflammation despite treatment; symptoms
may lead to respiratory or − Short-term Objectives:
cardiac failure. a. Liquify secretions
b. Easily expectorate and drain secretions
BRONCHIAL ASTHMA c. Relieve spasms
• ALLERGY – STRONGEST predisposing factor d. Decrease swelling of airways
(allergens) • NURSING ACTIONS:
1. Liquify secretions.
• Heredity + Allergens - Increase fluid intake @ 2-3 l/day
• Release of IgE from B lymphocytes - Nebulization
• IgE + Mast cells of respiratory tract = damage - Steam inhalation
to mast cells - Avoid creams, milk
• Release of: Histamine, Bradykinin, Serotonin, - Humidify room
Leukotrienes, Prostaglandins, ECF-A, SRS-A - Mucolytics as ordered
from damaged mast cells to respiratory Bromhexine HCl... (Bisolvon)
membranes Ambroxol...(Solmux Broncho; Broncho fluid)
Guiafenesin...(Robitussin)
BRONCHIAL ASTHMA: PATHOPHYSIOLOGY Carboxycisteine... (Loviscol)
Ammonium Citrate... (Citrex)
INFLAMMATORY REACTION at linings of the 2. Drain and easily expectorate secretions
airway - Deep breathing
S - welling - Coughing
H - eat - Vibration
A - airway obstruction - Percussion
R - edness - Postural Drainage
P - ain (Back pains) 3. Relieve bronchospasm and swelling of
airways
- Administer Bronchodilators
- Administer anti-histamines

b. Nsg. Dx.#2: Impaired Breathing Pattern r/t

airway obstruction
• GOAL:
– Improve ventilation
– Relieve signs of dyspnea
• NURSNG ACTIONS:
- Administer O2 @ 2-3 l/min via nasal
cannula
- Fowler’s or orthopneic position

– 27 –
c. Nsg. Dx.#2: Impaired Gas Exchange HOME CARE MEASURES
• GOAL: • Allergens control
– Improve gas exchange as shown by • Avoid extremes of temperature
normal ABGs • Avoid exposure to viral respiratory infection
• NURSNG ACTIONS:
• Recognize early symptoms
- Monitor ABG findings
- Intubate as needed. • Instruct the child in the administration of
- Connect to artificial ventilator medications as Rx
- Continue with bronchodilators and steroids • Adequate rest, sleep, and a well-balanced diet
- IVF to KVO. • Adequate fluid intake
• Exercise as tolerated
CHEST PHYSIOTHERAPY
• includes breathing exercises and physical
training
• not recommended during an acute exacerbation BRONCHIECTASIS
ALLERGEN CONTROL – Permanent dilation & distension of the
• prevents & reduces exposure to airborne bronchi; may lead to ⇑ mucus production
allergens ⇒ respi. Acidosis
• skin testing to identify allergens
• immunotherapy is not recommended for CAUSES:
allergens that can be eliminated effectively • Infection
• DUST MITES: Maintain the humidity in the house • Atelectasis
under 50% • Aspiration
• COCKROACHES: Exterminating, cleaning the
kitchen floors and cabinets, putting food away ASSESSMENT:
quickly after eating, taking the trash out in the a. Mucupurelent mucus
evening b. Dyspnea
b. Fever
MEDICATIONS: c. Orthopneic position
1. B2 agonists d. Anxiety
− Albuterol (Proventil HFA, Ventolin) COPD: NURSING DIAGNOSES
− Metaproterenol sulfate (Alupent) o Impaired Gas Exchange and Airway Clearance
− Terbutaline sulfate (Brethaire, Brethine, R/T Chronic Inhalation of Toxins
Bricanyl) o Activity Intolerance R/T Fatigue, Ineffective
2. ANTICHOLERGENICS Breathing Patterns, And Hypoxemia
− Atropine sulfate, Ipratropium bromide o Ineffective Coping R/T Anxiety, Depression,
(Atrovent) Sexual Problems, Inability to Work
3. SYSTEMIC CORTICOSTEROIDS
COPD: NURSING MANAGEMENT
MEDSICATION for MAINTENANCE: a. BREATHING EXERCISES:
1. CORTICOSTEROIDS – DEEP BREATHING OR DIAPHRAGMATIC
2. CROMOLYN SODIUM (INTAL) BREATHING and PURSED-LIP BREATHING
(slows expiration, prevents collapse of the
3. NECOCROMIL SODIUM (TILADE) small airways, promotes relaxation
4. LONG-ACTING B2 AGONISTS enabling patient to gain control of
o for the prevention of exercise-induced dyspnea)
bronchospasm (EIB) b. ACTIVITY PACING
o Albuterol (Proventil HFA, Ventolin) − DO NOT SCHEDULE TOO MANY ACTIVITIES
o Metaproterenol sulfate (Alupent) upon WAKING UP in the MORNING
o Terbutaline sulfate (Brethaire, Brethine, (secretions have accumulated overnight, in the
Bricanyl) morning patient is usually fatigued trying to
5. METHYLXANTHINES expectorate the secretions)
6. LEUKOTRIENE MODIFIER c. SELF-CARE ACTIVITIES:
o Zafirlukast (Accolate) and Zileuton (Zyflo) – BATHING, WALKING, CHANGING OF
o used in children older than 12 years CLOTHES, ORAL CARE encouraged 1 to 2
7. LONG-ACTING BRONCHODILATOR hours after waking up when patient’s
o Salmeterol (Serevent) airways have been cleared and breathing
pattern has already improved.
– 28 –
d. EXERCISES: short walks, bending stretching,
climbing of stairs should be alternating with rest DIFFUSIVE DISORDERS
--- treadmills, stationary bikes, distance walking
with portable oxygen therapy nearby for PRN – Disorders affecting Alveolar Diffusion
use. • LOSS OF AERATING SURFACE
e. NUTRITIONAL THERAPY: • ↓ PULMONARY PERFUSION
– HIGH PROTEIN HIGH CALORIE INTAKE IN
SMALL FREQUENT SERVINGS • Pneumonia
f. WEIGHT LOSS AND LOSS OF FAT MASS are ALVEOLAR INFEC. • PTB
the results of appetite loss and too much energy • Histoplasmosis
expenditure (negative balance between dietary • Pulmonary Edema
intake and energy use) FLUIDS IN ALVEOLI
• A.R.D.S.
COPD: GOALS of NURSING MANAGMENT ATELECTASIS • Pneumothorax
• Improving gas exchange • (Compliance, Recoil)
• Achieving airway clearance and improved OVERSTRETCHING • Pulmonary
breathing pattern Emphysema
• Improving activity tolerance • Bronchiectasis
• Promoting cessation of smoking • PTB Fibrosis
• Enhancing individual coping strategies COMPLIANCE • Consolidations
• Avoiding temperature extremes (Pneumonia, Tumors)
• Pneumothorax
CHRONIC OBSTRUCTIVE PULMONARY
DISEASE
1.BRONCHODILATORS: Xanthines,
aminophyline, theophylline RESTRICTIVE DISORDERS
2.ADRENERGICS: Isoproterenol (Isuprel), ◦ Poliomyelitis
Terbutaline, (Brethine), Metaproterenol ◦ Myasthenia Gravis
(Aluputent)
4.EXPECTORANTS: Guaifenessin (Robitusin) I. RESTRICTION or ◦ Guillain-Barre’ Syndrome
5.MUCOLYTICS: Acetylcysteine (Mucomyst) PARALYSIS OF ◦ Multiple Sclerosis
6.STEROIDS: Prednisone RESP. MUSCLE: ◦ Amyotropic Latera
7.PROPYLAXIS (anti-allergy): Cromolyn Sclerosis (ALS)
Na(Intal) ◦ Scleroderma
◦ Kyphoscoliosis
NURSING CARE
◦ Obesity
• V/S
• ⇓ O2 conc. (2-3L/min) as Rx ◦ Brain/SC Injury
• Monitor pulse oximetry ◦ General Anesthesia/
• Respiratory ttt & chest physiotherapy Narcotic O.
• Pursed-lip breathing ◦ Pneumothorax
• Record the color, amount & consistency of II. LOSS OF
sputum NORMAL ◦ Hemothorax
• Suction NEGATIVE ◦ Pleural Effusion
• Daily wt. PRESSURE: ◦ Empyema Thoracic
• Small, frequent feedings ◦ Multiple Rib Fracture
• ⇑ calorie & CHON diet with supplements (Flail Chest)
• Encourage fluids
• ⇑ Fowler’s
• Stop Smoking
• Activity as tolerated
• Avoid powerful odors
– 29 –
 CHEST INJURIES
RUB FRACTURE FLIAL CHEST
• results from blunt chest trauma • a blunt chest trauma associated w/
• causes a potential for intra-thoracic injury: accidents
pneumothorax or pulmonary contusion • resulting to loose chest wall
ASSESSMENT: ASSESSMENT
a. Pain a. Paradoxical respirations
b. Tenderness b. Severe chest pain
c. Shallow respirations c. Dyspnea
d. Client splints chest d. Cyanosis
e. Fractures noted on CXR e. Tachycardia
f. Hypotension
NURSING CARE: g. Tachypnea
• Note that ribs unite spontaneously h. Diminished breath sounds
• ⇑ Fowler’s
• Pain medications PARADOXICAL BREATHING
• Monitor for respiratory distress – When inhaling the chest (affected area) sucks in
• Instruct the client to self-splinting and when exhaling the chest balloons out, there
• Prepare for possible intercostal nerve block is pain AND DIFFICULTY during the breathing
process
PULMONARY CONTUSION – DANGER: end of fractured rib may PUNCTURE
• intra-alveolar hemorrhage resulting to the lung tissue resulting in PNEUMOTHORAX
(CLOSED OR TENSION PNEUMOTHORAX)
ADULT RESPIRATORY DISTRESS – INTUBATION
SYNDROME (ARDS)
NURSING CARE
ASSESSMENT
• ⇑ Fowler’s
a. Dyspnea • Humidified O2
b. Hypoxemia • Monitor respiratory distress
c. ⇑ bronchial secretions • Coughing & deep breathing
d. Hemoptysis • Pain meds
e. Restlessness • Bed rest
f. Decreased breath sounds • Prepare for intubation with mechanical
g. Rales & wheezes ventilation with positive end-expiratory pressure
(PEEP) for severe respiratory failure
NURSING CARE
• Maintain airway CHEST TRAUMA
• ⇑Fowler’s – GUNSHOT WOUND, STAB WOUND results in
• O2 as Rx OPEN PNEUMOTHORAX with HEMOTHORAX
• Monitor respiratory distress (thoracic cavity builds up pressure)
• Maintain bed rest – MGT: chest tube insertion or thoracostomy to
• Prepare for mechanical ventilation with remove atmospheric air and blood
positive end- expiratory pressure (PEEP) if – NURSING RESPONSIBILITY: care of the chest
required tube, monitoring of the bubbling of the water
in the water-bottle-drainage system

– 30 –
 PNEUMOTHORAX
• accumulation of atmospheric air in the
pleural space
• may lead to lung collapse
KINDS
1. SPONTANEOUS PNEUMOTHORAX
2. OPEN PNEUMOTHORAX
3. 3TENSION PNEUMOTHORAX

ASSESSMENT:
◦ Dyspnea
◦ Tachycardia LOSS OF AERATING SURFACE
◦ Tachypnea o ALVEOLAR INFEC.
◦ Sharp chest pain • Pneumonia
• PTB
◦ Absent breath sounds
• Histoplasmosis
◦ ⇓ chest expansion unilaterally o FLUIDS IN ALVEOLI
◦ Cyanosis • Pulmonary Edema
◦ Hypotension • A.R.D.S.
◦ Sucking sound o ATELECTASIS
◦ Tracheal deviation to the unaffected side • IRDS
with tension pneumothorax • Pneumothorax
NURSING CARE: o OVERSTRETCHING
a. Apply dressing over an open chest wound • ( Compliance,  Recoil)
b. O2 as Rx • Pul. Emphysema
c. ⇑ Fowler’s • Bronchiectasis
d. Chest tube placement o COMPLIANCE
e. Monitor for chest tube system • PTB Fibrosis
f. Monitor for subcutaneous emphysema • Consolidations: (Tumors, Pneumonias)
• Pneumothorax

ADULT RESPIRATORY DISTRESS SYNDORME

(ARDS)
• caused by a lung injury leading to extravascular ASSESSMENT
lung fluid a. Tachypnea
• interstitial edema b. Dyspnea
• respiratory acidosis & hypoxemia c. ⇓ breath sounds
• the CXR film shows interstitial edema d. Deteriorating blood gas
e. ⇓ O2
NURSING CARE
• Identify & treat the cause
• O2 as Rx
• ⇑ Fowler’s
• Restrict fluid
• Respiratory
• Administer diuretics, anticoagulants,
or corticosteroids as Rx
• Prepare the client for intubation &
mechanical ventilation using (+)
end-expiratory pressure (PEEP

– 31 –
 PNEUMONIA
• inflammation of the alveoli caused by a virus
mycoplasmal agents, bacteria or the
aspiration of foreign substances
TYPES
a. VIRAL PNEUMONIA
b. PRIMARY ATYPICAL PNEUMONIA
(MYCOPLASMA PNEMONIAE)
– Ages 5 - 12 y.o.
– occurs primarily in the fall & winter months
and is more prevalent in crowded living
conditions
c. BACTERIAL PNEUMONIA
– hospitalization is indicated when pleural
effusion or emphyema
– staphylococcal pneumonia
d. ASPIRATION PNEUMONIA
– occurs when food, secretions, liquids, or other PRIMARY ATYPICAL PNEUMONIA
materials enter the lung & cause inflammation. ASSESSMENT:
a. Fever
ASSESSMENT: b. Malaise
• ⇑ grade fever c. Headache
• Chills d. Rhinitis
• Chest pain
• Grating sound e. Sore throat
• Rusty Sputum f. Cough
• Rales or crackles on auscultation g. Nonproductive cough initially then produces
• Dullness or hyperresonance seromucoid sputum that becomes mucopurulent or
bld. streaked
DIAGNOSTIC TEST: NURSING CARE:
− X-Ray Nursing care: SYMPTOMATIC
− Gram-Staining
− Sputum Culture & Sensitivity
PRIMARY ATYPICAL PNEUMONIA
NURSING CARE for PNEUMONIA
• ⇑ Fluids ASSESSMENT:
• Chest Physiotherapy a. Fever
• Chest splinting b. INFANT: irritability, lethargy, poor feeding,
• Incentive Spirometer abrupt fever, respiratory distress
• ⇑ calorie & CHON diet c. OLDER CHILD: headache, chills, abdominal pain,
• Small frequent meals chest pain, meningeal symptoms
• Rest & activity as tolerated d. Hacking, nonproductive cough
• Administer antibiotics as Rx – Penicillin DOC e. Diminished breath sounds or scattered crackles
• Administer antipyretics, bronchodilators, cough
suppressants, mucolytic agents & expectorants f. Purulent sputum
as Rx NURSING CARE:
• Handwashing & proper disposal of secretions • Antimicrobial therapy
• Thoracentesis – POC • Administer O2
• Mist tent
VIRAL PNEUMONIA • Suction PRN
ASSESSMENT: • Chest physiotherapy
a. Whitish sputum • Bed rest
b. Fever, cough, malaise and prostration • Lie on the affected side
c. Wheezing • Oral & IV
NURSING CARE: • Antipyretics
• O2 with cool mist • Isolation precaution
• ⇑ fluid • Anti-tussives
• Antipyretics • Thoracenthesis
• Chest physiotherapy
• Antimicrobial / anti-viral – 32 –
 PULMONARY TUBERCULOSIS
• Highly communicable disease caused by a ASSESSMENT:
gram + acid-fast bacilli (mycobacterium a. Asymptomatic
b. Anorexia
tuberculosis) c. Wt. Loss
CAUSES/⇑ RISK GROUPS: d. Fatigue
1. Immunosuppression e. Low grade P.M. fever
2. Overcrowding f. Night sweats
3. 3rd world country g. Sputum – yellow green
4. Children ⇓ 5 years old h. Hemoptysis
i. Chest pain
5. Alcoholics j. ⇑ tactile fremitus
6. Smoking
NSG. CARE:
DIAGNOSTIC TEST: • Chemoprophylaxis – only indicated in primary
◦ Sputum test infection
◦ Sputum Culture – TOC • Multi-drug theraphy
◦ Tuberculin test – Check for the presence of 1st line drug: 2nd line drugs:
antibodies due to exposure - Rifampicin - Kanamycin
a. Mantoux test - INH - Capneomycin
- Streptomycin - Para aminosalycilic acid
b. Multiple puncture test (Tine or Monovac) - Pyrazinamid

HISTOPLASMOSIS PLEURAL EFFUSION

• Fungal infection caused by spores of • The collection of fluid in the pleural
Histoplasma capsulatum space
• Transmitted by inhalation of spores, which
are commonly located in contaminated soil ASSESSMENT:
• Found in bird droppings a. Sharp pleuritic pain
b. Dyspnea
ASSESSMENT: c. Dry non-productive cough
a. Dyspnea d. Tachycardia
b. Chills e. ⇑ temperature
c. Fever f. ⇓ breath sounds
d. Chest pain g. CXR shows pleural effusion & a
e. Pulmonary infiltrates on CXR mediastinal shift away from the fluid
f. Elevated WBC
g. Splenomegaly & hepatomegaly NURSING CARE:
• Identify & treat underlying cause
NURSING CARE: • Monitor breath sounds
• O2 as Rx • Monitor pulse oximetry
• Monitor breath sounds • ⇑ Fowler’s
• Antiemetics, antihistamines, antipyretics & • Coughing & DBE
corticosteroids as Rx • Thoracentesis
• Fungicidal medications • If pleural effusion is recurrent, prepare the
• Coughing & DBE client for pleurectomy or pleurodesis
• ⇑ Fowler’s
• V/S
• Monitor for nephrotoxicity

PLEURECTOMY
– surgically stripping the parietal pleura
PLEURECTOMY
& PLEURODESIS PLEURODESIS
– involves instillation of a sclerosing substance into the
pleural space via a thoracotomy tube
q
– 33 –
 EMPYEMA PLEURISY
• pus within the pleural cavity • inflammation of the visceral & parietal
• fluid is thick, opaque & foul smelling membranes
• may be caused by pulmonary infarction or
ASSESSMENT:
a. Fever & chills
pneumonia
b. Chest pain ASSESSMENT:
c. Cough a. Knife-like pain
d. Dyspnea b. Dyspnea
e. Anorexia & wt. loss c. Pleural friction
f. Malaise d. Apprehension
g. Night sweats
NURSING CARE:
h. Diminished chest wall movement on the affected
side • Identify & treat cause
i. Pleural exudate on chest CXR • Monior lung sounds
• Analgesics as Rx
NURSING CARE: • Appy hot & cold applications as Rx
• Monitor breath sounds • Coughing & DBE
• ⇑ Fowler’s • Instruct the client to lie on affected side to splint
• Coughing & DBE Antibiotics as Rx chest
• Chest splinting
• If marked pleural thickening occurs, prepare the
client for decortication, if Rx

PULMONARY EMBOLISM
• Dislodgement of thrombus to the pulmonary PREVENTION:
artery • Ambulation or leg exercise in patients on bed rest
• Caused by thrombus & pulmonary emboli • Anticoagulant therapy before abdominothoracic
• Other risk factors: deep vein thrombosis, surgery and every 8 to12 hours until discharge
immobilization, surgery, obesity, pregnancy,
CHF, advanced age, prior history of from the hospital
thromboembolism • Application of antiembolism stockings
• Obstruction of the base or one or more MANAGEMENTS:
branches of the pulmonary arteries by a
thrombus. 1. Stabilize cardiorespiratory system
• Life threatening within the first 1 to 2 hours a. Nasal O2
after the embolic event b. Pulmonary angiography, perfusion lung scans
• It is associated with trauma, surgery, & ABGs
pregnancy, CHF, age older than 50, hyper- c. An indwelling urethral catheter is inserted to
coagulable stress and prolonged immobility. monitor urine output
ASSESSMENT: d. Hypotension is treated by infusion of
a. Dyspnea DOBUTAMINE or DOPAMINE
b. Chest pain e. ECG to monitor dysrhythmias and heart
c. Tachypnea & tachycardia failure
d. Hypotension f. digitalis, IV diuretics and antiarrhymic agents
e. Shallow respirations g. Volume controlled ventilator and small doses
f. Rales on auscultation of morphine
g. Cough 2. Anticoagulation therapy
h. Blood-tinged sputum a. PTT is maintained at 1.5 to 2.5 times normal,
i. Distended neck veins PT 1.5 to 2.5 times normal
j. Cyanosis b. Heparin administered for 5 to 7 days
MANIFESTATION: c. Warfarin (Coumadin is begun within 24 hours
(depends’ on the size of the thrombus & the area of ff the start of heparin and continued for 3 to
occlusion) 6 months)
• Dyspnea – most common symptom 3. Thrombolytic therapy
• Chest pain with sudden onset and pleuritic in a. May include UROKINASE, ALTEPLACE,
nature STREPTOKINASE etc, these causes
• Fever, tachycardia, cough, diaphoresis, hemodynamic instability (BLEEDING IS THE
hemoptysis, syncope, shock and sudden death
may occur SIDE EFFECT)
– 34 –
4. Surgical Management
a. EMBOLECTOMY by means of thoracotomy
with cardiopulmonary bypass
b. Transvenous catheter embolectomy with or
without insertion of an inferior vena cava
NURSING CARE
• O2 as Rx
• ⇑ Fowler’s
• Maintain bed rest
• Incentive spirometry as Rx
• Pulse oximetry
• Prepare for intubation
& mechanical ventilation
• IV heparin (bolus)
• Warfarin (Coumadin)
• Monitor PT & PTT closely
• Prepare the client for embolectomy, vein ligation,
or insertion of an umbrella filter as Rx

ACUTE PULMONARY EDEMA

• Abnormal accumulation of fluid in the lung
tissue or alveoli. Major factor is blood
backing up into the pulmonary circulation.
• The most common cause is cardiac disease r/t
atherosclerosis, hpn and valvular and
myopathic d/o
• Prognosis is good with appropriate measures
MANIFESTATION:
1. Typical attack occurs at night after lying down
for a few hours preceded by increasing
restlessness, anxiety and inability to sleep
2. Sudden onset of breathlessness and a sense of
suffocation, hands become cold and moist,
nailbeds become cyanotic and skin turns gray
3. Rapid and weak pulse with distended neck veins
4. Increase coughing produces quantities of mucoid
sputum
SPL NURSING CONSIDERATIONS:
5. If it progresses client become confuse and stupor ✓ Position patient upright or with legs and feet
6. Breathing is noisy. down to promote circulation
✓ Monitor effects of medications
✓ Promote mobility and circulation
MANAGEMENT:
✓ Auscultate lung sounds
a. Oxygenation (ET tube and mechanical vent if
resp failure occurs, PEEP, monitor ABGs)
b. Pharmacologic therapy
– Morphine is given via IV in small doses to
reduce anxiety but contraindicated in CVA,
COPD, cardiogenic shock)
– Diuretics (Lasix, Hydrodiuril)
– IV meds such as MILRINONE to dilate
arteries And NATRECOR to improve stroke
volume

– 35 –
 RESPIRATORY FAILURE
• occurs when the client can’t eliminate CO2 from
the alveoli
• the CO2 retention results in hypoxemia
• O2 reaches the alveoli but can’t be absorbed
or used properly
• the lungs can move air sufficiently but can’t
oxygenate the pulmonary blood properly
• occurs as a result of a mechanism abnormality
of the lungs or chest wall, a defect in the
respiratory control center in the brain, or an
impairment in the function of the respiratory
muscles
• the PaCO2 level is greater than 45 mm Hg
ASSESSMENT:
a. Dyspnea
b. Headache
c. Restlessness
d. Confusion
e. Tachycardia
f. Cyanosis
g. Dysrhythmias
h. Decreased level of consciousness
i. Alterations in respirations & breath sounds
NURSING CARE:
• Identify & treat the cause of respiratory failure
• Administer O2 to maintain the PaO2 level
above 60-70 mm Hg
• Position the client in high Fowler’s
• Encourage DBE
• Administer bronchodilators as Rx
• Prepare the client for mechanical ventilation if
supplemental O2 can’t maintain acceptable
PaO2 levels

– 36 –
 MEDICAL SURGICAL I

CARDIOVASCULAR SYSTEM
HEART'S NORMAL ANATOMY:
• The heart is located in the LEFT side of the
mediastinum
• Consists of Three layers - epicardium,
myocardium and endocardium
- The EPICARDIUM covers the outer surface
of the heart
- The MYOCARDIUM is the middle muscular
layer of the heart
- The ENDOCARDIUM lines the chambers
and the valves
• The layer that covers the heart is the
PERICARDIUM
- There are two parts - parietal and visceral
pericardium
- The space between the two pericardial
layers is the pericardial space THE CONDUCTING SYSTEM OF THE HEART
• The heart also has FOUR CHAMBERS - two Consists of the:
atria and two ventricles 1. SA node - the pacemaker
- The Left atrium and the right atrium 2. AV node - slowest conduction
- The left ventricle and the right ventricle 3. Bundle of His - branches into the Right and the
Left bundle branch
THE HEART CHAMBERS ARE
4. Purkinje fibers - fastest conduction
GUARDED BY VALVES
◦ THE ATRIO-VENTRICULAR VALVES THE HEART SOUNDS
– Tricuspid and Bicuspid ◦ S1- due to closure of the AV valves (Normal) lub
◦ THE SEMI-LUNAR VALVES ◦ S2 - due to the closure of the semi-lunar valves
– Pulmonic and Aortic valves (2nd sound) dub
◦ S3 - due to increased ventricular filling. Not
THE BLOOD SUPPLY OF THE HEART COMES considered normal increase ventricular
FROM THE CORONARY ARTERIES ◦ S4 - due to forceful atrial contraction
1. RIGHT CORONARY ARTERY – supplies the
RIGHT atrium and RIGHT ventricle, inferior portion HEART RATE
of the LEFT ventricle, the POSTERIOR septal wall • Normal range is 60-100 beats per minute
and the two nodes- AV (90%) and SA node • TACHYCARDIA is greater than 100 bpm
(55%) • BRADYCARDIA is less than 60 bpm
2. LEFT CORONARY ARTERY- branches into the • Sympathetic system INCREASES HR
LAD and the circumflex branch • Parasympathetic system (Vagus) DECREASES HR
• The LAD supplies blood to the anterior wall of
the LEFT ventricle, the anterior septum and the BLOOD PRESSURE
Apex of the left ventricle ◦ Cardiac output X peripheral resistance
◦ Control is neural (central and peripheral) and
• The CIRCUMFLEX branch supplies the left hormonal
atrium and the posterior LEFT ventricle ◦ Baroreceptors in the carotid and aorta
◦ Hormones - ADH, aldosterone, epinephrine can
increase BP; ANF can decrease BP
◦ The vascular system consists of the arteries, veins
and capillaries
◦ The arteries are vessels that carry blood away
from the heart to the periphery
◦ The veins are the vessels that carry blood to the
heart
◦ The capillaries are lined with squamos cells, they
connect the veins and arteries
◦ The lymphatic system also is part of the vascular
system and the function of this system is to collect
the extravasated fluid from the tissues and returns
it to the blood
– 37 –
 DIAGNOSTIC TEST
LABARATORY TEST RATIONALE: Troponin I and T
✓ To assist in diagnosing MI ◦ Troponin I is usually utilized for MI
✓ To identify abnormalities ◦ Elevates within 3-4 hours, peaks in 4-24 hours
✓ To assess inflammation
✓ To determine baseline value and persists for 7 days to 3 weeks!
✓ To monitor serum level of medications ◦ Normal value for Troponin I is less than 0.6 ng/mL
✓ To assess the effects of medications ◦ REMEMBER to AVOID IM injections before
obtaining blood sample!
LABORATORY PROCEDURES: ◦ Early and late diagnosis can be made!

CARDIAC Proteins and enzymes SERUM LIPIDS

• CK-MB (creatine kinase) ◦ Lipid profile measures the serum cholesterol,
– Elevates in MI within 4 hours, peaks in 18 triglycerides and lipoprotein levels
hours and then declines till 3 days ◦ Cholesterol = 200 mg/dL
– Normal value is 0-7 U/L ◦ Triglycerides = 40-150 mg/dL
• Lactic Dehydrogenase (LDH) ◦ LDH = 130 mg/dL
– Elevates in MI in 24 hours, peaks in 48-72 ◦ HDL = 30-70-mg/dL
hours ◦ NPO post-midnight (usually 12 hours)
– Normally LDH1 is greater than LDH2
– MI-LDH2 greater than LDH1 (flipped LDH
pattern) ELECTROCARDIOGRAM (ECG)
– Normal value is 70 - 200 IU/L ◦ A non-invasive procedure
• Myoglobin that evaluates the electrical
– Rises within 1- 3 hours activity of the heart
– Peaks in 4 - 12 hours ◦ Electrodes and wires are
– Returns to normal in a day attached to the patient
– Not used alone
– Muscular and RENAL disease can have
elevated myoglobin
– 38 –
 HOLTER MONITORING
– A non-invasive test in which the client wears a
Holter monitor, and an ECG tracing recorded
continuously over a period of 24 hours
– Instruct the client to resume normal activities and
maintain a diary of activities and any symptoms
that may develop

PHARMACOLOGICAL STRESS TEST

– Use of DIPYRIDAMOLE
– Maximally dilates coronary artery
– Side-effect: flushing of face
◦ PRE-TEST:
ECHOCARDIOGRAM 4 hours fasting, avoid alcohol, caffeine
– Non-invasive test that studies the structural and ◦ POST TEST:
functional changes of the heart with the use of report symptoms of chest pain
ultrasound
– No special preparation is needed CARDIAC catheterization
(invasive procedure)
– Insertion of a catheter into the heart and
surrounding vessels
– Determines the structure and performance of
the heart valves and surrounding vessels
– Used to diagnose CAD, assess coronary
artery patency and determine extent of
atherosclerosis.

STRESS TEST
– A non-invasive test that studies the heart during
activity and detects and evaluates CAD
– Exercise test, pharmacologic test and emotional
test
– TREADMILL TESTING is the most commonly
used stress test
– Used to determine CAD, Chest pain causes,
drug effects and dysrhythmias in exercise
◦ PRE-TEST:
consent may be required, adequate rest, eat a
light meal or fast for 4 hours and avoid
smoking, alcohol and caffeine
◦ POST-TEST:
instruct client to notify the physician if any chest
pain, dizziness or shortness of breath. Instruct
client to avoid taking a hot shower for 10-12
hours after the test (avoid hot shower
vasodilation).

– 39 –
 CARDIAC CATHETERIZATION
◦ PRE-TEST: CENTRAL VENOUS PRESSURE
- Ensure Consent, assess for allergy to seafood (CVP)
and iodine, NPO, document weight and – The CVP is the pressure within the SVC
height, baseline VS, blood tests and – Reflects the pressure under which blood is
document the peripheral pulses. returned to the SVC and right atrium.
- Fast for 8-12 hours, teachings, medications to
allay anxiety Normal CVP – 0 to 8 mmHg/ 4-10 cm H20
◦ INTRA-TEST: Elevated – indicates increase in blood
- Inform patient of a fluttery feeling as the CVP volume, excessive IVF or
catheter passes through the heart; inform heart/renal failure
the patient that a feeling of warmth and Low CVP – may indicated hypovolemia,
metallic taste may occur when dye is hemorrhage and severe
administered vasodilatation
◦ POST-TEST: MEASURING CVP
- Monitor VS and cardiac rhythm 1. Position the client supine with bed elevated at 45
– Monitor peripheral pulses, color and warmth degrees
and sensation of the extremity distal to 2. Position the zero point of the CVP line at the level
insertion site of the right atrium. Usually this is at the MAL, 4th
– Maintain sandbag to the insertion site if ICS.
required to maintain pressure 3. Instruct the client to be relaxed and avoid
– Monitor for bleeding and hematoma coughing.
formation
– Maintain strict bed rest for 6-12 hours
– Client may turn from side to side but bed
should not be elevated more than 30 degrees
and legs always straight
– Encourage fluid intake to flush out the dye
– Immobilize the arm if the antecubital vein is
used
– Monitor for dye allergy

CARDIAC ASSESSMENT
1. Health History:
• Obtain description of present illness and the
chief complaint
• Chest pain, SOB, Edema, etc.
• Assess risk factors
2. Physical examination x
• Vital signs- BP, PP, MAP
• Inspection of the skin
• Inspection of the thorax
• Palpation of the PMI, pulses
• Auscultation of the heart sounds
3. Laboratory and diagnostic studies
• СВС cardiac catheterization
• Lipid profile
• Arteriography
• Cardiac enzymes and proteins
• CXR
• CVP
• EEG
• Holter monitoring
• Exercise ECG

– 40 –
 CARDIAC IMPLEMENTATION
1. Assess the cardio-pulmonary status
◦ VS, BP, Cardiac assessment
2. Enhance cardiac output 6. Promote adequate sleep
◦ Establish IV line to administer fluids 7. Prevent infection
3. Promote gas exchange ◦ Monitor skin integrity of lower extremities
◦ Administer 02 ◦ Assess skin site for edema, redness and
◦ Position client in SEMI-Fowler's warmth
◦ Encourage coughing and deep breathing ◦ Monitor for fever
exercises ◦ Change position frequently
4. Increase client activity tolerance
◦ Balance rest and activity periods 8. Minimize patient anxiety
◦ Assist in daily activities ◦ Encourage verbalization of feelings, fears
5. Promote client comfort and concerns
◦ Assess the client's description of pain and chest ◦ Answer client questions. Provide
discomfort information about procedures and
◦ Administer medication as prescribed medications.

CARDIAC DISEASE VASCULAR DISEASE

◦ Coronary Artery Disease ◦ Hypertension
◦ Myocardial Infarction ◦ Buerger's disease
◦ Congestive Heart Failure ◦ Varicose veins
◦ Infective Endocarditis ◦ Deep vein thrombosis
◦ Cardiac Tamponade ◦ Aneurysm
◦ Cardiogenic Shock

CORONARY ARTERY DISEASE

⎯ CAD results from the focal narrowing of PATHOPHYSIOLOGY
the large and medium-sized coronary Fatty streak formation in the vascular intima
arteries due to deposition of → T-cells and monocytes ingest lipids in the
atheromatous plaque in the vessel wall area of deposition → atheroma → narrowing
RISK FACTORS: of the arterial lumen → reduced coronary
1. Age above 45/55 and Sex- Males and blood flow → myocardial ischemia
post-menopausal females • There is decreased perfusion of myocardial tissue
2. Family History and inadequate myocardial oxygen supply
3. Hypertension • If 50% of the left coronary arterial lumen is
4. DM reduced or 75% of the other coronary artery, this
5. Smoking becomes significant
6. Obesity • Potential for Thrombosis and embolism
7. Sedentary lifestyle
8. Hyperlipidemia
Most important MODIFIABLE factors:
• Smoking
• Hypertension
• Diabetes
• Cholesterol abnormalities

– 41 –
 ANGINA PECTORIS
⎯ Chest pain resulting from coronary
atherosclerosis or myocardial ischemia
CLINICAL SYNDROMES
THREE COMMON TYPES of ANGINA
– The typical angina that occurs
during exertion, relieved by rest
STABLE and drugs and the severity does
ANGINA not change.
– (TRIMETAZIDINE) PAIN WILL
RELIEVE
– Occurs unpredictably during NURSING MANAGEMENT:
UNSTABLE exertion and emotion, severity 1. Administer prescribed medications
ANGINA increases with time and pain • Nitrates – to dilate the coronary arteries
may not be relieved by rest and • Aspirin – to prevent thrombus formation
drug.
• Beta-blockers – to reduce BP and HR
– Prinzmetal angina, results from
VARIANT • Calcium-channel blockers – to dilate
coronary artery VASOSPASMS,
ANGINA coronary artery and reduce vasospasm
may occur at rest
2. Teach the patient management of anginal
attacks
– Advise patient to stop all activities
– Put one nitroglycerin tablet under the
tongue
– Wait for 5 minutes
– If not relieved, take another tablet and wait
for 5 minutes
– Another tablet can be taken (third tablet)
– If unrelieved after THREE tablets→ seek
medical attention
3. Obtain a 12-lead ECG
4. Promote myocardial perfusion
ASSESSMENT FINDINGS: • Instruct patient to maintain bed rest
a. Chest pain – ANGINA • Administer 02 @ 3 lpm
– The most characteristic symptom
– PAIN is described as mild to severe • Advise to avoid valsalva maneuvers (pag
retrosternal pain, squeezing, tightness or ire) Decrease heart rate until the heart stop
burning sensation • Provide laxatives or high fiber diet to lessen
– Radiates to the jaw and left arm constipation
– Precipitated by Exercise, Eating heavy meals, • Encourage to avoid increased physical
Emotions like excitement and anxiety and activities
Extremes of temperature 5. Assist in possible treatment modalities
– Relieved by REST and Nitroglycerin
b. Diaphoresis ◦ PTCA - percutaneous transluminal
c. Nausea and vomiting coronary angioplasty x
d. Cold clammy skin – To compress the plaque against the
e. Sense of apprehension and doom vessel wall, increasing the arterial
f. Dizziness and syncope lumen
◦ CABG-coronary artery bypass graft
LABORATORY FINDINGS: – To improve the blood flow to the
o ECG may show normal tracing if patient is pain- myocardial tissue
free. Ischemic changes may show ST depression 6. Provide information to family members to
and T wave inversion minimize anxiety and promote family
o Cardiac catheterization cooperation
– Provides the MOST DEFINITIVE source of
diagnosis by showing the presence of the 7. Assist client to identify risk factors that can
atherosclerotic lesions be modified
8. Refer patient to proper agencies
– 42 –
 LABORATORY FINDINGS:
MYOCARDIAL INFARCTION ◦ ECG – the ST segment is
ELEVATED. T wave inversion,
⎯ Death of myocardial tissue in regions of presence of Q wave
the heart with abrupt interruption of ◦ Myocardial enzymes –
coronary blood supply elevated CK- MB, LDH and
Troponin levels
◦ CBC – may show elevated WBC count
◦ Test after the acute stage – Exercise tolerance
test, thallium scans, cardiac catheterization
NURSING INTERVENTIONS:
1. Provide Oxygen at 2-1pm, Semi-fowler's
2. Administer medications
- Morphine to relieve pain
- nitrates, thrombolytics, aspirin and
anticoagulants
- Stool softener and hypolipidemics
3. Minimize patient anxiety
- Provide information as to procedures and
ETIOLOGY AND RISK FACTORS: drug therapy
• CAD 4. Provide adequate rest periods
• Coronary vasospasm 5. Minimize metabolic demands
• Coronary artery occlusion by embolus and - Provide soft diet
thrombus - Provide a low-sodium, low cholesterol and
• Conditions that decrease perfusion - hemorrhage, low-fat diet
shock 6. Minimize anxiety
– Reassure client and provide information as
RISK FACTORS: needed
1. Hypercholesterolemia 7. Assist in treatment modalities such as PTCA and
2. Smoking CABG
3. Hypertension 8. Monitor for complications of MI- especially
4. Obesity dysrhythmias, since ventricular tachycardia can
5. Stress happen in the first few hours after MI
6. Sedentary lifestyle 9. Provide client teaching.
PATHOPHYSIOLOGY MEDICAL MANAGEMENT:
Interrupted coronary blood flow → a. ANALGESIC
myocardial ischemia → anaerobic – The choice is MORPHINE
– It reduces pain and anxiety
myocardial metabolism for several hours → – Relaxes bronchioles to enhance oxygenation
myocardial death → depressed cardiac b. ACE inhibitors
function → triggers autonomic nervous – Prevents formation of angiotensin II
– Limits the area of infarction
system response → further imbalance of c. Thrombolytics
myocardial O2 demand and supply – Streptokinase, Alteplase
– Dissolve clots in the coronary artery allowing
ASSESSMENT FINDINGS: blood to flow
a. CHEST PAIN
– Chest pain is described as severe, NURSING INTERVENTIONS AFTER ACUTE
persistent, crushing substernal discomfort EPISODE
– Radiates to the neck, arm, jaw and back 1. Maintain bed rest for the first 3 days
– Occurs without cause, primarily early 2. Provide passive ROM exercises
morning 3. Progress with dangling of the feet at side of
– NOT relieved by rest or nitroglycerin bed
4. Proceed with sitting out of bed, on the chair for
– Lasts 30 minutes or longer 30 minutes TID
b. Dyspnea 5. Proceed with ambulation in the room → toilet
c. Diaphoresis → hallway TID
d. cold clammy skin
e. N/V CARDIAC REHABILITATION
f. restlessness, sense of doom • To extend and improve quality of life
g. tachycardia or bradycardia • Physical conditioning
h. Hypotension • Patients who are able to walk 3-4 mph are usually
i. S3 and dysrhythmias ready to resume sexual activities
– 43 –
 CARDIOMYOPATHIES
⎯ Heart muscle disease associated with
cardiac dysfunction
TYPES
1. Dilated Cardiomyopathy
2. Hypertrophic Cardiomyopathy
3. Restrictive cardiomyopathy
DILATED CARDIOMYOPATHY
ASSOCIATED FACTORS:
1. Heavy alcohol intake
2. Pregnancy
3. Viral infection
4. Idiopathic
PATHOPHYSIOLOGY:
Diminished contractile proteins → poor
contraction → decreased blood ejection →
increased blood remaining in the ventricle→
ventricular stretching and dilatation.
SYSTOLIC DYSFUNCTION
HYPERTROPHIC CARDIOMYOPATHY
ASSOCIATED FACTORS:
1. Genetic
2. Idiopathic
PATHOPHYSIOLOGY
Increased size of myocardium → reduced
ventricular volume→ increased resistance to
ventricular filling → diastolic dysfunction
RESTRICTIVE CARDIOMYOPATHY
ASSOCIATED FACTORS
1. Infiltrative diseases like AMYLOIDOSIS
2. Idiopathic
PATHOPHYSIOLOGY
MEDICAL MANAGEMENT:
a. SURGERY
Rigid ventricular wall → impaired stretch b. Pacemaker insertion
and diastolic filling decreased output c. Pharmacological drugs for symptom relief
DIASTOLIC DYSFUNCTION
NURSING MANAGEMENT:
ASSESSMENT FINDINGS: 1. Improve cardiac output
a. PND - paroxysmal nocturnal dyspnea • Adequate rest
(nahihirapan huminga pag nakahiga) • Oxygen therapy
b. Orthopnea • Low sodium diet
c. Edema 2. Increase patient tolerance
d. Chest pain • Schedule activities with rest periods in
e. Palpitations between
f. Dizziness 3. Reduce patient anxiety
g. Syncope with exertion • Support
LABORATORY FINDINGS: • Offer information about transplantations
• Support family in anticipatory grieving
◦ CXR - may reveal cardiomegaly (lumaki puso
nya)
◦ ECHOCARDIOGRAM
◦ ECG
◦ Myocardial Biopsy
– 44 –
 INEFECTIVE ENDOCARDITIS ASSESSMENT FINDINGS:
a. Intermittent fever
⎯ Infection of the heart valves and the b. Anorexia, weight loss
endothelial surface of the heart c. Cough, back pain and joint pain
d. Splinter hemorrhages under nails
⎯ Can be acute or chronic
e. OSLER'S NODES - painful nodules on
ETIOLOGIC FACTORS fingerpads
• Bacteria- Organism depends on several factors f. ROTH'S SPOTS - pale hemorrhages in the
• Fungi retina
RISK FACTORS g. Heart murmurs
1. Prosthetic valves h. Heart failure
2. Congenital malformation
3. Cardiomyopathy LABORATORY EXAM:
4. IV drug users ◦ Blood Cultures to determine the exact organism
5. Valvular dysfunctions
NURSING MANAGEMENT:
PATHOPHYSIOLOGY 1. Regular monitoring of temperature, heart
sounds
Direct invasion of microbes → microbes
2. Manage infection
adhere to damaged valve surface and 3. Long-term antibiotic therapy
proliferate → damage attracts platelets
causing clot formation → erosion of valvular MEDICAL MANAGEMENT:
leaflets and vegetation can embolize a. Pharmacotherapy
- IV antibiotic for 2-6 weeks
PREVENTION: - Antifungal agents are given - amphotericin
✓ Antibiotic prophylaxis if patient is undergoing B
procedures like dental extractions, b. Surgery
bronchoscopy, surgery, etc. - Valvular replacement

CONGESTIVE HEART FAILURE

(CHF)
⎯ A syndrome of congestion of both
ETIOLOGY OF CHF:
pulmonary and systemic circulation caused
• CAD
by inadequate cardiac function and • Valvular heart diseases
inadequate cardiac output to meet the • Hypertension
metabolic demands of tissues • MI
1. Inability of the heart to pump sufficiently • Cardiomyopathy
2. The heart is unable to maintain adequate • Lung diseases
circulation to meet the metabolic needs of the • Post-partum
body • Pericarditis and cardiac tamponade
3. Classified according to the major ventricular
dysfunction - Left or Right NEW YORK HEART ASSOCIATION:
CLASS 1 • Ordinary physical activity does NOT
cause chest pain and fatigue
• No pulmonary congestion
• Asymptomatic
• NO limitation of ADLS
CLASS 2 • SLIGHT limitation of ADLS
• NO symptom at rest
• Symptom with INCREASED activity
• Basilar crackles and S3
CLASS 3 • Markedly limitation on ADLS
• Comfortable at rest BUT symptoms
present in LESS than ordinary activity
CLASS 4 • •SYMPTOMS are present at rest
– 45 –
 CONGESTIVE HEART FAILURE NURSING INTERVENTIONS:
PATHOPHYSIOLOGY • Assess patient's cardio - pulmonary status
LEFT Ventricular pump failure → back up of • Assess VS, CVP and PCWP. Weigh patient daily
blood into the pulmonary veins → increased to monitor fluid retention
pulmonary capillary pressure → pulmonary • Administer medications- usually cardiac
glycosides are given - DIGOXIN or DIGITOXIN,
congestion Diuretics, vasodilators and hypolipidemics are
LEFT ventricular failure → decreased cardiac prescribed
output → decreased perfusion to the brain, • Provide a LOW sodium diet. Limit fluid intake as
kidney and other tissues oliguria, dizziness necessary
• Provide adequate rest periods to prevent
RIGHT ventricular failure → blood pooling in fatigue
the venous circulation → increased hydrostatic • Position on semi-fowler's to fowler's for
pressure peripheral edema adequate chest expansion
• Prevent complications of immobility
RIGHT ventricular failure → blood pooling →
venous congestion in the kidney, liver and GIT NURSING INTERVENTION AFTER THE ACUTE
STAGE:
LEFT SIDED CHF ASSESSMENT FINDINGS: 1. Provide opportunities for verbalization of
a. Dyspnea on exertion feelings
b. PND 2. Instruct the patient about the medication regimen
c. Orthopnea -digitalis, vasodilators and diuretics
d. Pulmonary crackles/rales 3. Instruct to avoid OTC drugs, Stimulants, smoking
e. cough with Pinkish, frothy sputum and alcohol
f. Tachycardia 4. Provide a LOW fat and LOW sodium diet
g. Cool extremities 5. Provide potassium supplements
h. Cyanosis 6. Instruct about fluid restriction
i. decreased peripheral pulses 7. Provide adequate rest periods and schedule
j. Fatigue activities
k. Oliguria 8. Monitor daily weight and report signs of fluid
l. signs of cerebral anoxia retention
RIGHT SIDED CHF ASSESSMENT FINDINGS:
a. Peripheral dependent, pitting edema
b. Weight gain
c. Distended neck vein
d. Hepatomegaly
e. Ascites
f. Body weakness
g. Anorexia, nausea
h. Pulsus alternans
LABORATORY FINDINGS:
o CXR may reveal cardiomegaly
o ECG may identify Cardiac hypertrophy
o Echocardiogram may show hypokinetic heart
o ABG and Pulse oximetry may show decreased
O2 saturation
o PCWP is increased in LEFT sided CHF and CVP
is increased in RIGHT sided CHF

– 46 –
 CARDIOGENIC SHOCK CARDIAC TAMPONADE
⎯ Heart fails to pump adequately resulting ⎯ A condition where the heart is unable to
to a decreased cardiac output and pump blood due to accumulation of fluid
decreased tissue perfusion in the pericardial sac (pericardial
effusion)
ETIOLOGY:
• Massive MI ⎯ This condition restricts ventricular filling
resulting to decreased cardiac output
• Severe CHF
• Cardiomyopathy
⎯ Acute tamponade may happen when
there is a sudden accumulation of more
• Cardiac trauma
than 50 ml fluid in the pericardial sac
• Cardiac tamponade
CAUSATIVE FACTORS:
ASSESSMENT FINDINGS:
a. HYPOTENSION
• Cardiac trauma
b. oliguria (less than 30 ml/hour) • Complication of Myocardial infarction
c. Tachycardia • Pericarditis
d. narrow pulse pressure • Cancer metastasis
e. weak peripheral pulses ASSESSMENT FINDINGS:
f. cold clammy skin
a. BECK's Triad - Jugular vein distention,
g. changes in sensorium/LOC
hypotension and distant/muffled heart sound
h. pulmonary congestion
b. Pulsus paradoxus
LABORATORY FINDINGS: c. Increased CVP
• Increased CVP d. decreased cardiac output
o Normal is 4-10 cmH2O e. Syncope
f. Anxiety
NURSING INTERVENTIONS: g. Dyspnea
1. Place patient in a modified Trendelenburg h. Percussion - Flatness across the anterior chest
(shock) position
2. Administer IVF, vasopressors and inotropics
LABORATORY FINDINGS:
such as DOPAMINE and DOBUTAMINE ◦ Echocardiogram
3. Administer 02 ◦ Chest X-ray
4. Morphine is administered to decreased NURSING INTERVENTIONS:
pulmonary congestion and to relieve pain 1. Assist in PERICARDIOCENTESIS
5. Assist in intubation, mechanical ventilation, 2. Administer IVF
PTCA, CABG, insertion of Swan-Ganz cath 3. Monitor ECG, urine output and BP
and IABP 4. Monitor for recurrence of tamponade
6. Monitor urinary output, BP and pulses
7. cautiously administer diuretics and nitrates PERICARDIOCENTESIS
• Patient is monitored by ECG
• Maintain emergency equipment
• Elevate head of bed 45-60 degrees
• Monitor for complications - coronary artery
rupture, dysrhythmias, pleural laceration and
myocardial trauma

– 47 –
 HYPERTENSION
⎯ A systolic BP greater than 140 mmHg and CLASSIFICATION OF HYPERTENSION by JNC- VII
a diastolic pressure greater than 90 mmHg
over a sustained period, based on two or
more BP measurements.
TYPES of HYPERTENSION
• Primary or ESSENTIAL
– most common type
• Hypertrophic Cardiomyopathy
– Due to other conditions like
Pheochromocytoma, renovascular
hypertension, Cushing's, Conn's,
SIADH
DRUG THERAPY:
PATHOPHYSIOLOGY ◦ Diuretics
◦ Beta blockers
• Multi-factorial etiology ◦ Calcium channel blockers
• BP = CO (SV X HR) x TPR ◦ ACE inhibitors
• Any increase in the above parameters will ◦ A2 Receptor blockers
increase BP ◦ Vasodilators
• Increased sympathetic activity
• Increased absorption of Sodium, and water in NURSING INTERVENTIONS:
the kidney a. Provide health teaching to patient
• Increased activity of the RAAS - Teach about the disease process
• Increased vasoconstriction of the peripheral - Elaborate on lifestyle changes
- Assist in meal planning to lose weight
vessels - Provide list of LOW fat, LOW sodium diet of
• insulin resistance less than 2-3 grams of Na/day
RISK FACTORS FOR CARDIOVASCULAR - Limit alcohol intake to 30 ml/day
- Regular aerobic exercise
PROBLEMS IN HYPERTENSIVE PATIENTS - Advise to completely Stop smoking
MAJOR RISK FACTORS: b. Provide information about anti- hypertensive
• Smoking drugs
• Hyperlipidemia - Instruct proper compliance and not abrupt
cessation of drugs even if pt becomes
• DM asymptomatic/ improved condition
• Age older than 60 - Instruct to avoid over-the-counter drugs that
• Gender- Male and post-menopausal may interfere with the current medication
• Family History c. Promote Home care management
- Instruct regular monitoring of BP
ASSESSMENT FINDINGS: - Involve family members in care
1. Headache - Instruct regular follow-up
2. Visual changes d. Manage hypertensive emergency and urgency
3. chest pain properly
4. Dizziness
5. N/V
DIAGNOSTIC STUDIES:
◦ Health history and PE
◦ Routine laboratory - urinalysis, ECG, lipid
profile, BUN, serum creatinine, FBS
◦ Other lab- CXR, creatinine clearance, 24-hour
urine protein
MEDICAL MANAGEMENT:
a. Lifestyle modification
b. Drug therapy
c. Diet therapy

– 48 –
 ANEURYSM PATHOPHYSIOLOGY
Damage to the intima and media → weakness
⎯ Dilation involving an artery formed at a → outpouching
weak point in the vessel wall Dissecting aneurysm → tear in the intima and
• Saccular = when one side of the vessel is affected media with dissection of blood through the layers
• Fusiform = when the entire segment becomes
ASSESSMENT:
dilated
• Asymptomatic
• Pulsatile sensation on the abdomen
• Palpable bruit
LABORATORY:
◦ CT scan
◦ Ultrasound
◦ X-ray
◦ Aortography
MEDICAL MANAGEMENT:
a. Anti-hypertensives
b. Synthetic graft
NURSING MANAGEMENT:
a. Administer medications
RISK FACTORS b. Emphasize the need to avoid increased
• Atherosclerosis abdominal pressure
• Infection = syphilis c. No deep abdominal palpation
• Connective tissue disorder d. Remind patient the need for serial ultrasound
• Genetic disorder = Marfan's Syndrome to detect diameter changes

PERIPHERAL ARTERIAL OCCLUSIVE DISEASE

⎯ Refers to arterial insufficiency of the DIAGNOSTIC FINDINGS:
extremities usually secondary to peripheral ◦ Unequal pulses between the extremities
atherosclerosis. ◦ Duplex ultrasonography
⎯ Usually found in males age 50 and above ◦ Doppler flow studies
⎯ The legs are most often affected
MEDICAL MANAGEMENT:
RISK FACTORS 1. DRUG THERAPY
NON MODIFIABLE: – Pentoxyfylline (Trental) reduces blood
• Age viscosity and improves supply of O2 blood to
• Gender
• Family predisposition muscles
MODIFIABLE: – Cilostazol (Pletaal) inhibits platelet
• Smoking aggregation and increases vasodilatation
• HPN 2. SURGERY - Bypass graft and anastomoses
• Obesity
• Sedentary lifestyle NURSING INTERVENTIONS:
• DM a. Maintain Circulation to the extremity
• Stress
• Evaluate regularly peripheral pulses,
ASSESSMENT FINDINGS: temperature, sensation, motor function and
• INTERMITTENT CLAUDICATION - the hallmark of capillary refill time
PAOD • Administer post-operative care to patient who
- This is PAIN described as aching, cramping or underwent surgery
fatiguing discomfort consistently reproduced with b. Monitor and manage complications
the same degree of exercise or activity
• Note for bleeding, hematoma, decreased
- This pain is RELIEVED by REST urine output
- This commonly affects the muscle group below the • Elevate the legs to diminish edema
arterial occlusion • Encourage exercise of the extremity while on
• Progressive pain on the extremity as the disease bed
advances • Teach patient to avoid leg-crossing
• Sensation of cold and numbness of the extremities c. Promote Home management
• Skin is pale when elevated and cyanotic/ruddy • Encourage lifestyle changes
when placed on a dependent position • Instruct to AVOID smoking
• Muscle atrophy, leg ulceration and gangrene • Instruct to avoid leg crossing
– 49 –
 BUERGER'S DISEASE RAYNAUD'S DISEASE
⎯ Thromboangitis obliterans ⎯ A form of intermittent arteriolar
⎯ A disease characterized by recurring VASOCONSTRICTION that results in coldness,
inflammation of the medium and small pain and pallor of the fingertips or toes
arteries and veins of the lower extremities CAUSE: UNKNOWN
⎯ Occurs in MEN ages 20-35 Most commonly affects WOMEN, 16- 40
RISK FACTOR: SMOKING! years old
ASSESSMENT FINDINGS
PATHOPHYSIOLOGY 1. Raynaud's phenomenon
• Cause is UNKNOWN • A localized episode of vasoconstriction of the
• Probably an Autoimmune disease small arteries of the hands and feet that
• Inflammation of the arteries → thrombus causes color and temperature changes
formation →occlusion of the vessels • W-B-R
ASSESSMENT FINDINGS: • Pallor - due to vasoconstriction, then
• Leg PAIN • Blue - due to pooling of Deoxygenated
- Foot cramps in the arch (instep claudication) blood
after exercise • Red - due to exaggerated
- Relieved by rest reflow/hyperemia
- Aggravated by smoking, emotional 2. Tingling sensation
disturbance and cold chilling 3. Burning pain on the hands and feet
• Digital rest pain not changed by activity or rest MEDICAL MANAGEMENT
• Intense RUBOR (reddish-blue discoloration),
• Drug therapy with the use of CALCIUM channel
progresses to CYANOSIS as disease advances
blockers = To prevent vasospasms
• Paresthesia
NURSING INTERVENTIONS
a. Instruct patient to avoid situations that may be
stressful
b. Instruct to avoid exposure to cold and remain
indoors when the climate is cold
c. Instruct to avoid all kinds of nicotine
d. Instruct about safety. Careful handling of sharp
objects

DIAGNOSTIC STUDIES:
◦ Duplex ultrasonography
◦ Contrast angiography
NURSING INTERVENTIONS:
a. Assist in the medical and surgical
management
• Bypass graft
• amputation
b. Strongly advise to AVOID smoking
c. Manage complications appropriately
POST-OPERATIVE CARE: after amputation
• Elevate stump for the FIRST 24 HOURS to
minimize edema and promote venous return
• Place patient on PRONE position after 24 hours
• Assess skin for bleeding and hematoma
• Wrap the extremity with elastic bandage
– 50 –
 VARICOSE VEINS DEEP VEIN THROMBOSIS
⎯ These are dilated veins usually in the lower ⎯ Inflammation of the deep veins of the
extremities lower extremities and the pelvic veins
PREDISPOSING FACTORS: ⎯ The inflammation results to formation of
• Pregnancy blood clots in the area
• Prolonged standing or sitting
• Constipation (for hemorrhoids) PREDISPOSING FACTORS:
• Incompetent venous valves • Prolonged immobility
• Varicosities
PATHOPHYSIOLOGY • Traumatic procedures
Factors → venous stasis → increased COMPLICATION: PULMONARY thromboembolism
hydrostatic pressure → edema
ASSESSMENT FINDINGS:
ASSESSMENT FINDINGS: • Leg tenderness
• Tortuous superficial veins on the legs • Leg pain and edema
• Leg pain and Heaviness • Positive HOMAN'S SIGN
• Dependent edema
LABORATORY FINDINGS:
LABORATORY FINDINGS: ◦ Venography
◦ Venography ◦ Duplex scan
◦ Duplex scan pletysmography
MEDICAL MANAGEMENT:
MEDICAL MANAGEMENT: a. Antiplatelets
a. Pharmacological therapy b. Anticoagulants
b. Leg vein stripping c. Vein stripping and grafting
c. Anti-embolic stockings d. Anti-embolic stockings
NURSING MANAGEMENT: NURSING MANAGEMENT:
a. Advise patient to elevate the legs a. Provide measures to avoid prolonged immobility
b. Caution patient to avoid prolonged standing – Repositioning Q2
or sitting – Provide passive ROM
c. Provide high-fiber foods to prevent – Early ambulation
constipation b. Provide skin care to prevent the complication of
d. Teach simple exercise to promote venous leg ulcers
return c. Provide anti-embolic stockings
e. Caution patient to avoid knee-length stockings d. Administer anticoagulants as prescribed
and constrictive clotting e. Monitor for signs of pulmonary embolism
f. Apply anti-embolic stockings as directed
g. Avoid massage on the affected area

– 51 –
 BLOOD INJURIES
ANEMIA
⎯ A condition in which the hemoglobin • Nutritional/Hypoproliferative Anemia
concentration is lower than normal • Megaloblastic anemia
THREE BROAD CATEGORIES: • Aplastic anemia
1. Loss of RBC- occurs with bleeding • Pernicious anemia
2. Decreased RBC production • Hemolytic anemia: Sickle cell anemia
3. Increased RBC destruction

HYPOPROLIFERATIVE ANEMIA MEDICAL MANAGEMENT:

⎯ IRON DEFICIENCY ANEMIA a. Hematinics
⎯ Results when the dietary intake of iron is b. Blood transfusion
inadequate to produce hemoglobin NURSING MANAGEMENT:
ETIOLOGIC FACTORS: 1. Provide iron rich-foods
• Bleeding - the most common cause − Organ meats (liver)
• Mal-absorption − Beans
• Malnutrition − Leafy green vegetables
• Alcoholism
− Raisins and molasses
PATHOPHYSIOLOGY: 2. Administer iron
The body stores of iron decrease, leading to – Oral preparations tablets - Fe fumarate,
depletion of hemoglobin synthesis sulfate and gluconate
The oxygen carrying capacity of hemoglobin – Advise to take iron ONE hour before meals
is reduced→ tissue hypoxia – Take it with vitamin C
ASSESSMENT FINDINGS: – Continue taking it for several months
• Pallor of the skin and mucous membrane – Oral preparations – liquid
• Weakness and fatigue – It stains teeth
• General malaise – Drink it with a straw
• Pica – Stool may turn blackish - dark in color
• Brittle nails – Advise to eat high-fiber diet to counteract
• Smooth and sore tongue
• Angular cheilosis constipation
LABORATORY FINDINGS: − IM preparation
◦ CBC - Low levels of Hct, Hgb and RBC count. − Administer DEEP IM using the Z - track method
◦ Low serum iron, low ferritin − Avoid vigorous rubbing
◦ Bone marrow aspiration - MOST definitive − Can cause local pain and staining

MEGALOBLASTIC ANEMIA
⎯ Anemias characterized by abnormally
VITAMIN B12 DEFICIENCY
large RBC secondary to impaired DNA CAUSATIVE FACTORS:
synthesis due to deficiency of Folic acid • Strict vegetarian diet
and/or vitamin B12 • Gastrointestinal malabsorption
• Crohn's disease
FOLIC ACID DEFICIENCY • Gastrectomy
CAUSATIVE FACTORS:
• Alcoholism
• Mal-absorption
• Diet deficient in uncooked vegetables
PATHOPHYSIOLOGY:
Decreased folic acid → impaired DNA
synthesis in the bone marrow → impaired
RBC development, impaired nuclear
maturation but Cytoplasmic maturation
continues → large size
– 52 –
 APLASTIC ANEMIA PERNICIOUS ANEMIA
⎯ A condition characterized by decreased ⎯ Due to the absence of Intrinsic Factor
number of RBC as well as WBC and secreted by the parietal cells
platelets ⎯ Intrinsic factor binds with Vit. B12 to
CAUSATIVE FACTORS: promote absorption
• Environmental toxins- pesticides, benzene
• Certain drugs - Chemotherapeutic agents, ASSESSMENT FINDINGS:
chloramphenicol, phenothiazines, Sulfonamides • Weakness
• Heavy metals • Fatigue
• Radiation • Listless
PATHOPHYSIOLOGY • Neurologic manifestations are present only in
Toxins cause a direct bone marrow depression → • Beefy, red, swollen tongue
acellular bone marrow → decreased production • Mild diarrhea
of blood elements • Extreme pallor
ASSESSMENT FINDINGS: • Paresthesias in the extremities
• Fatigue LABORATORY FINDINGS:
• Pallor o Peripheral blood smear-shows giant RBCs,
• Dyspnea
WBCs with giant hyper-segmented nuclei
• Bruising
• Splenomegaly o Very high MCV
• Retinal hemorrhages o Schilling's test
o Intrinsic factor antibody test
LABORATORY FINDINGS:
o CBC - decreased blood cell numbers MEDICAL MANAGEMENT:
o Bone marrow aspiration confirms the anemia - a. Vitamin supplementation
hypoplastic or acellular marrow replaced by - Folic acid 1 mg daily
fats b. Diet supplementation
- Vegetarians should have vitamin intake
MEDICAL MANAGEMENT: c. Lifetime monthly injection of IM Vit B12
a. Bone marrow transplantation
b. Immunosupressant drugs NURSING MANAGEMENT:
c. Rarely, steroids 1. Monitor patient
d. Blood transfusion 2. Provide assistance in ambulation
3. Oral care for tongue sore
NURSING MANAGEMENT: 4. Explain the need for lifetime IM injection of vit
1. Assess for signs of bleeding and infection B12
2. Instruct to avoid exposure to offending agents

– 53 –
 HEMOLYTIC ANEMIA: NURSING MANAGEMENT:
1. Manage the pain
SICKLE CELL − Support and elevate acutely inflamed joint
⎯ A severe chronic incurable hemolytic − Relaxation techniques
− Analgesics
anemia that results from heritance of the 2. Prevent and manage infection
sickle hemoglobin gene. − Monitor status of patient
CAUSATIVE FACTOR: − Initiate prompt antibiotic therapy
Genetic inheritance of the sickle gene 3. Promote coping skills
− Provide accurate information
– HbS gene
− Allow patient to verbalize her concerns about
PATHOPHYSIOLOGY medication, prognosis and future pregnancy
Decreased 02, Cold, Vasoconstriction can 4. Monitor and prevent potential complications
− Provide always adequate hydration
precipitate sickling process
− Avoid cold, temperature that may cause
Factors → cause defective hemoglobin to vasoconstriction
acquire a rigid, crystal-like C-shaped − Leg ulcer
▪ Aseptic technique
configuration → Sickled RBCs will adhere − Priapism
to endothelium → pile up and plug the ▪ Sudden painful erection
vessels → ischemia results → pain, ▪ Instruct patient to empty bladder, then take
swelling and fever a warm bath

ASSESSMENT FINDINGS:
• Jaundice
• Enlarged skull and Facial bones
• Tachycardia, murmurs and cardiomegaly
- Primary sites of thrombotic occlusion: spleen,
lungs and CNS
- Chest pain, dyspnea
1. Sickle cell crises
− Results from tissue hypoxia and necrosis
2. Acute chest syndrome
− Manifested by a rapidly falling hemoglobin
level, tachycardia, fever and chest infiltrates
in the CXR
MEDICAL MANAGEMENT:
a. Bone marrow transplant
b. Hydroxyurea Increases the HbF
c. Long term RBC transfusion

;
POLYCETHEMIA
⎯ Refers to an INCREASE volume of RBCs CAUSATIVE FACTOR – unknown
⎯ The hematocrit is ELEVATED to more than
PATHOPHYSIOLOGY
55% • The stem cells grow uncontrollably
⎯ Classified as Primary or Secondary • The bone marrow becomes HYPERcellular and
POLYCYTHEMIA VERA all the blood cells are increased in number
• Primary Polycythemia • The spleen resumes its function of hematopoiesis
• A proliferative disorder in which the myeloid and enlarges
stem cells become uncontrolled • Blood becomes thick and viscous causing sluggish
circulation
• Overtime, the bone marrow becomes fibrotic

– 54 –
 POLYCETHEMIA POLYCETHEMIA
ASSESSMENT FINDINGS: MEDICAL MANAGEMENT:
• Skin is ruddy a. To reduce the high blood cell mass –
• Splenomegaly PHLEBOTOMY
• Headache b. Allopurinol
• dizziness, blurred vision c. Dipyridamole
• Angina, dyspnea and thrombophlebitis d. Chemotherapy to suppress bone marrow
LABORATORY FINDINGS: NURSING MANAGEMENT:
o CBC - shows elevated RBC mass 1. Primary role of the nurse is EDUCATOR
o Normal oxygen saturation 2. Regularly assess for the development of
o Elevated WBC and Platelets complications
3. Assist in weekly phlebotomy
COMPLICATIONS: 4. Advise to avoid alcohol and aspirin
• Increased risk for thrombophlebitis, CVA and MI 5. Advise tepid sponge bath or cool water to
• Bleeding due to dysfunctional blood cells manage pruritus

LEUKEMIA
⎯ Malignant disorders of blood forming cells
ASSESSMENT FINDINGS:
characterized by UNCONTROLLED
ACUTE LEUKEMIA
proliferation of WHITE BLOOD CELLS in
• Pallor
the bone marrow-replacing marrow • Fatigue
elements. The WBC can alsoproliferate in • Dyspnea
the liver, spleen and lymph nodes. • Hemorrhages
⎯ The leukemias are named after the specific • Organomegaly
lines of blood cells affected primarily • Headache
• Myeloid • Vomiting
• Lymphoid CHRONIC LEUKEMIA
• Monocytic • Less severe symptoms
⎯ The leukemias are named also according • organomegaly
to the maturation of cells LABORATORY FINDINGS:
ETIOLOGIC FACTORS ◦ Peripheral WBC count varies widely I
• UNKNOWN ◦ Bone marrow aspiration biopsy reveals a large
• Probably exposure to radiation percentage of immature cells – BLASTS
• Chemical agents ◦ Erythrocytes and platelets are decreased
• Infectious agents
• Genetic MEDICAL MANAGEMENT:
ACUTE = The cells are primarily immature a. Chemotherapy
• ACUTE myelocytic leukemia b. Bone marrow transplantation
• ACUTE lymphocytic leukemia NURSING MANAGEMENT:
CHRONIC = The cells are primarily mature or 1. Manage AND prevent infection
differentiated − Monitor temperature
• CHRONIC myelocytic leukemia − Assess for signs of infection
• CHRONIC lymphocytic leukemia − Be alert if the neutrophil count drops below
1,000 cells/mm3
PATHOPHYSIOLOGY of ACUTE Leukemia 2. Maintain skin integrity
Uncontrolled proliferation of immature cells 3. Provide pain relief
→ suppresses bone marrow function → 4. Provide information as to therapy- chemo and
severe anemia, thrombocytopenia and bone marrow transplantation
granulocytopenia
PATHOPHYSIOLOGY of ACUTE Leukemia
Uncontrolled proliferation of DIFFERENTIATED
cells → slow suppression of bone marrow
function → milder symptoms
– 55 –
 MEDICAL SURGICAL I

GENITOURINARY SYSTEM
ANATOMY AND PHYSIOLOGY
KIDNEYS
• Each person has 2 kidneys; each is
attached to the abdominal wall at
the level of the thoracic and first 3
lumbar vertebrae
• The kidneys are enclosed in the
renal capsule
• CORTEX – outer layer; contains
blood-filtering mechanisms
• MEDULLA – inner layer;
surrounded by the cortex which
contains the renal pyramids
• NEPHRON – functional unit of the
kidneys
FUNCTIONS OF KIDNEYS:
1. Maintain homeostasis of blood and acid-base
SECRETION:
balance - PROXIMAL TUBULE – uric acid, bile salts,
2. Excrete end products of body metabolism metabolites, some drugs, some creatinine
3. Control fluid and electrolyte balance - DISTAL TUBULE – most active secretion takes
4. Excrete bacterial toxins, water-soluble drugs, place here including organic acids, K+, H+,
and drug metabolites drugs, Tamm-Horsfall protein (main component
5. Secrete renin and erythropoietin, which play a of hyaline casts)
role in the function of the parathyroid hormones BLADDER
and vit. D • The bladder detrusor muscle, composed of smooth
NEPHRON muscle
- The nephron ids the functional renal unit o Filling – distends; emptying – contracts
- The nephron is composed of glomerulus and • URETEROVESICAL SPHINCTER – prevents urine
tubules reflux from bladder to the ureter
- Functional renal unit (1,000,000) • CAPACITY: 500-1500 mL
- Responsible for urine formation: filtration, • OUTER LAYER – loose connective tissue
secretion, • MIDDLE LAYER – smooth muscle and elastic fibers
- reabsorption
• INNER LAYER – lined with transitional epithelium
GLOMERULUS
• Is encased in Bowman’s capsule URETHRA
• Filters the fluid out of blood • Extends from the base of the bladder to the
outside world
TUBULES • Anatomical differences:
- Include proximal, distal, and Henle’s loop − Female: 3-5 cm
- Fluid is converted to urine in the tubules, and
− Male: 14-16 cm
then the urine moves to the pelvis of the kidney
- The urine flows from the pelvis of the kidney URETERS – 25-30 cm long
through the ureter and empties into the bladder
ADRENAL GLANDS
GLOMERULAR FILTRATION RATE • One adrenal gland is on top of each kidney
– measure of functional capacity of the kidney • Influence blood pressure, sodium and water
• Dependent on the difference in pressures retention
between capillaries and Bowman’s space
PROSTATE GLAND
• Depends on the difference in hydrostatic and • Surrounds the male urethra
oncotic pressure on either side of the glomerular • Contains a duct that opens into the prostatic
basement membrane portion of the urethra and secretes the alkaline
• N = 120 mL/min = 7.2 L/h = 180 L/day (99% of portion of seminal fluid, which protects passing
fluid filtered is reabsorbed) sperm
– 56 –
 RISK FACTORS ASSOCIATED WITH RENAL DISORDERS
• Chemical or environmental toxin exposure
• Contact sports
• Diabetes mellitus
• Family history of renal disease
• Frequent UTIs
• Heart failure
• High sodium diet

DIAGNOSTIC TEST
URINE STUDIES URINE COLLECTION METHODS
1. URINALYSIS – examination to assess the nature 1. ROUTINE URINALYSIS
of urine produced. - Wash perineal area if soiled
a. Evaluates color, pH, and specific gravity - Obtain first voided morning specimen
• Color: pale to amber - Send to lab immediately – should be
• Volume: 30 ml/hr examined within 1 hour of voiding
• Appearance: clear 2. CLEAN CATCH (MIDSTREAM) SPECIMEN
• Odor: aromatic then strong ammoniacal FOR URINE CULTURE
odor
• Specific gravity: 1.015-1.025 (24h urine • Cleanse perineal area
collection) ◦ FEMALE – spread the labia and cleanse the
• 1.003-1.030 (random specimen) meatus front to back using anti-septic
• pH: 4.8 – 8.0 sponges
b. Determines the presence of glucose, protein, ◦ MALE – retract foreskin (if uncircumcised)
ketones, and blood and cleanse glass with antiseptic sponges
c. Analyzes sediment for cells (WBC, casts
bacteria, crystals)
• Have client initiate urine stream then stop
2. URINE CULTURE AND SENSITIVITY
• Collect specimen in a sterile container
– diagnoses bacterial infection of the urinary • Have client complete urination, but not in
tract specimen container
3. 24-HOUR URINE SPECIMEN
3. RESIDUAL URINE
– preferred method for creatinine clearance test
– amount of urine left in the bladder after
voiding measured via catheter (permanent ◦ Have client void and discard specimen; note
or temporary) in bladder time
4. CREATININE CLEARANCE ◦ Collect all subsequent urine specimens for 24h
– determines amount of creatinine in the ◦ If specimen is accidentally discarded, the test
urine over 24h; measures overall renal must be restarted
function; measures GFR ◦ Record exact start and finish of collection;
include date and time
BLOOD STUDIES
BICARBONATE – 22-26 mEq/L KIDNEY, URETER, BLADDER
– measures renal ability to – x-ray of the urinary system and adjacent
BUN excrete urea nitrogen structures used to detect urinary calculi
– Normal: 5-20 mg/dL
INTRAVENOUS PYELOGRAM (IVP)
CALCIUM – 9.0-10.5 mg/dL – fluoroscopic visualization of the urinary tract
– Specific tests for renal after injection with a radiopaque dye
SERUM disorders reflect ability of
CREATININE kidneys to excrete Pre-test nursing care:
creatinine • Assess for iodine sensitivity
– 0.7-1.5 mg/dL • Obtain consent
PHOSPHORUS – 2.5-4.5 mg/dL • Inform client he will lie on a table throughout the
SODIUM – 136-145 mEq/L procedure
• Administer cathartic or enema the night before
POTASSIUM – 3.5-5 mEq/L
• Keep the client NPO for 8h pretest
SERUM URIC – 2.5-8.0 mg/d
• Inform client about possible throat irritations,
ACID face flushing, warmth or salty taste that may be
experienced during the test
– 57 –
 IVP CYSTOSCOPY
Post-test nursing care:
• Force fluids – Use of a lighted scope (cystoscope) to inspect
• Assess venipuncture site for bleeding the bladder
• Monitor VS for U/O – Inserted into the bladder via the urethra
– May be used to remove tumors, stones, or
RENAL ANGIOGRAPHY other foreign material or to implant radium,
– injection of a radiopaque dye through a place catheters in ureters
catheter for examination of the renal artery
supply Pre-test nursing care:
• Explain to client that the procedure will be
Pre-test nursing care: done under general/local anesthesia
• Obtain consent • Obtain consent
• Assess client for allergies to iodine, seafoods, • Confirm consent form is signed
and radiopaque dyes • Administer sedatives 1h before the test, as
• Inform patient about possible burning sensation ordered
along the vessel • General anesthesia – keep client on NPO
• NPO post-midnight before the test • Local anesthesia – offer liquid breakfast
• Instruct the client to void immediately before
the procedure Post-test nursing care:
• Shave injection sites as prescribed • Monitor V/S and I/O
• Assess and mark the peripheral pulses - Pink-tinged or tea-colored urine
= expected
Post-test nursing care: - Bright red urine or presence of large clots
• Assess V/S and peripheral pulses = report
• Provide bedrest and use of sandbag at the • Advise client that burning on urination is
insertion site for 4-8h normal and will subside
• NPO post-midnight before the test • Encourage DBE to relieve bladder spasms
• Assess color and temperature of the involved • Administer sitz baths for back and abdominal
extremity pain
• Force fluids unless contraindicated • Administer analgesics as prescribed
• Monitor urinary output DISORDERS OF THE • Force fluids as prescribed
GENITOURINARY SYSTEM

DISORDERS OF THE GENITO-URINARY TRACT

URINARY TRACT INFECTION CYSTITIS

CLINICAL FINDINGS:
PREDISPOSING FACTORS: ◦ Abdominal or flank pain/tenderness
• Poor hygiene ◦ Frequency and urgency of urination
• Irritation from bubble baths ◦ Pain on voiding
• Urinary reflux ◦ Nocturia
CLINICAL FINDINGS: ◦ Fever
◦ Low-grade fever CAUSES:
◦ Abdominal pain ◦ Bubble bath, allergens, bladder distention,
invasive urinary tract procedures
◦ Pain/burning on urination ◦ Sexually active and pregnant women are most
◦ Frequency of urination vulnerable
◦ Hematuria ◦ Poor-fitting diaphragms
NURSING CARE: ◦ Use of spermicides
a. Administer antibiotics as ordered ◦ Wet bathing suits
- Prevention of kidney DIAGNOSTIC TESTS:
infection/glomerulonephritis • Urine culture and sensitivity
- Obtain cultures before starting antibiotics − presence of E. coli (80%)
b. Provide warm sitz baths to alleviate painful • MOST COMMON CAUSITIVE AGENT:
E. coli, Enterobacter, pseudomonas, serratia
voiding
c. Force fluids NURSING CARE:
d. Encourage measures to acidify urine a. Force fluids – 3L/day
e. Provide client teaching and discharge b. Warm sitz bath for comfort
c. Assess urine for odor, hematuria, and sediment
planning d. Use strict aseptic technique in FBC
– 58 – e. Administer medications as ordered
 CYSTITIS
CLIENT TEACHING:
1. Acidic urine diminishes the action of aminoglycoside, sulfonamide, nitrofurantoin (macrodantin)
2. Discourage caffeine products such as coffee, tea, cola
3. Avoid alcohol
4. Wipe perineal area from front to back
5. Void and drink a glass of water after intercourse
6. Void q2h
7. Encourage menopausal women to use estrogen vaginal creams to restore Ph
8. Instruct female client to use water-soluble lubricants for coitus, especially after menopause

PYELONEPHRITIS
⎯ Inflammation of the renal pelvis and NURSING CARE:
parenchyma, commonly caused by a. Monitor I/O
bacterial invasion b. EOF
ACUTE INFECTION c. Encourage adequate rest
d. Administer antibiotics and analgesics as
– Usually ascends from the lower urinary tract or
ordered
following on invasive procedures of the urinary
e. Support client and significant others and
tract
explain the possibility of dialysis, transplant
– Can progress to bacteremia or chronic options, if there is significant renal
pyelonephritis deterioration
ASSESSMENT: f. Provide client teaching and discharge
• Fever, chills, planning
• Nausea, vomiting
• CVA tenderness, flank pain on affected side − Medication regimen
• Headache, muscular pain, dysuria − Diet: high calorie, low protein
• Frequency and urgency
CHRONIC INFECTION
– Major cause: ureterovesical reflux
– Result of recurrent infections is eventual
parenchymal deterioration and possible renal
failure
ASSESSMENT:
• Usually unaware of the disease
• May have bladder irritability
• Chronic fatigue
• Slight dull ache over kidneys
• Eventually develops HPN, kidney atrophy
• azotemia

NEPHROTIC SYNDROME
(NEPHROSIS)
GENERAL INFORMATION:
– Autoimmune process leading to structural
alteration of glomerular membrane that
results in increased permeability to
plasma proteins, particularly albumin
– Course of the disease consists of
exacerbations and remissions over a
period of months to years
– Commonly affects preschoolers (boys
more often than girls)
– Prognosis is good unless edema does not
respond to steroids

– 59 –
 NEPHROSIS NEPHROSIS
CLINICAL FINDINGS: NURSING CARE:
◦ Proteinuria, hypoproteinemia, hyperlipidemia a. Provide bedrest
◦ Dependent body edema − Conserve energy
- Puffiness around eyes during AM − Find activities for quiet play
- Ascites b. Provide high protein, low sodium diet during
- Scrotal edema
- Ankle edema edema phase only
◦ Anorexia, vomiting, diarrhea, malnutrition c. Maintain skin integrity
◦ Pallor, lethargy − Don’t use band-aids
◦ Hepatomegaly − Avoid IM injections – medication is not
absorbed (edema)
MEDICAL MANAGEMENT:
d. Obtain morning urine for protein studies
a. Drug therapy
e. Provide scrotal support
• Corticosteroids – to resolve edema f. Monitor I/O, V/S, and watch out for
• Antibiotics – for bacterial infections dehydration
• Thiazide diuretics – edematous stage g. Administer steroids – to suppress autoimmune
b. Bedrest response
c. Diet modification – high protein, low sodium h. Protect from known sources of infection

ACUTE GLOMERULONEPHRITIS
GENERAL INFORMATION: NURSING CARE:
– Immune complex disease resulting from an a. Monitor I/O, BP, urine, and watch out for
antigen-antibody reaction dehydration
– Secondary to a beta-hemolytic streptococcal b. Provide diversional therapy
c. Provide client teaching and planning
infection occurring elsewhere
- Medication administration
– Occurs more frequently in boys, usually - Prevention of infection
between ages 6-7 years - Signs of renal complications
– Usually resolves in about 14 days - Importance of long-term follow-up
– Self-limiting
CLINICAL FINDINGS:
◦ Hx of a precipitating strep infection, usually
URTI or impetigo
◦ Edema, anorexia, lethargy
◦ Hematuria or dark-colored urine
◦ Fever
◦ Hypertension
DIAGNOSTIC FINDINGS:
• U/A
− reveals RBCs, WBCs, CHON, cellular casts
• ↑ urine specific gravity, BUN, serum creatinine,
ESR
• ↓ Hgb, Hct

– 60 –
 HYDRONEPHROSIS
CLINICAL FINDINGS:
◦ Repeated UTIs
◦ Failure to thrive
◦ Abdominal pain, fever
◦ Fluctuating mass in region of kidney
MEDICAL MANAGEMENT:
• Surgery to correct or remove obstruction
NURSING CARE:
a. Monitor V/S frequently Post-operative care:
b. Monitor for fluid and electrolyte imbalance • Monitor drains
including dehydration after the obstruction is • may have one from bladder and one from each
relieved ureter (ureteral stents)
c. Monitor diuresis which could lead to fluid • Check output from all drains and record carefully
depletion • expect bloody urine initially
d. Watch out for dehydration • Observe drainage from abdominal dressing and
e. Monitor urine for specific gravity, albumin, and note color, amount, and frequency
glucose • Administer medication for bladder spasms as
f. Administer fluid replacement as prescribed ordered

NEPHROLITHIASIS/UROLITHIASIS
GENERAL INFORMATION:
– Presence of stones anywhere in the urinary
tract
– Frequent composition of stones:Calcium
(phosphate), uric acid, cystine (rare) stones
– Most often occurs in men aged 20-55 years;
more common in the summer
PREDISPOSING FACTORS:
• Diet – large amount of calcium, oxalate
• ↑ uric acid levels
• Sedentary lifestyles, immobility
• Family history of gout or calculi
• Hyperparathyroidism
CLINICAL FINDINGS:
◦ Abdominal/flank pain
◦ Renal colic MEDICAL MANAGEMENT:
− severe pain in the kidney area radiating a. SURGERY
down the flank to the pubic area • PERCUTANEOUS NEPHROSTOMY – tube is
◦ Hematuria, frequency, urgency, nausea inserted through skin and underlying tissues
◦ Hx of prior associated health problems into renal pelvis to remove calculi
− Gout, Parathyroidism, Immobility, • PERCUTANEOUS NEPHROLITHOTOMY –
Dehydration, UTI delivers ultrasonic waves through a probe
◦ Diaphoresis, pallor, grimacing, vomiting placed on the calculus
◦ Pyuria if infection is present
b. PERCUTANEOUS ULTRASONIC LITHOTRIPSY
NURSING CARE: (PUL)
a. Strain all urine through gauze to detect stones – nephroscope is inserted through skin into kidney;
and crush all clots ultrasonic waves disintegrate stones that are
b. Force fluids – (3000 – 4000 ml/day)4 L/day then removed by suction and irrigation
c. Encourage ambulation to prevent stasis
c. Extracorporeal shock-wave lithotripsy (ESWL)
d. Relieve pain by administration of analgesics as
ordered and application of moist heat to flank – a non-invasive procedure where client is
area placed in water and exposed to shock waves
e. Monitor I/O that disintegrate stones so they can be passed
f. Provide modified diet, depending upon stone with urine
consistency
– 61 –
 NEPHROLITHIASIS/UROLITHIASIS
DIET MODIFIED/STONE ❖ CYSTINE STONES (rare)
❖ CALCIUM STONES • Low methionine
• Low Calcium diet (400 mg daily) − Methionine is the essential amino acid
• Achieved by eliminating milk/dairy products from which the non-essential amino acid
• Provide acid-ash diet to acidify urine cystine is formed
- Cranberry • Limit protein foods
- Prune juice
- Meat − Meat, milk, eggs, cheese
- Eggs • Maintain alkaline-ash diet
- Poultry
- Fish NURSING CARE:
- Grapes a. Administer allopurinol (Zyloprim) as ordered
- Whole grains − To decrease uric acid production
- Take Vit. A & C, folic acid supplements − Force fluids when giving allopurinol
and riboflavin b. Encourage daily weight-bearing exercises
❖ OXALATE STONES c. Provide client teaching and discharge planning
• Avoid excess intake of foods/fluids high in – Prevention of urinary stasis by EOF especially
oxalate in hot weather and during illness, mobility,
- Tea voiding whenever the urge is felt and at least
- Chocolate twice during the night
- Rhubarb – Adherence to prescribed diet
- Spinach – Need for routine urinalysis – at least q3-4
• Maintain alkaline-ash diet to alkalinize urine months
- Milk – Need to recognize and report s/s of
- Vegetables recurrence: hematuria, flank pain
- Fruits except prunes, cranberries, and plums d. Provide care following a nephrolithotomy or PUL
– Change dressings frequently during the first
❖ URIC ACID STONES 24h after a nephrolithotomy
• Uric acid – metabolic product of purines – Maintain patency of ureteral and urethral
• Reduce foods high in purine catheter to prevent hydronephrosis
− Liver, brains, kidneys, venison, shellfish, – Encourage use of incentive spirometry and
meat soups, gravies, legumes, whole grains coughing and deep breathing to prevent
• Maintain alkaline urine – alkaline-ash diet atelectasis

ACUTE RENAL FAILURE

⎯ Sudden loss of kidney function and is
caused by renal cell damage from
ischemia or toxic substances
⎯ Occurs abruptly and can be reversible
⎯ It leads to hypoperfusion, cell death, and
decompensation in renal function
PRE-RENAL POST-RENAL
INTRARENAL
CAUSES CAUSES
Hypotension Acute Tubular Calculi
Necrosis (ATN) PATHOPHYSIOLOGY
Cardiogenic Diabetes Mellitus Tumors • Acute Renal Failure (ARF) is a reversible clinical
shock syndrome where there is a sudden and almost
Acute Malignant Blood clots complete loss of kidney function (↓ GFR) over a
Vasoconstriction Hypertension period of hours to days with failure to excrete
Hemorrhage Acute BPH nitrogenous waste products and to maintain fluid
Glomerulonephritis and electrolyte homeostasis
• ARF manifests as an increase in serum creatinine
Burns Tumors Strictures and BUN
Septicemia Blood Transfusion Trauma • Urine volume may be normal, or changes may
reaction occur. Possible changes include; oliguria,
CHF Nephrotoxins Anatomic polyuria, or anuria
malformation • Some of the factors may be reversible or
identified and treated promptly, before kidney
function is impaired
– 62 –
 PHASES OF ACUTE RENAL FAILURE: ASSESSMENT AND DIAGNOSTIC FINDINGS:
THERE ARE FOUR CLINICAL PAHSES OF ARF: • U/O varies (scanty to normal volume), hematuria
1. INITIATION PERIOD may be present, and the urine has a low specific
– begins with the initial insult and ends when gravity
oliguria develops • Ultrasonography is a critical component of the
evaluation of patients with renal failure
2. OLIGURIA PERIOD • A renal sonogram or CT/MRI scan may show
– is accompanied by an increase in the serum
evidence of anatomical changes
concentration of substances usually excreted by
• BUN level increases
the kidneys (urea, creatinine, uric acid, organic
• Serum creatinine increases. Serum creatinine
acids, and the intracellular cations [potassium
levels are useful in monitoring kidney function and
and magnesium])
disease progression
Oliguric phase: • Hyperkalemia
1. Duration of 5-8 days; the longer the duration,
the less chance of recovery
• Metabolic acidosis
2. Sudden drop in urine output (<400 mL/day) • Increase in blood phosphate concentrations
3. ↓ urine specific gravity • Calcium levels may be low
4. Anorexia, nausea, vomiting • Anemia is another common laboratory finding in
5. Hypertension ARF, as a result of reduced erythropoietin
6. ↓ skin turgor production, uremic GI lesions, reduced RBC life
7. Pruritus, tingling of the extremities span, and blood loss – usually from the GI tract
8. Drowsiness progressing to disorientation to coma
9. Edema MEDICAL MANAGEMENT:
10. Dysrhythmias – Objectives: restore normal chemical balance and
11. Signs of CHF and pulmonary edema prevent complications until repair of renal tissue
12. Signs of pericarditis and restoration of renal function can occur
13. Signs of acidosis
– Maintaining fluid balance
3. DIURESIS PERIOD – Avoiding fluid excess
– marked by a gradual increase in urine output, a. PHARMACOLOGIC THERAPY
which signals that glomerular filtration has ◦ Carbon-exchange resins
started to recover - sodium polystyrene sulfonate (Kayexalate)
Diuretic phase: orally or by retention enema
1. Urine output rises slowly, then diuresis occurs (4-5 - to reduce elevated K levels
L/day) ◦ Sorbitol in conjunction with Kayexalate – to
2. Excessive urine output = recovery of damaged induce a diarrheatype effect (induces water
nephrons loss in the GI tract)
3. Hypotension ◦ Kayexalate retention enema is administered
4. Tachycardia ◦ If the patient is hemodynamically unstable (low
5. Level of consciousness improves
blood pressure, changes in mental status,
4. RECOVERY PERIOD dysrhythmia)
– signals the improvement of renal function and ◦ IV dextrose 50%, insulin and calcium
may take 3-12 months replacement may be administered to shift
CLINICAL MANIFESTATIONS: potassium back into the cells
◦ Adjust antibiotic medications (aminoglycosides),
• The patient may appear critically ill and
lethargic digoxin, ACE inhibitors, and magnesium-
containing agents
• The skin and mucous membranes are dry from
◦ Diuretic agents
dehydration
◦ Severe acidosis
• CNS s/s include: drowsiness, headache, muscle
twitching, seizures b. NUTRITIONAL THERAPY
◦ The patient is weighed daily
CLINICAL FINDINGS ◦ Dietary proteins
OLIGURIC DIURETIC CONVALASCENT ◦ High-carbohydrate meals
PHASE PHASE PHASE ◦ Foods and fluids containing potassium or
Hypernatremia Hyponatremia Normal Urine Volume phosphorus (bananas, citrus fruits and juices,
Hypocalcemia Hypokalemia Increase in LOC coffee) are restricted
Hyperkalemia hypovolemia BUN stable and normal
Hyperphosphatemia May develop CHF ◦ Parenteral nutrition
Hypermagnesemia ◦ Following the diuretic phase, the patient is
Metabolic Acidosis placed on a high-protein diet and is
encouraged to resume activities gradually

– 63 –
 ACUTE RENAL FAILURE
NURSING MANAGEMENT:
a. MONITORING FLUID AND ELECTROLYTE d. PREVENTING INFECTION
BALANCE – Asepsis is essential with invasive lines and
– Parenteral fluids, all oral intake, and all catheters
medications are screened carefully – Indwelling urinary catheter is avoided
– Patient’s cardiac function and musculoskeletal e. PROVIDING SKIN CARE
status are monitored closely for signs of – Meticulous skin care is important
hyperkalemia – Turning the patient frequently, bathing
b. REDUCING METABOLIC RATE them with cool water, and keeping the skin
– Bedrest clean and well-moisturized and the
– Fever and infection are prevented or treated fingernails trimmed to avoid excoriation
c. PROMOTING PULMONARY FUNCTION f. PROVIDING SUPPORT
– Attention is given to pulmonary function – May require treatment with hemodialysis,
– The patient is assisted to turn, cough, and take peritoneal dialysis, to prevent serious
deep breaths frequently complications.

CHRONIC RENAL FAILURE

⎯ Progressive, irreversible destruction of the
CLINICAL FINDINGS:
kidneys that continues until nephrons are
replaced by scar tissue ◦ Nausea, vomiting
⎯ Loss of renal function is gradual ◦ ↓ U/O
◦ Azotemia
⎯ Hypervolemia can occur owing to the
inability of the kidneys to excrete sodium ◦ Hypertension (later)
and water, or hypovolemia can occur owing ◦ Convulsions
to inability of the kidneys to conserve sodium ◦ Pericardial friction rub
and water ◦ Uremic frost
◦ Dyspnea
CLINICAL FINDINGS ◦ Hypotension (early)
STAGE 1 STAGE 2 STAGE 3 ◦ Lethargy
Diminishes Renal End Stage ◦ Memory impairment
Renal Reserve Insufficiency
◦ CHF
STAGE 1 DIMINISHED RENAL RESERVE NURSING CARE:
• ↓ renal function a. Prevent neurologic complications
• No accumulation of metabolic wastes b. Promote optimal GI function
• The healthier kidney compensates c. Monitor/prevent alteration in fluid and
• Nocturia and polyuria occur as a result of electrolytes
decreased ability to concentrate urine d. Promote maintenance of skin integrity
e. Monitor for bleeding complications and prevent
STAGE 2 RENAL INSUFFICIENCY injury
• Metabolic wastes begin to accumulate f. Assess for hyperphosphatemia: paresthesias,
• Oliguria and edema occur as a result of muscle cramps, seizures, abnormal reflexes
decreased responsiveness to diuretics g. Administer aluminum hydroxide gels as ordered
(Amphogel, Alternagel)
STAGE 3 END STAGE h. Promote/maintain maximal cardiovascular
• Excessive accumulation of metabolic wastes function
• Kidneys are unable to maintain homeostasis i. Provide care for client receiving dialysis
• Dialysis or other renal replacement treatment is
required

– 64 –
 DIALYSIS
DIFFUSION ODMOSIS UNTRAFILTRATION
HEMODIALYSIS PERITONEAL DIALYSIS
⎯ Shunting off blood from the client’s vascular NURSING CARE:
system through an artificial dialyzing system a. Chart client’s weight
and return of dialyzed blood to the client’s b. Assess V/S before, q15min during first
circulation exchange, and qh thereafter
c. Assemble specially-prepared dialysate solution
⎯ Dialysis coil acts as the semi-permeable with added medications
membrane d. Have client void
⎯ Dialysate is a specially prepared solution e. Warm dialysate solution to body temperature
⎯ External AV shunt, AV fistula, femoral vein f. Assist physician with trocar insertion
catheterization, subclavian vein ✓ INFLOW – allow dialysate to flow unrestricted
catheterization into peritoneal cavity; 10-20 mins.
✓ DWELL – allow fluid to remain in peritoneal
Pre-Nursing Care: cavity for prescribed period; 30-45 mins.
• Have client void ✓ DRAIN – unclamp outflow tube and allow to
• Chart client’s weight flow by gravity
g. Observe characteristics of dialysate outflow
• Assess V/S before and q30min during ✓ Clear, pale yellow = normal
procedure ✓ Cloudy = infection, peritonitis
• Withhold antihypertensives, sedatives, and ✓ Brownish = bowel perforation
vasodilators – to prevent hypotensive episode ✓ Bloody = common during first few exchanges;
(unless ordered otherwise) abnormal if continuous
• Ensure bedrest with frequent position changes h. Monitor I/O and maintain records
for comfort i. Assess for complications
• Inform client that headache and nausea may j. Peritonitis
occur k. Respiratory difficulty
• Monitor closely for signs of bleeding since blood l. Protein loss
has been heparinized for procedure
KIDNEY TRANSPLANTATION
Post-Nursing Care:
• Transplantation of a kidney from a donor to
• Chart client’s weight
recipient to prolong the life of person with renal
• Assess for complications:
failure
✓ HYPOVOLEMIC SHOCK – may occur as a
result of rapid removal or ultrafiltration of SOURCES OF DONOR SELECTION:
fluid from the intravascular compartment − Living relative with compatible serum and tissue
✓ DIALYSIS DISEQUILIBRIUM SYNDROME – studies, free from systemic infection and
urea is removed more rapidly from the blood emotionally stable
than from the brain; assess for nausea, − Cadavers with good serum and tissue
vomiting, elevated BP, disorientation, leg crossmatching, free from renal disease,
cramps, and peripheral paresthesias neoplasm and sepsis, absence of
ischemia/trauma
NUSRING CARE: POST OP
PERITONEAL DIALYSIS a. Assess for signs of rejection.
⎯ Introduction of a specially-prepared Note for:
dialysate solution into the abdominal cavity, - Decreased urine output
where the peritoneum acts as a semi- - Fever/pain over transplant site
permeable membrane between the - Edema
dialysate and blood into the abdominal - Sudden weight gain
- Increasing BP
vessels - Generalized malaise
• Continuous ambulatory peritoneal dialysis - Rise in serum creatinine
• APD - Decrease in creatinine clearance
✓ CCPD b. Provide client teaching and discharge planning
✓ IPD concerning:
✓ NPD - Medication regimen
- S/Sx of tissue rejection and the need to report it
immediately to the physician
– 65 –
 - Dietary restrictions - Restricted Na and calories
Increased CHON PROTATITIS
- Daily weights
- Daily measurements of I & 0 PROSTATE
- Resumption of activity and avoidance of contact
sports in which the transplanted kidney may be
– located below the bladder and front of the
injured rectum
– secretes milk fluid that aids the passage of
NEPHRECTOMY sperm and keeps them viable
INDICATIONS: – Inflammatory condition that affects the prostate
• Renal tumor gland
• Massive trauma TYPES
• Removal for a donor
• Polycystic kidneys • Acute Bacterial Prostatitis
• Chronic Bacterial Prostatitis
NURSING CARE: POST-OP
– N. gonorrhea, Enterobacter, proteus
a. Teach client teaching and discharge planning
species, group D streptococci
concerning:
- Need to notify physician if cold or other • Abacterial Prostatitis
infection present for more than 3 days – caused by viral illness, decreased in sexual
- Medication regimen and avoidance of OTC activity, lower UTIs
drugs that may be nephrotoxic (except with
physician approval) ASSESSMENT FINDINGS:
ACUTE
• Fever
• Chills
EPIDIDYMITIS • Dysuria
EPIDIDYMIS: • Urethral discharge
• 1st part of the ductal system • Prostatic tenderness
• Stored spermatozoa while they mature • Copious purulent discharge upon palpation
• Presence of WBC in prostatic secretions
EPIDIDYMITIS
– Inflammation of epididymis CHRONIC
– one of the most common intra-scrotal infections • Backache
• Perineal pain
• Mild dysuria
ETIOLOGY: May be sexually transmitted, usually
• Frequency
caused by N. gonorrhea, C. trachomatis, also • Enlarged, firm prostate
caused by GU instrumentation, urinary reflux, UTI, or • Hematuria
prolonged used of foley catheter • Slightly tender prostate upon palpation
ASSESSMENT FINDINGS: DIAGNOSTIC TEST:
• Sudden scrotal pain ◦ WBC elevated
• Scrotal edema ◦ Bacteria in initial urinalysis specimens
• Tenderness over the spermatic cord
• Groin pain, swelling in groin NURSING INTERVENTIONS:
• Pus in the urine a. Administer antibiotics, analgesics,
• Fever, chills antispasmodic, and stool softeners as ordered
• (+) bacteria in urine b. Increase OFI
• Abscess development c. Provide sitz bath and rest to relieve discomfort
d. Provide client teaching
DIAGNOSTIC TEST: urine culture
– Maintaining adequate hydration
NURSING INTERVENTIONS: – Antibiotic therapy
a. Administer antibiotics and analgesics as ordered – Activities that drain the prostate
b. Provide bedrest with elevation of the scrotum to (masturbation, sexual intercourse, prostatic
prevent traction on the spermatic cord to massage)
facilitate drainage and relieve pain
c. Apply ice packs to scrotal area to decrease
edema
d. Increase fluid intake
e. Instruct to use sitz bath
f. Avoid lifting, straining, and sexual contact until
the infection subsides
– 66 –
 BENIGN PROSTATIC HYPERTROPHY
⎯ Mild to moderate glandular enlargement, CLINICAL FINDINGS:
hyperplasia, and overgrowth of the • Nocturia
smooth muscles and connective tissue • Frequency
⎯ As the gland enlarges, it compresses the • Decreased force and amount of urinary stream
urethra resulting to urinary retention • Hesitancy – difficulty in starting voiding
• Hematuria
GENERAL INFORMATION • Enlargement of prostate gland upon palpation
• Most common problem of the male reproductive by digital rectal exam
system DIAGNOSTIC TESTS
– Occurs in 50% of men over 50, ◦ Urinalysis - ↑ alkalinity, specific gravity
– 75% of men over age 75 ◦ Elevated BUN, creatinine – if long-standing BPH
• Etiology is unknown, may be r/t hormonal ◦ Prostate-specific antigen elevated – n: <4
mechanism ng/mL
◦ Cystoscopy – reveals enlargement of gland and
Unknown, Aging process, Hormonal urine flow obstruction
◦ UTZ, MRI, CT scan
(testosterone)
↓ NURSING CARE:
Increased size of prostate gland a. Administer antibiotics as ordered
↓ b. Provide client teaching concerning medications
Narrowing of the urethral lumen – Terazocin (Hytrin) – relaxes bladder
↓ sphincter and makes it easier to urinate;
Change in bladder patterns may cause hypotension and dizziness
– Finasteride (Proscar) – shrinks enlarged
↓ prostate
frequency, residual >50ml, nocturia, c. Force fluids
hesitancy, decrease in urinary dynamic flow d. Provide care for the catheterized client
↓ e. Provide care for the client with prostatic
Renal insufficiency surgery

PROSTATIC SURGERY
Indicated for BPH and prostatic cancer
PROSTATIC SURGERY
T Y P E S
Indicated for
1. BPH and prostatic cancer
TRANSURETHRAL RESECTION
◦ Prostatic tissuesTYPES are excised through a resectoscope
◦ STAGE
Does not I (BEGINNING
cause incontinence ANESTHESIA)
or impotence
◦ Patient
◦ Continuous
feels warm,bladderdizzy with a feeling
irrigation (CBI) of
detachment
◦ Done post-op to irrigate the bladder and remove blood clots
◦ Patient
◦ Donemay have3-way
through ringing,foley
buzzing in the ear,
catheter
still conscious, sense inability to move
extremities 2. SUPRAPUBIC PROSTATECTOMY
◦ Noises are exaggerated
◦ Involves removal of the prostate gland through
◦ Avoidabdominal
unnecessary andnoises
bladderor motions
incision
◦ ClientSTAGE
will haveII: cystostorhy
EXCITEMENT and 2-way foley catheter
◦ TIME:
◦ CBI
lossis of consciousness
prescribed and to loss of reflexes
administered to keep urine pink
◦ Characterized by struggling, shouting, talking,
crying. 3. RETROPUBIC PROSTATECTOMY
◦ pupils
◦ Removaldilate, ofrapid
the prostate
pulse and gland
irregular
throughRRa lower abdominal incision
◦ restrain the patient
◦ No incision site into the bladder
◦ CBI may III:
STAGE be prescribed
SURGICAL ANESTHESIA
◦ Surgical4.anesthesia
RADICAL is reached
PERINEAL PROSTATECTOMY
◦ Patient unconscious and lies quietly
◦ ◦ Respirations
Removal of are the regular
prostateand gland CR through
may bean incision made
maintained
between the forscrotum
hours ifandproperly
the anusgiven
◦ Causes incontinence and sterility
STAGE
◦ AvoidIV: MEDULLARY
inserting DEPRESSION
rectal tubes, rectal temperature taking, enemas
◦ stage is reached when too much anesthesia is
given – 67 –
◦ RR becomes shallow, pulse is weak and thready,
 4. RADICAL PERINEAL PROSTATECTOMY cont.
NURSING CARE: PRE-OP
• Provide routine pre-op care
• Information about the procedure and the expected post-op care, including
catheter drainage, irrigation, and monitoring of hematuria is discussed
• Reinforce what surgeon has told client/significant others regarding effects of
surgery on sexual function
• Bowel prep
• Force fluids, administer antibiotics, acid-ash diet to eradicate UTI
NURSING CARE: POST-OP
• Provide routine post-op care
• Maintain patency of urethral catheter placed after surgery (3-way catheter,
continuous bladder irrigation/cystoclysis)
• Prevent infection
• Relieve pain
• Reduce anxiety
• Health education and health maintenance
• Expect hematuria for 2-3 days
• Control/treat bladder spasms, encourage short frequent walks, administer
anticholinergic, antispasmodic, stool softener as ordered
• Avoid rectal temperature, enemas, monitor Hgb, hct.
• Report bright red, thick blood in the catheter, persistent clots, persistent
drainage on dressings
• Avoid heavy lifting, straining defecation and prolonged travel (at least 8-12
weeks)
TURP- CONTINUOUS BLADDER IRRIGATION
◦ Prevent bleeding and infection
◦ Teach kegel exercise prevent retention and dribbling
◦ Avoid vigorous exercise, heavy lifting, sexual intercourse for 3 weeks
after discharge
◦ Avoid straining, prolonged sitting/standing, crossing legs, long trips for
2 weeks after discharge

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 MEDICAL SURGICAL I

ONCOLOGY
CANCER Oncogenes
– are the mutated versions of the normal genes
⎯ The term cancer is generally used to refer
(commonly known as PROTO-ONCOGENES ) that
to a group of diseases associated with normally code for the growth factors and
the abnormal growth of cells. receptors, thus ensuring normal cell survival and
⎯ This growth leads to the formation of a proliferation (division).
swelling, commonly known as a tumor. – Therefore, the oncogenes are associated with
⎯ The type of tumor associated with cancer abnormal or uncontrolled cell survival and
is known as a malignant tumor. proliferation. The activation of oncogenes leads
to cancer development.
⎯ Normally, the cells of this tumor invade
the neighboring tissues and other parts of Tumor Suppressor Genes
the body, whereby they establish a – are associated with coding proteins which inhibit
secondary growth area. This phenomenon cell division (ensure controlled cell division) and
is known as metastasis. promote the normal death of cells. Mutation of
tumor suppressor genes robs their ability to
PATHOLOGICAL STAGE OF CANCER control dividing cells. Ultimately, this leads to the
Pathological stage of cancer is the stage in development of cancer.
cancer that is dictated by the appearance of the
cancer cells compared to normal cells. This is PATHOPHYSIOLOGY
normally achieved through biopsy. The pathophysiology of cancer includes the physical
and hormonal changes associated with cancer and
HOW DOES CANCER START? paraneoplastic syndrome. In general, cancer occurs in
– Cancer begins when body cells in the body begin four main stages. The pathological stage of cancer is
to grow uncontrollably. This may be triggered by determined through biopsy (removal of small body
agents that cause mutation such as radiation or tissue for laboratory examination) where the
exposure to heavy metals such as asbestos. Cancer cancerous cells are compared to normal cells.
normally starts growing in a small area and then
eventually spread to other body parts if not PHYSICAL CHANGES ASSOCIATED WITH
detected early. CANCER
MALIGNANT BENIGN
LUMPS
TUMOR TUMOR
Referred to Spread and Slow growth
as tumors, establish new rate, fixed
that can tumors in other position, less
either be tissues and life
malignant or organs around threatening
benign the body

PARANEOPLASTIC SYNDROME
Local signs and symptoms of cancer normally
manifest themselves at the primary and metastatic
sites associated with particular cancer.
One of the main causes of cancer is mutation. A
Cancer cell can also produce hormones and other
mutation is the spontaneous changes that occur in the
circulating compounds in the body such as peptides
genetic material (genes).
(chains of short amino acids). The release of such
The TWO TYPES OF GENES associated with cancer compounds leads to other clinical manifestations of
development include oncogenes and tumor this disease in sites that are not directly affected by
suppressor genes. it. These types of clinical manifestations are
collectively known as ARANEOPLASTIC
SYNDROME.
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These manifestations normally occur at distant target THE TNM STAGING SYSTEM
sites that are not directly involved with cancer. For
Tumor-Node-Metastasis
instance, a CARCINOID TUMOR (a tumor occurring in
The TNM system is the most widely used
the neuroendocrine system) releases some peptides cancer staging system and uses numbers and letters
whose effects cause wheezing, flushing, and to describe these three aspects of a cancer. It
diarrhea. In addition, lymphoma (cancer of the categorizes cancer progression for most solid tumors
lymphatic system), leads to indirect effects such as that spread to other sites in the body.
melanin deposition that is manifested as MELANOSIS • The T refers to the size and extent of the
(skin darkening). main tumor.
• The N refers to the number of nearby lymph
SIGNS AND SYMPTOMS nodes that have cancer.
• Fatigue • The M refers to whether the cancer
• Lump or area of thickening under the skin. has metastasized. This means that the cancer has
• Unintended weight loss or gain. spread from the primary tumor to other parts of
• Yellowing, darkening, or redness of skin. Sores the body.
not healing, and alterations of existing moles. T - Primary Tumor
• Changes in bowel/bladder habits. TX: Main tumor cannot be measured.
• Persistent cough and trouble breathing. T0: Main tumor cannot be found.
• Difficulty swallowing. T1, T2, T3, T4: Refers to the size and/or extent of
the main tumor. The higher the number after the T,
• Hoarseness.
the larger the tumor or the more it has grown into
• Persistent indigestion nearby tissues.
• Unexplained muscle or joint pain. N - Regional Lymph Nodes
• Fevers or night sweats. NX: Cancer in nearby lymph nodes cannot be
• Unexpected bleeding or bruising. measured.
N0: There is no cancer in nearby lymph nodes.
N1, N2, N3: Refers to the number and location of
STAGING lymph nodes that contain cancer. The higher the
number after the N, the more lymph nodes that
Cancer staging typically depends on the test results contain cancer.
or the tumor’s size to decide the overall stage. M - Distant Metastasis
– Carcinoma MX: Metastasis cannot be measured.
STAGE 0 – means there’s no cancer. M0: Cancer has not spread to other parts of the
However abnormal cells that body.
have the potential to eventually M1: Cancer has spread to other parts of the
become a cancer are present. body.
This is also called
– means the cancer is small and is
STAGE 1 present in 1 area. This is typically GRADING
called early-stage cancer.
– Early locally advanced cancer • Tumor grade is the description of a tumor
based on how abnormal the tumor cells and
STAGE 2 – slight larger that the stage 1, but the tumor tissue look under a microscope.
they’re still confined to the organ
where they started, sometimes • It assesses tumor cells under a microscope
stage tumors have spread to for size, shape, color arrangement.
small amount of nearby lymph
nodes GENERAL GRADING:
– Advanced locally advanced GX grade cannot be assessed; undetermined
cancer grade
STAGE 3
– quite large, sometimes it has well differentiated; low grade, tumor cells
spread to nearby organs that G1 look like normal tissue cells tend to spread
were initially not involves with and grow slowly
cancer and almost always include G2 moderately differentiated; intermediate
some involvement with lymph grade, somewhat abnormal
nodes. poorly differentiated; high grade, most of
– Metastatic cancer G3 the cells look abnormal tend to spread and
STAGE 4 – indicates the cancer has spread grow quickly
to other body parts. undifferentiated; highest grade, all are
G4
most abnormal cells
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ASSESSMENT: DIAGNOSTIC TESTS:
• Physical Assessment a. Biopsy
o MOLES; asymmetrical, ragged, or irregular - A procedure done in which tissue samples are
border, uneven color, large, changing in obtained to diagnose malignancy.
size, shape and color. b. X-ray
o LUMPS; large, hard, painless to touch, and - Procedures such as Mammogram and Barium
appear spontaneously. enemas are done for better visualization of
• Family History the condition.
o Obtain information both maternal and c. Bone Marrow Biopsy
paternal sides of the family to trace if the - A procedure involved in obtaining a sample of
disease is genetic. the bone marrow using a small needle being
• Personal History inserted in the bone.
o Obtain past and previous medical history d. Scans
for precancerous lesions or previous - Scans such as Bone Scans, Computed
cancer. Tomography (CT) scan, MUGA scan, and
Positron Emission Tomography and Computed
Tomography (PET-CT) scans are done for
imaging.
e. MRI
- This procedure gives a more accurate and
detailed results in imagery compared to
normal scans.
f. Endoscopic Procedures
- Procedures such as Colonoscopy,
Sigmoidoscopy, and Upper Endoscopy gives
us a clearer image of the colon to assess for
abnormal growths.
g. Tumor Marker Test
– This procedure is most often used after a
cancer diagnosis. This procedure helps
determine whether the cancer has spread to
the other parts of the body.
h. Fecal Occult Blood Tests
- A lab test used to check stool samples for
hidden (occult) blood. As blood may be an
indication of colon cancer or polyps.
i. Pap test
- This procedure is a test for cervical cancer in
women, which involves collecting cells from
the cervix for laboratory testing.

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 • INTRINSIC FACTOR: necessary for the small
STOMACH CANCER
intestine to absorb vitamin B12.

• Stomach cancer is also known as gastric cancer PATHOPHYSIOLOGY

• It is a type of disease that occurs when cells in
the stomach grow out of control RISK FACTORS
INCIDENCE in THE PHILIPPINES • H. Pylori
• Stomach cancer incidence in the Philippines is • Diet Rich in Salt, Smoked,
lower than other Asian countries. According to • Pickled, Cured, Processed Foods
WHO, deaths caused by the cancer in2020 • Smoking and Alcohol
reached 1, 868 or 0.28% of total deaths. • Family History

ANATOMY N PHYSIOLOGY CHRONIC INFLAMMMATION

STOMACH
- A digestive organ located in the upper left
abdomen
PreCancerous Lesions
- Situated next to the liver and spleen in the
upper left section of the abdomen, under the Development of Early Tumor
diaphragm
- Located between T10 and L3 vertebral segment.
LAYERS
Malignant Tumor
• SEROSA- outermost layer, protective covering.
• MUSCULARIS- smooth muscle layer for mixing METASTITIS
and moving food.
• SUBMUCOSA- connective tissue layer with blood
vessels and nerves. SIGN N SYMPTOMS
• MUCOSA -innermost layer, secretes gastric EARLY LATE
juices and protects the stomach lining.
MANIFESTATIONS MANIFESTATIONS
PARTS • Loss of appetite • Weight loss
• CARDIA- entrance of stomach near the stomach • Nausea and • Anemia
near the esophagus. vomiting • Blood usually occult in
• FUNDUS- the upper part that expands to store • Upper abdominal the stool
food. pain • Hemorrhage
• BODY- main central region for mixing and • Heartburn • Difficulty of swallowing
digestion Bloating • Loss of strength
• PYLORUS- lower part connected to the small
intestine
GASTRIC SECRETION RISK FACTORS
– combination of mucus, intrinsic factor, a. Sex – More common in men
pepsinogen, and hydrochloric acid (HCl). b. Age – 55 years old above
AMOUNT c. Ethnicity – Hispanic Americans, African
– Stomach secretes about 2-3 liters of gastric juice Americans, Native Americans, Asian Americans,
daily Pacific Islanders
PRODUCTION d. Type A blood
– Gastric acid is secreted by parietal cells in the e. Obesity
gastric glands, mainly in the body and fundus f. Epstein-Barr virus infection
regions. g. Pernicious Anemia
FUNCTIONS h. Family history of stomach cancer and genetic
• ACID PRODUCTION: Produces an acidic syndromes
environment (pH 1.5– 3.5) that supports pathogen i. Consumption of foods that are cured, smoked,
defense and enzyme activity. processed and others that are high in salt
• PEPSIN ACTIVATION: When gastric acid is j. Diet low in fruits and vegetables
present, the inactive form of pepsinogen (which k. Infection caused by Helicobacter pylori
aids in the digestion of proteins) is transformed l. Gastritis
into the active enzyme pepsin. m. Smoking
• MUCUS PROTECTION: The stomach lining is
n. Presence of polyps
shielded from acid damage by the mucus layer.

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 DIAGNOSTIC TESTS
TYPES OF STOMACH 1. Endoscopy
CANCER 2.
3.
Biopsy
CT Scan
4. Laparoscopy
❖ ADENOCARCINOMA
– It is the most common type of stomach cancer TREATMENT
that develops from the gland cells in the 1. SURGERY – Partial or Total gastrectomy
mucosa. 2. Immunotherapy
3. Chemotherapy
❖ LYMPHOMA 4. Radiation
– It is a cancer that starts in immune system cells
called lymphocytes. Some lymphomas start in
the wall of the stomach. Most lymphomas that
start in the stomach are a type of non- NURSING MANAGEMENT
Hodgkin's lymphoma. PREOPERATIVE
– Obtain consent
❖ CARCINOID TUMORS
– Check medical history (past illness, surgery,
– They start in the neuroendocrine cells, which are
medications)
found in many areas of the body.
– Check for previous use of tobacco and alcohol
❖ GIST Gastrointestinal Stromal consumption
Tumors – Do the bowel preparation
– They start in the neuroendocrine cells, which are – Administer preop medications
found in many areas of the body. – Maintain NPO 12 hours prior surgery
– Prepare the patient psychologically and
reduce the patient’s anxiety

POSTOPERATIVE
– Monitor VS
– Maintain airway patency
– Assess neurologic status
– Manage pain
– Assess the surgical site
– Assess fluid and electrolyte imbalance
– Check WBC level to monitor for infection
MOST COMMON SITES – Monitor for input and output.
1. Pyloric Antrum – Monitor for return of gag reflex.
2. Lesser Curvacture – Monitor for dumping syndrome.
3. Cardia
4. Fundus
5. Body COMPLICATIONS
❖ PLEURAL EFFUSION
❖ HEPATOMEGALY
❖ BOWEL OBCTRUCTION

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 C E R V I C AL CANCER
• Cervical cancer is a growth of cells that starts in SIGN N SYMPTOMS
the cervix. Various strains of the human • Pelvic Pain
papillomavirus, also called HPV, play a role in • Unusual vaginal discharge (watery, bloody
causing most cervical cancers. HPV is a common vaginal discharge that may be
infection that's passed through sexual contact. • heavy and have a foul odor)
• When cervical cancer happens, it's often first • Lower back pain
treated with surgery to remove the cancer. • Pain during sex
• Other treatments may include medicines to kill • Vaginal bleeding after sex
the cancer cells. • Vagina bleeding between periods
• Longer or heavier menstrual periods than
• CERVIX is a muscular, tunnel-like organ. It’s the usual
lower part of the uterus, and it connects the • Leg pain
uterus and vagina. Sometimes called the “neck • Edema of the extremities
of the uterus. • Hematuria
• Rectal pain
ANATOMY AND PHYSIOLOGY • Diarrhea
• Menstruation
• Pregnancy TYPES of CERVICAL CANCER
• Fertility • SQUAMOUS CELL CARCINOMA
– this type of cervical cancer begins in thin,
• Vaginal delivery flat cells, called squamous cells.
• Protecting the Uterus • ADENOCARCINOMA
– this type of cervical cancer begins in the
column-shaped gland cells that line the
cervical canal

STAGES OF CERVICAL CANCER

STAGE 1 - The cancer is confined to the cervix,
and has not spread beyond it.
STAGE 2 - The cancer has grown beyond the
cervix and uterus, but has not spread
to the walls of the pelvis or the lower
part of the vagina.
STAGE 3 - The cancer has spread to the lower
part of the vagina or the walls of the
pelvis. The cancer may be blocking
the ureters.
STAGE 4 - The cancer has grown into the
RISK FACTORS bladder or rectum, or to other organs
a. Smoking tobacco like the lungs or bones.
b. Increasing number of sexual partners
c. Early sexual activity SCREENING
d. Other sexually transmitted infections • Pap test - During a Pap test, a member of a
e. A weakened immune system healthcare team scrapes and brushes cells from the
f. Exposure to miscarriage prevention cervix. The cells are then examined in a lab to
medicine check for cells that look different.
• HPV DNA test - The HPV DNA test involves
PREVENTION testing cells from the cervix for infection with any
1. HPV vaccine of the types of HPV that are most likely to lead to
2. Routine Pap tests cervical cancer.
3. Practice safe sex
4. Don’t smoke

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 STAGING
• Imaging tests - Imaging tests make pictures of the
body. They can show the location and size of the
cancer. Tests might include X-ray, MRI, CT and
positron emission tomography (PET) scan.
• Visual examination of your bladder and rectum
– The doctor may use special scopes to look for
signs of cancer inside the bladder and rectum.

DIAGNOSTIC TEST
a. PUNCH BIOPSY - which uses a sharp tool to
pinch off small samples of cervical tissue.
b. ENDOCERVICAL CURETTAGE - which uses a
small, spoon-shaped instrument, called a curet,
or a thin brush to scrape a tissue sample from
the cervix.
c. ELECTRICAL WIRE LOOP - which uses a thin, low-
voltage electrified wire to take a small tissue
sample. This test also may be called a loop
electrosurgical excision procedure, also known as
LEEP.
d. CONE BIOPSY - also called conization, is a
procedure that allows your doctor to take
deeper layers of cervical cells for testing.

MANAGEMENT AND TREATMENT

a. Radiation
• Two types of Radiation:
- External beam radiation therapy
(EBRT)
- Brachytherapy
b. Chemo therapy
c. Surgery
- Some of the most common kinds of surgery
for cervical cancer include:
- Laser surgery
- Cyrosurgery
- Cone biopsy
- Simple hysterectomy
- Radical hysterectomy with pelvic lymph
node dissection
- Trachelectomy
- Pelvic exenteration
d. Targeted therapy
e. Immunotherapy

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 PANCREATIC CANCER
⎯ The pancreas lies behind the lower part of SIGN & SYMPTOMS
the stomach. It makes enzymes that help • Jaundice
digest food and hormones that help manage • Dark urine
• Light-colored stool
blood sugar.
• Upper abdominal pain
⎯ Pancreatic cancer is a type of cancer that • Middle back pain
begins as a growth of cells in the pancreas. • Fatigue
Pancreatic cancer rarely is found at its early • Itchy skin
stages when the chance of curing it is • Nausea and vomiting
greatest. This is because it often doesn't
cause symptoms until after it has spread to STAGING
other organs. – This is also known as carcinoma in
STAGE 0 situ. Cancer cells are found only in
STATISTICS the top layers of cells lining the
Incidence Mortality pancreatic ducts. It's considered a
• Pancreatic cancer • Ranks as the third pre-cancerous condition.
ranks as the twelfth leading cause of – At this stage, cancer is confined to
most common cancer-related deaths STAGE 1 the pancreas and hasn't spread
cancer globally in many countries beyond
• Accounting for 3% • The five-year survival ◦ Stage IA: Tumor is less than 2 cm in
of all cancer cases rate for pancreatic size and limited to the pancreas.
• It is also the seventh cancer is generally ◦ Stage IB: Tumor is more than 2 cm but
leading cause of low, usually ranging less than 4 cm and limited to the
cancer-related between 10% and pancreas.it.
deaths worldwide 20%. – Cancer has spread beyond the
STAGE 2 pancreas to nearby tissues or lymph
nodes but hasn't metastasized to
ETIOLOGY distant organs.
• GENETIC FACTORS
– Hereditary chronic pancreatitis due to gene – Cancer has spread beyond the
changes (mutations). STAGE 3 pancreas, involving major blood
– Hereditary syndromes with changes vessels and possibly nearby lymph
nodes, but it hasn't metastasized to
(mutations) in genes, such as BRCA1 or BRCA2
distant organs.
genes.
– Cancer has spread to distant
• LIFESTYLE FACTORS STAGE 4 organs, such as the liver, lungs, or
– Smoking peritoneum (the lining of the
– Obesity abdominal cavity).
– Alcohol Consumption
DIAGNOSTICS & LAB
DEMOGRAPHIC FACTORS ◦ Imaging Test
• Age – Occurring in individuals over 60 years – Used to diagnose pancreatic cancer include
old. ultrasound, CT scans, MRI scans and,
• Gender – Men have a slightly higher risk sometimes, positron emission tomography
compared to women. scans, also called PET scans.
• Ethnicity/Race – More common in African
Americans ◦ Genetic Testing
– Uses a sample of blood or saliva to look for
PRE-EXISTING MEDICAL CONDITIONS inherited DNA changes that increase the risk
• Chronic Pancreatitis of cancer.
• Diabetes ◦ Blood Test
• Liver Conditions – Blood tests might show proteins called tumor
markers that pancreatic cancer cells make.

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 DISCHARGE PLANNING
TREATMENT
1. SURGERY MEDICATION
– Surgery is needed to remove the tumor and – Review the patient's medication regimen.
any affected tissues, which can potentially cure – Provide detailed instructions on medication
the cancer or significantly prolong survival. administration, including dosage, timing, and
◦ Whipple Procedure (Pancreaticoduodenectomy) potential side effects.
◦ Distal Pancreatectomy – Educate the patient and family about the
importance of medication adherence and the
◦ Total Pancreatectomy
significance of each medication in managing
2. CHEMOTHERAPY
– Uses drugs to kill cancer cells or stop their TREATMENT
growth. It can be given before surgery • Schedule follow-up appointments with the
patient's oncologist, surgeon, and other healthcare
(neoadjuvant therapy) to shrink the tumor or
providers
after surgery (adjuvant therapy) to eliminate • Provide the patient and family with a detailed
remaining cancer cells. schedule of upcoming appointments, including
3. RADIATION THERAPY dates, times, and locations.
– Uses high-energy rays to target and destroy • Explain the importance of regular follow- up visits
cancer cells. It can be used in combination with to monitor treatment response, manage symptoms,
chemotherapy or as a standalone treatment. and address any concerns.

4. IMMUNOTHERAPY HEALTH TEACHING

– Discuss the importance of maintaining a healthy
– Immunotherapy helps fight pancreatic cancer
lifestyle
by enhancing the immune system's ability to – Provide resources and referrals to
recognize and attack cancer cells. dietitians/nutritionists to help the patient develop
5. TARGETED THERAPY appropriate meal plans and address nutritional
– Uses drugs that specifically target the cancer needs.
cells' genetic mutations. – Offer guidance on managing the side effects of
treatment.
6. PALLIATIVE CARE
OUT PATIENT
– Focuses on relieving symptoms and improving
• Coordinate appointments with the patient's
quality of life. This may involve pain
healthcare team.
management, nutritional support, and
• Provide the patient with a schedule of upcoming
procedures to relieve blockages in the bile duct appointments and instructions on how to prepare
or intestines. for each visit.
• Collaborate with the primary care physician to
NURSING MANAGEMENT ensure continuity of care and regular follow-up.
a. Monitor hemodynamic level • Facilitate communication between the patient and
b. Maintain hydration the healthcare team to address any concerns or
c. Assess for dehydration questions that may arise.
d. Manage pain
e. Monitor intake and output DIET
f. Provide aggressive pulmonary care – Diet as tolerated as possible.
g. Manage pancreatic enzyme insufficiency
h. Provide insulin supplementation SPIRITUAL
i. Assess for coagulopathies • Offer a compassionate & empathetic presence,
j. Assess for depression manage treatment actively listening to the patient's fears and
toxicities
k. Manage treatment toxicities anxieties.
l. Assess for psychological support • Validate the patient's emotions and provide
reassurance.
• Encourage the patient to express their feelings
DISCHARGE PLANNING openly, fostering an environment of trust and
As a nurse involved in the discharge planning for understanding.
pancreatic cancer patients, your role is vital in • Encourage the patient and family to seek
ensuring a smooth transition from the hospital to emotional and psychological support through
home or another care setting. Here are some counseling, support groups, or therapy to help
important considerations for pancreatic cancer cope with the challenges of pancreatic cancer.
discharge planning from a nursing perspective:

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