To Prank Reviewer Merged

NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH
LET*PSYCHOMET*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM

NCLEX*DHA*HAAD* PROMETRIC* UK-CBT
Fundamentals of Nursing
DEFINITIONS OF NURSING
v American Nursing Association (2003)
• “Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury,
alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of
individuals, families, communities and populations”.
v Florence Nightingale
• “Act of utilizing ENVIRONMENT of the patient to assist him in his recovery”.
v Virginia Henderson
• The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities
contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the
necessary strength, will, or knowledge, and to do his in such a way as to help him gain independence as rapidly
as possible.
NURSING THEORIESAND CONCEPTUAL FRAMEWORK

v FLORENCE NIGHTINGALE (1820 – 1910)
• Considered the first nursing theorist and earned the title “Nursing with a Lamp”
• Environmental Theory
• Five environmental factors:
ü Pure/fresh air
ü Pure water
ü Efficient drainage
ü Cleanliness
ü Light (direct sunlight)
• Deficiencies in this five factors produce lack of health or illness
• Stressed the importance of keeping the client warm, maintaining a noise free environment, attending the client’s
diet
v VIRGINIA HENDERSON
• The Nature of Nursing Model
• Conceptualizes the nurse’s role as assisting sick or healthy individuals to gain independence in meeting the
14 Fundamental Needs:
1. Breathing normally
2. Eating and drinking adequately
3. Eliminating body wastes
4. Moving and maintaining a desirable position
5. Sleeping and resting
6. Selecting suitable clothes
7. Maintaining body temperature
8. Keeping the body clean and well groomed
9. Avoiding dangers and injuring others
10. Communicating with others
11. Worshipping according to one’s faith
12. Working in such a way that one feels a sense of accomplishments
13. Participating in various recreation
14. Learning, discovering or satisfying the curiosity that leads to normal development and health
v FAYE GLENN ABDELLAH
• Patient-Centered Approaches to Nursing Model
• Identifies 21 nursing problems
• Defines nursing as a service to individuals and families
• Conceptualizes nursing as an art and science that molds the attitudes, intellectual competencies and technical
skills of the individual nurse into the desire and ability to help people, sick or well and cope with their needs
v DOROTHY E. JOHNSON
• Behavioral System Model
• Each person as a behavioral system is composed of 7 subsystem:
ü Injective
ü Eliminative
1 TOPRANK REVIEW ACADEMY- NURSING MODULE
ü Affiliative
ü Aggressive
ü Dependence
ü Achievement
ü Sexual and role identity
v IMOGENE KING
• Goal Attainment Theory
• Viewed nursing as an interaction process between patient and nurse that lead to goal attainment
• Patient has 3 interacting system
ü Operational system (individuals)
ü Interpersonal system (nurse-patient)
ü Social system (health care system)
v MADELEINE LEININGER
• Transcultural Nursing Model (Cultural Care Diversity and Universality Theory)
• Emphasizes that human caring, although universal, varies among cultures in its expressions, process and
patterns; it is largely culturally derived
• Presents 3 intervention modes:
ü Culture care preservation and maintenance
ü Culture care accommodation, negotiation or both
ü Culture care restructuring and re patterning
v MYRA ESTRIN LEVINE
• Four Conservation Principles
• Proposed principles which are concerned with the unity and integrity of the individuals
ü Conservation of energy
ü Conservation of structural integrity
ü Conservation of personal integrity
ü Conservation of social integrity
v BETTY NEUMAN
• Health Care System Model
• Asserted that nursing is unique profession in that is concerned with all the variables affecting the individuals
response to stress, which are intrapersonal stressors (within the individual), interpersonal (occurs between
individuals ) and extra personal (outside the person) in the nature
• Nursing interventions focus on retaining or maintaining system stability
v DOROTHEA OREM
• Self-care and Self-care deficit Nursing Theory
• Defines self-care as performing activities independently by individual throughout life to promote and maintain
personal well being
• Identifies 3 types of nursing system:
ü Wholly Compensatory- for individuals who are unable to control and monitor their environment
and process information
ü Partly Compensatory- designed for individuals who are unable to perform some, but not all self-
care activities
ü Supportive-Educative- for clients who need to learn to perform self-care measure and need
assistant to do so
v HILDEGARD PEPLAU
• Psychodynamic (interpersonal relations) Model
• Use of therapeutic relationship between nurse and the client
• 4 phases:
ü Orientation
ü Identification
ü Exploitation
ü Resolution
v MARTHA ROGERS
• Science of Unitary Human Being
• Views the person as an irreducible whole, the whole being is greater than the sum of its parts
• According to Rogers, unitary man:
ü Is an irreducible, four-dimensional energy field by pattern
ü Manifests characteristics different from the sum of the parts
ü Interacts continuously and creatively with the environment
ü Behaves as a totality
ü As a sentient being, participates creatively in change
v SISTER CALLISTA ROY
• Adaptation Model
• Defines adaptation as the process and outcome whereby the thinking and feeling person uses conscious
awareness and choice to create human and environmental integration
• Goal of model is to enhance life processes through adaptation in four adaptive modes:
ü Physiologic Mode
ü Self-concept mode
ü Role-function mode
ü Interdependence mode
v LYDIA HALL
• Care, Core and Cure Model
• Care- nurturance and is exclusive to nursing
• Core- involves the therapeutic use of self and emphasize the use of reflection
• Cure- focuses on nursing related to the physician’s orders
v IDA JEAN ORLANDO (1961)
• The Dynamic Nurse-Patient Relationship Model
• Nurses provide direct assistance to meet an immediate need for help in order to avoid or to alleviate distress
or helplessness
• She advocated that the three elements composing the nursing situation are:
ü Client behavior
ü Nurse reaction
ü Nurse action
v JEAN WATSON (1979)
• Human Caring Theory
• Practice of caring is central to nursing: it is the unifying focus for practice
• 10 curative factors
1. Formation of Humanistic- altruistic system of values
2. Instillation of faith and hope
3. Cultivation of sensitivity to one’s self and others
4. Development of helping – trusting relationship
5. Promoting and accepting the expression of positive and negative feelings
6. Systematically using the scientific problem-solving method for decision making
7. Promoting transpersonal teaching-learning
8. Provision of a supportive, protective and/or corrective mental, physical, societal and spiritual
environment
9. Assisting with gratification of human needs
10. Allowance for existential- phenomenological - spiritual forces
v ROSEMARIE RIZZO PARSE
• Human Becoming Theory
• Proposed 3 assumptions about human becoming:
1. Human becoming is freely choosing personal meaning in situations in the inter subjective process of
relating value priorities
2. Human becoming is co-creating rhythmic patterns or relating in mutual process with the universe
3. Human becoming is contrascending multidimensional with the emerging possibilities emphasizes how
individuals choose and bear responsibility for patterns of personal health
SCOPE OF NURSING PRACTICE

v PROMOTING HEALTH AND WELLNESS
• A process that engages in activities and behaviors that enhance quality of life and maximize personal
potential
• Activities that enhance healthy lifestyle:
ü Improving nutrition and physical fitness
ü Preventing drug and alcohol misuse
ü Restricting smoking
ü Preventing accidents and injury at home and workplace
v PREVENTING ILLNESS
• Goal of illness prevention program is to maintain optimal health by preventing disease which includes:
ü Immunizations
ü Prenatal and infant care
ü Prevention of STI
v RESTORING HEALTH
• Focuses on the ill client and it extends from early detection of disease through helping the client during the
recovery period
• Activities include:
ü Providing direct care to the ill client
ü Performing diagnostic and assessment procedures
ü Teaching clients about recovery activities
ü Rehabilitating clients to their optimal functional level
v CARING FOR DYING
• Comforting and caring for people of all ages who are dying which includes:
ü Helping clients live as comfortably as possible until death
ü Helping support persons to cope with death
STANDARD OF NURSING PRACTICE

v ASSESSMENT
• Collect comprehensive data pertinent to the patient’s health or situation
v DIAGNOSIS
• Analyzes the assessment data to determine the diagnose or issue
v OUTCOME INDENTIFICATION
• Identifies expected outcomes for a plan individualized to the patient or the situation
v PLANNING
• Develops a plan that prescribe strategies and alternatives to attain expected outcomes
v IMPLEMENTATION
• Implements the identified plan
v EVALUTION
• Evaluates progress towards attainment of outcomes
v QUALITY OF PRACTICE
• Systematically enhance the quality and effectiveness of nursing practice
v EDUCATION
• Attains knowledge and competency that reflects current nursing practice
v PROFESSIONAL PRACTICE EVALUATION
• Evaluate one’s own practice in relation to professional practice standards and guidelines, relevant statutes,
rules and regulation
v COLLEGIALITY
• Interacts with and contributes to the professional development of peers and colleagues
v COLLABORATION
• Collaborates with patients, family and others in the conduct of nursing practice
v ETHICS
• Integrates ethical provisions in all areas of practice
v RESEARCH
• Integrate research findings into practice
v RESOURCE UTILIZATION
• Considers factors related to safety, effectiveness, cost and impact on practice on the planning and delivery of
nursing services
v LEADERSHIP
• Provides leadership in the professional practice setting and the profession

ROLES AND FUNCTIONS OF A NURSE
v CAREGIVER
• Encompasses activities that assist the client physically and psychologically while preserving the dignity of the
client
• Nurse is primarily concerned with the client’s needs
v COMMUNICATOR
• Communicates the identified problem of the client to other health care team
v TEACHER
• Nurse teaches client about their health and procedures they need to perform to restore their health
v CLIENT ADVOCATE
• Acts to protect the client
• Nurse assist clients in exercising their rights and help them speak for themselves
v COUNSELOR
• Nurse provides emotional, intellectual and psychological support
v CHANGE AGENT
• Nurse assists clients to make modification in their behavior
v LEADER
• Influences others to work together to accomplish a specific goal
v MANAGER
• Nurse plans, give direction, develop staffs, monitors operation, give rewards fairly and represents both staff
members and administration as needed.
v CASE MANAGER
• Works with multidisciplinary health care team to measure the effectiveness of the case management plan and
monitor outcomes.
v RESEARCHER
• Nurse participates in scientific investigation and uses research findings to improve client care
v COLLABORATOR
• Nurse works in combined effort with all those involve in care delivery
EXPANDED CAREER ROLES FOR NURSES

v NURSE PRACTITIONER
• Nurse who has advanced education & graduated from a nurse practitioner program
• Employed in health care agencies or community-based settings
• Deals with non-emergency acute or chronic illness & provide primary ambulatory care
v CLINICAL NURSE SPECIALIST
• Has an advanced degree or expertise and is considered to be an expert in a specialized area of practice
(gerontology, oncology)
• Provides direct client care, educates others, conducts research, and manages care.
v CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA)
• Completed advanced education in an accredited program in the anesthesiology
• Carries out pre-op and post-op visits and assessment
• Administers general anesthesia for surgery under the supervision of a physician prepared in anesthesiology
and also assesses the postoperative status of clients
v NURSE-MIDWIFE
• RN who has completed a program in midwifery and gives prenatal & postnatal care and manages deliveries in
normal pregnancies
• May also conduct pap smears, family planning and routine breast exams
v NURSE RESEARCHER
• Investigates nurse problems to improve nursing care and to refine and expand nursing knowledge
• Employed in academic institutions, teaching hospitals and research center, and usually has advanced
education at the doctorate level
v NURSE ADMINISTRATOR
• Manages client care, including the delivery of nursing services
• Function:
ü Budgeting
ü Staffing and
ü Planning programs
v NURSE EDUCATOR
• Responsible for classroom and clinical teaching
v NURSE ENTREPRENEUR
• Manages health-related businesses
PATRICIA BENNER’S STAGES OF NURSING EXPERTISE

v STAGE I (Novice)
• No experience (student nurse)
• Performance is limited, flexible, and governed by context-free rules and regulations rather than experience
v STAGE II (Advanced Beginner)
• Demonstrates marginally acceptable performance
• Recognizes meaningful “aspects” of a real situation
• Experienced enough real situations to make judgments about them
v STAGE III (Competent)
• 2-3 years of experience
• Demonstrates organizational and planning abilities
• Differentiates important factors from less important aspects of care
• Coordinates multiple complex care demands
v STAGE IV (Proficient)
• 3-5 years of experience
• Perceives situations as a whole rather than in terms of parts
• Uses maxims as guides for what to consider in a situation
• Has holistic understanding of the client, which improves decision making
• Focuses on long term goal
v STAGE V (Expert)
• Performance is fluid, flexible, and highly proficient
• No longer requires rules, guidelines, or maxims to connect an understanding of the situations to appropriate
actions
• Inclined to take a certain action because “it felt right”.
COMMUNICATION IN NURSING
v Interchange of information between two or more people: exchange of ideas and thoughts. In addition, thoughts are
conveyed to other not only buy spoken or written words but also by gestures or body actions
v Verbal Communication uses spoken or written words
v Non-verbal communication uses gestures, facial expressions, posture/gait, body movements, physical
appearance, eye contact and tone of voice
v Components of communication
• Sender- is the person who encodes and deliver message
• Message- the content of the communication, may contain verbal, nonverbal, and symbolic language
• Receiver - the person who receives and decodes the message
• Channel- means of conveying and receiving messages through visual, auditory and tactile senses
• Response/feedback- message returned by the receiver to the sender
CHARACTERISTICS OF COMMUNICATION
v Simplicity – use of commonly understood words
v Pace and Intonation – modifies the feeling and the impact of the message
v Clarity and Brevity – message that is direct and simple
v Timing and Relevance – require choice of time and consideration of client’s interest and concern
v Adaptability – message needs to be altered in accordance with behavioral cues from the client
v Credibility – means worthiness of belief, trustworthiness, and reliability
v Humor – used to help clients adjust to difficult and painful situation
DOCUMENTATION
v Written or computer-based
v Served as a permanent record of client’s information and progress care
v Formal, legal document that provide evidence of a client’s care
v PURPOSES OF DOCUMENTATION
• Planning client care
• Communication
• For legal documents purposes
• For research
• For education
• Reimbursement
• For statistics, reporting, epidemiology
• Auditing health agencies
• Health care analysis
v TYPES OF RECORDS
• Source-Oriented Medical Record (Traditional Client Record/ SOMR)
ü Each person or department makes notations in a separate section/s of client’s chart
ü Specific information is easier to locate
• Components of SOMR
ü Admission sheet
ü Face sheet
ü Medical history and physical examination and sheet
ü Diagnostic finding sheet
ü TPR graphic sheet
ü Doctor’s treatment and order sheet
ü Therapeutic sheet
ü Special flow sheet
ü Medication record
ü Nurses notes
ü Client discharge plan and referral summary
ü Initial nursing assessment
v PROBLEM-ORIENTED MEDICAL RECORD
• Data about the client are recorded and arrange according to the sources of the information
• Records integrates all data about the problem, gathered by members of health team
• 4 BASIC COMPONENTS OF POMR
1. DATABASE- contains all information from the patient when he first entered the agency. It includes
nursing assessment, physician’s history, social and family data, results of physician’s examination.
2. Problem Lists- contains all the aspects of the person’s life requiring health care
-Kept in front of the chart
-Problems are listed in the order, which they are identified
-Continually updated as new problems are identified and others are resolved
3. Initial list of orders or plan of care- made with reference to the active problems and are
generated by the person who lists the problem
4. Progress Notes- which includes nurses narrative notes (SOAPIE, SOAPIE, SOAPIER)
v KARDEX
• Provides a concise method of organizing and recording data about the client, making information readily
accessible to all members of the health care team
• May be written in a pencil to ease in recording frequent change in details of client care
• A series to flip cards usually kept in portable file
GENERAL GUIDELINES FOR RECORDING

v Date and Time
• For legal reasons and client’s safety
• Record the time in conventional manner (ex. 9:00 am or 3:15 pm) or according to 24-hour clock (military
time) to avoid confusion about whether time was am or pm
v Timing
• Adjust the frequency a per client’s condition indicates
• No recording should be done BEFORE providing nursing care
• Documenting should be done as soon as possible after assessment/ intervention
v Legibility
• All entries must be easy to read prevent interpretation errors
v Permanence
• Records are made in the dark permanent ink
v Use of accepted terminology
• Use only commonly accepted abbreviation, symbols and terms that are specified by the agency
v Correct Spelling
• Is essential for accuracy in recording
• If unsure how to spell, look it up in a dictionary or other resource book
v Signature
• Each recording in nursing notes is signed by the nurse making it
• Include name and title (ex. Ralf Jake M. Faustino RN)
v Accuracy
• Clients name should be written on each page of the clinical record
• Accurate notations consist of facts/ observations rather than opinions or interpretation
ü e.g. Fact “ Client refused Medication”
ü Opinion “ Client was Uncooperative”
• When recording MISTAKE is made, draw a line through it and write the words “mistaken entry” (avoid
writing the word error) above or next to the original entry with your initials or name
• Do not erase, blot out or use correction fluid
• Write every line but not between line
• If a blank appears in the notation, draw a through the blank space and sign the notation
v Sequence
• Document events in the order which they occur
v Appropriateness
• Record only information that pertains to the client’s health problems and care
• Recording irrelevant information may be considered an invasion of the client privacy
v Completeness
• Information needs to be complete and helpful to the client and health care professionals
• Care that is omitted because of client’s refusal of treatment must also be recorded. Document what and
why it is omitted and who was notified
v Conciseness
• Recording needs to be brief as well as completed to save time in communication
v Legal Prudence
• Accurate and complete documentation should be a legal protection to the client and health care team
v Confidentiality
• Only the health professionals who participate in the care of the client are allowed to read the chart
REPORTING
v Takes place when two or more people share information about client care, either face-face o via telephone
Types of Reporting
v Change-of-shifts report or endorsement
• For continuity of care of clients by providing quick summary of health care needs and details of care to be
given
• It is not merely reciting the content or the KARDEX
v Telephone Reports
• Provide clear, accurate and concise information:
ü Date and time
ü Name of the person giving the information
ü Subject of information received
ü Name and signature of the receiver
• Person receiving the information should repeat it back to the sender to ensure accuracy
v Telephone Orders
• Only RN’s may receive telephone orders.
• Another RN should listen in another telephone line to countercheck the details.
• Write the date and time the telephone order was received.
• Write the complete order and read it back.
• Question primary care provider about any order that is unusual or contraindicated to client’s condition

•The order should be countersigned by the physician who made the order within the prescribed period of
time (within 24 hours)
v Transfer Report
• Done when transferring a client to other unit
NURSING PROCESS
v Purposes of nursing process
1. To identify client’s health status
• Actual health problem
• Potential health problems or needs
2. To establish plans to meet identified needs
3. To deliver specific nursing care and improve the quality of care
CHARACTERISTICS OR NURSING CARE

v Cyclical (regularly repeated events) and Dynamic (continuously changing)
v Client-centered – organizes the plan or care according to client’s problems rather than nursing goal
v Focused on Problem Solving- nursing process is directed towards a client ‘s responses to disease and illness
v Decision making- involved in every phase of nursing process
v Interpersonal and Collaborative
• Communicates with the client and family
• Collaborates with other members of the health care team
v Universally applicable- used in all types of health care setting with the clients of all age group
v Nurses must use a variety of critical thinking skills to carry out the nursing process
COMPONENTS OF THE NURSING PROCESS (ADPIE)

v Assessment
v Diagnosis
v Planning
v Implementation
v Evaluation
ASSESSMENT
v Assessment is a systematic and continuous collection, organization, validation and documentation of data about
the client health status
• Purpose: establish a database
v Activities during assessment

• Data Collection
ü Gathering information about client, considering the physical, psychological, emotional, social-
cultural, and spiritual factors that may affect his /her health status
• Sources of data
ü Client (primary)
ü Support people (secondary)
ü Family members, friends, and caregivers who know the client well
ü Client records
ü Medical records- past and present health and illness patterns
ü Records of therapies social – workers, nutritionist, dieticians,
ü Physical therapist
ü Laboratory record
ü Health care professionals
ü Literature
v Data collection methods
• Observing - gathers data by using the senses
2 aspects:
ü Noticing the data
ü Selecting, organizing and interpreting data
• Interviewing – is a planned communication or a conversation with a purpose
2 approaches:
ü Directive
Ø Highly structured and elicits specific information
Ø Uses closed-ended questions (YES/NO)
Ø The nurse stablishes the purposes & control the interview
Ø Used when you need to elicit specific data
Ø Used in emergency situation
ü Non-directive (rapport-building)
Ø Nurse allow the client to control the purpose, subject matter & pacing
Ø Uses more open-ended questions
Ø Advantage: allows the patient to explain certain information
v Stages of Interview
• The Opening
ü Most important
ü Establish rapport
ü Orientation
• The Body- the client communicates what he or she thinks, feels, and perceives in response to the
question
• The Closing- termination of the interview
v Data Organization
• Clustering/ organizing of facts into group of information
• Nurse uses a written/computerized data systematically
v Validating Data
• Double checking or verifying data to confirm that it is accurate and factual
v Documenting Data
• Accurate documentation is essential and should include all data collected about the client’s health status
v 4 Types of Assessment
• Initial Assessment
ü Perform within the specified time after admission
ü Main purpose is to create data base for problem identification reference and future comparison
• Problem-focused Assessment
ü Integrated throughout the nursing process
ü Purpose is to determine the status of a specific health problem (ex. Hydration status every 15
minutes)
• Emergency assessment
ü Done during an acute physiologic and psychologic crisis of the client
ü Purpose: identify life-threatening condition and to identify new or overlooked problems
ü Framework and principle in emergency assessment
A- Airway
B- Breathing
C- Circulation
ü Use either Maslow’s Hierarchy of needs or ABC principles
• Time-lapsed Assessment
ü Done several months after initial assessment
ü Purpose: to compare clients current status to base line data (initial assessment) previously obtained
DIAGNOSIS
v 2ND PHASE of nursing process
v The process, which results to a diagnostic statement or nursing diagnosis. It is the clinical act of identifying
problems.
v Purpose: to identify the client’s health care needs and to prepare diagnostic statement.
v Activities during diagnosing
• Organized cluster/group of data
• Compare data with standards (norm)
• Analyze data after comparing with standards
• Identifying gaps & inconsistencies in data
• Determine the client's health problems, risks, and strengths
• Final output: Nursing Diagnosis statement
v Nursing diagnosis is a statement of client's potential or actual alteration of health status. It uses the critical-
thinking skills of analysis and synthesis.
v Basic 2-part statements
• Problem (statement of the client's response)
• Etiology (factors contributing to or probable causes of the responses)
• The two parts are joined by the words "related to" (implies relationship)
e.g.: Constipation related to prolonged laxative use
e.g.: Ineffective breast feeding related to breast engorgement
v Basic 3-part statements (PES format)
• Problem
• Etiology
• Signs and symptoms (defining
characteristics manifested by the client)
• e.g.: Situational low self-esteem related to rejection by husband as manifested by hypersensitivity to
criticism; states "I don't know if I can manage by myself" and rejects positive feedback.
v One-part statements
• Consists of NANDA label only
e.g.: Rape-Trauma syndrome; Anticipatory grieving
v Collaborative problems
• Suggested that all collaborative problems begin with diagnosing label “Potential Complications”
e.g.: Potential complications of head injury: Increased intracranial pressure
v Purpose of NANDA
• To define, refine, and promote taxonomy (classification or system or set of categories arranged on basis of a
single principle or set of principles) of nursing diagnostic terminology of general use to professional nurses
• Members
ü Staff nurses
ü Clinical specialists
ü Faculty, directors of nursing
ü Deans, theorists, and researchers
v Types of Nursing Diagnosis
• Actual diagnosis
ü Client problem that is present at the time of the nursing assessment (based on the presence of associated
signs and symptoms)
eg: Ineffective breathing pattern; Anxiety
• Risk nursing diagnosis
ü Clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is
likely to develop unless nurses intervene
eg: Risk for Infection
• Wellness diagnosis
ü Describes human responses to levels of wellness in an individual, family or community that have a
readiness for enhancement"
eg: Readiness for enhanced spiritual well -being; Readiness for enhanced family coping
• Possible nursing diagnosis
ü Evidence about a health problem is incomplete or unclear
ü eg: Possible social isolation related to unknown etiology
• Syndrome diagnosis
ü Associated with a cluster of other diagnoses
eg: Risk for disuse syndrome; Impaired physical mobility; Risk for infection; Impaired gas exchange
PLANNING
v Deliberative, systematic phase of nursing process that involves decision making and problem solving
v Goal setting: to have criteria for evaluation
v For the goal to be useful during evaluation, it should be stated in BEHAVIORAL TERMS
v To be effective, involve the patient and family
Types of Planning
• Initial Planning — done by the nurse who performs the admission assessment
• Ongoing Planning
ü Done by all nurses who work with the client
ü Occurs at the beginning of a shift as the nurse plans the care to be given that day
• Discharge Planning
ü Process of anticipating and planning for needs after discharge, is a crucial part of comprehensive health care.
ü Begins at first client contact and involves comprehensive & ongoing assessment to obtain information about
client's ongoing needs.
v The Planning Process
1. Setting priorities
2. Establishing client goals/desired outcomes
3. Selecting nursing interventions
4. Writing individualized nursing interventions on care plans
v Guidelines for Writing Nursing Care Plans
1. Date and sign the plan.
2. Use category headings.
3. Use standardized/approved medical or English symbols and key words rather than complete sentences to
communicate your ideas unless the agency policy dictates otherwise.
4. Be specific.
5. Refer to procedure books or other sources of information rather than including all the steps on a written plan.
6. Tailor the plan to the unique characteristics of the client by ensuring that the client's choices such as
preferences about the times of care and methods used are included.
7. Ensure that the nursing plan incorporates preventive and health maintenance aspects as well as restorative
ones.
8. Ensure that the plan contains interventions for ongoing assessment of the client.
9. Include collaborative and coordination activities in the plan.
10. Include plans for the client's discharge and home care needs.
Characteristics of the Planning Process (CSMART)
C-Client-centered
S-Specific
M- Measurable
A-Attainable
R- Realistic
T-Time bound
IMPLEMENTATION
v Doing and documenting the activities that are specific nursing actions needed to carry out the interventions (or
nursing orders)
v Reassessing the client before implementing an intervention
v Determining the nurse's need for assistance
v Implementing the nursing interventions
v Supervising the delegated care
v Documenting nursing activities
REQUIREMENTS FOR IMPLEMENTATION
v Adequate knowledge
v Technical Skills
v Communication skills
v Therapeutic use of self
v Right attitude
EVALUATION
v Collecting data, comparing data, and relating nursing activities to outcomes
v Drawing conclusions about problem status
v Continuing, modifying or terminating the NCP (Nursing Care Plan)
TYPES OF EVALUATION
v On-going/Formative Evaluation
• Done during or immediately after the intervention
• Allows the nurse to decide and make on-the-spot modification/s in an intervention
v Intermittent Evaluation
• Done at a specified time & it shows the extent of progress of the patient
• Enables the nurse to correct deficiencies and modify the nursing care plan
v Terminal/Summative Evaluation
• Done at or immediately before discharge
• Importance: It determines whether the goals are met, partially met or unmet
• When goals have been partially met or when goals have not been met, two conclusions may be drawn:
ü The care plan may need to be revised, since the problem is only partially resolved
ü Or the care plan does not need revision, because the client merely needs more time to achieve the
previously established goal(s)
CONCEPTS OF HEALTH AND ILLNESS

v Health is state of complete physical, mental and social wellbeing, and not merely the absence of disease or
infirmity (WHO).
v Health is the ability to maintain homeostasis or dynamic equilibrium. Homeostasis is regulated by the negative
feedback mechanism (Walter Cannon).
MODELS OF HEALTH AND ILLNESS

Travis's Illness-Wellness Continuum
v The illness-wellness continuum developed by Travis ranges from high-level wellness to premature death.
v The model illustrates two arrows pointing in opposite directions and joined at a neutral point.
v Movement to the right of the neutral point indicates increasing levels of health and well-being for an individual.
This is achieved in three steps:
ü Awareness
ü Education
ü Growth
v In contrast, movement to the left of the neutral point indicates progressively decreasing levels of health.
Health Belief Model
v The model of Becker (1975) which describes the relationship between a person's belief and behavior
v Individual perceptions and modifying factors may influence health beliefs and preventive health behavior
v Individual perceptions include the following:
• Perceive susceptibility to illness
• Perceive seriousness of an illness
• Perceive threat of an illness
v Modifying factors including the following
• Demographic variables (age, sex, race, etc.)
• Socio-psychologic variables (pressure from peers)
• Structural variables (knowledge about the disease)
• Cues to action (internal: fatigue; external: mass media)
SMITH'S MODEL OF HEALTH
v Clinical model — identifies health as absence of signs and symptoms of disease or injury
v Role performance model — health is identified in terms of individual's ability to perform his/her work
v Adaptive model — Health is a creative process; disease is a failure in adaptation; focuses on the ability of the
person to cope
Eudemonistic model — health is seen as a condition of actualization or realization of person's potential
LEAVELL AND CLARK'S AGENT-HOST- ENVIRONMENTAL MODEL (ECOLOGIC MODEL)

v States that there are three interactive factors that affect health and illness
• Agent — any factor or stressor that can cause or lead to illness
• Host — person who may or may not be at risk of acquiring the disease
• Environment — any factor external to the host that may or may not predispose the person to the development
of the disease
• Illness — is the state in which the person's physical, emotional, intellectual, social, developmental, or spiritual
functioning is diminished or impaired compared with previous experiences
• Disease — an alteration in body functions resulting in reduction of capacities or a shortening of the normal life
span
v COMMON CAUSES OF DISEASE
• Biologic agents (microorganisms)
• Inherited genetic defects (hemophilia)
• Developmental defects (imperforated anus)
• Physical agents (hot and cold substances)
• Chemical agents (emissions from smoke)
• Tissue response to injury (inflammation)
• Faulty chemical / metabolic process (inadequate iodine — goiter)
• Emotional / physical reaction to strew (anxiety)
STAGES OF ILLNESS
v Symptom Experiences
• Person comes to believe something is wrong
ü Physical — experience of symptoms
ü Cognitive- the interpretation of the symptoms in terms that have some meaning to the person.
ü Emotional-fear and anxiety.
v Assumption of the sick role
• Acceptance of the illness
• Excused from normal duties and role expectations
• Confirmation from family and friends
v Medical care contact
• Seek advice of the health professionals for validation of real illness, explanation of symptoms, and reassurance or
prediction of what the outcome will be
v Dependent Patient Role
• Client becomes dependent on the health professionals for help
• Accepts / rejects health professional's suggestions
• Later becomes more passive and accepting
• May regress to an earlier behavior stage
v Recovery or Rehabilitation
• Client is expected to relinquish the dependent role and resume former roles and responsibilities
v Risk factors — any situation, habit, environmental, physiologic psychologic condition or other variable that
increases the vulnerability of the individual to illness or accident
• Genetic and physiological factors
• Age
• Environment
• Lifestyle
LEAVELL AND CLARK'S THREE LEVEL OF PREVENTION

v PRIMARY PREVENTION
• To encourage optimal health and to increase the person's resistance to illness
• Seeks to prevent a disease or a
condition at a pre-pathologic state
• Health promotion
• Specific protection
ü Quit smoking
ü Avoid / limit alcohol intake
ü Exercise regularly
ü Eat well-balanced diet
ü Reduce fat intake and increase fiber in the diet
v SECONDARY PREVENTION
• It is also known as health maintenance
• Seeks to identify specific illnesses or conditions at an early stage with prompt intervention to prevent or limit
disability
• Early diagnosis / detection / screening
ü Prompt treatment to limit disability
ü Have annual physical examination
ü Regular pap’s smear test for women
ü Monthly BSE for women
v TERTIARY PREVENTION
• Occurs after a disease or disability has occurred and the recovery process has begun
• Intent is to halt the disease or injury process and assist the person in obtaining an optimal health status
• Rehabilitation
ü Self-monitoring of blood glucose level among diabetics
ü Physical therapy after CVA
ü Undergoing speech therapy after laryngectomy
PHYSIOLOGIC RESPONSES TO STRESS AND ILLNESS

v STRESS
• Is a universal phenomenon, All person experience it
• Is a condition in which the person responds to changes in the formal balanced state
v STRESSOR – is any event or stimulus that causes an individual to experience stress
• When a person faces stress, responses are called coping strategies, coping responses, or coping mechanism
v SOURCES OF STRESS
• Internal stressor – originate within the person (Depression in cancer patients)
• External stressors – originate outside the individual. (A death in family)
• Developmental stressors – occurs at predictable times throughout an individual’s life. (Getting started in an
occupation by a young adult)
• Situational stressors – are unpredictable and may occur at any time during life, may be positive or negative.
(Marriage or divorce, birth of a child)
RESPONSE BASED MODEL OF STRESS
(HANS SELYE)
v Adaptation
• The adjustments that a person make in different situations
v Type of Adaptation
• General Adaptation Syndrome (GAS)
ü The entire body is involved wherever man responds to stress
ü There are many similar manifestations that characterized different disease conditions; and there are very
few specific manifestations that characterized by a particular disease
• Stage in GAS
vAlarm Reaction / Stage of Alarm
ü Alerts the body’s defense
ü The person becomes aware of the presence of threat or danger
ü Levels of resistance are decreased
ü Adaptive mechanism are mobilized
ü If the stress in intense enough, even at the stage of alarm, death may ensure
v Shock/Resistance Phase
ü The stressor may be perceived consciously or unconsciously by the person
ü Autonomic nervous system reacts, and large amount of epinephrine (adrenaline) and cortisone are
released into the body
ü “Fight or Flight”
ü This primary response is short, lasting from 1 minute to 24 hours
v Counter-shock/Exhaustion phase
ü The changes produced in the body during the shock phase are reversed
ü The person is best mobilized to react during the shock phases of the alarm reaction
vStage of Resistance
ü Is when the body’s adaptation takes place
ü The body attempts to cope with the stressor and limit the stressor to the smallest area of the body
that can deal with it
ü The person moves back to homeostasis
v Stage of Exhaustion
ü The adaptation that the body made during the second stage cannot be maintained
ü The ways used to coped with the stressors have been exhausted
ü If adaptation has not overcome the stressor, the stress affects may spread to the entire body
ü At the end of this stage, the body may either rest and return to normal, or death may be the ultimate
consequence
v Local Adaptation Syndrome (LAS)
• Man may respond to stress through a particular body part or body organ
(e.g. Inflammation, backache, headache and diarrhea)
vHomeostasis
• A state of dynamic equilibrium; stability, balance; uniformity
• It is now more commonly referred to as "hemodynamics", because it is
characterized by constant change.
• It is regulated by negative feedback mechanism.
v Concepts of Homeostasis
• Sympatho-Adreno-Medullary Responses (Walter Cannon)
ü SAMR or fight-or flight response
ü Adreno-cortical Response
ü Neurohypophyseal Response
v Local Physiologic Responses to Stress
• Inflammation involves mobilization of specific and nonspecific defense mechanism in response to tissue injury or
infection
• Purposes of Inflammation
ü To localize tissue injury
ü To protect tissue from injury
ü To prepare tissue for repair
v Cellular Response
• Neutrophils — are first to be launched at the site of injury
• Monocytes — perform phagocytosis in chronic tissue injury
• Lymphocytes — responsible for immune responses
Processes Involved:
• Marginal / pavementation — phagocytes line up at the peripheral walls of the blood vessels
• Emigration / diapedesis — phagocytes shift out of the blood vessels
• Chemotaxis — impaired tissues release substances which exert magnet-like force to the phagocytes to bring
them to the areas of injury
• Phagocytosis — phagocytes ingest or engulf the antigens
v EXUDATE PRODUCTION
• Inflammatory exudate is produced, consisting of fluid that escaped from the blood vessels, dead phagocytic cells,
and dead tissue cells and products that they release
• Plasma protein fibrinogen (which is converted to fibrin when it is released into the tissues), thromboplastic
(released by injured tissue cells), and platelets together form an interlacing network to wall off the area, and
prevent spread of the injurious agent
• During this stage, the injurious agent is overcome, and the exudate is cleared away by lymphatic drainage
v Healing Process (Reparative Phase)
• Regeneration — involves replacement of damaged tissue cells by new cells which are identical in structure
or function
• Scar Formation — involves replacement of damaged tissue cells by fibrous tissue formation
ü Granulation tissue (pink or red, fragile gelatinous tissue — early stage)
ü Cicatrix or scar — later stage, forms because the tissue shrinks and the collagen fibers contract
v Healing may also be classified as follows:
• First Intention — occurs in clean-cut wound. The wound edges are approximated and there is minimal or no
scar tissue formation
• Second Intention — occurs when the wound is extensive and there is a great amount of tissue loss. The
repair time is longer and the scarring is greater
• Third Intention — occurs when there is delayed surgical closure of infected wound
ASSESSING VITAL SIGNS / CARDINAL SIGNS

1. Temperature
2. Pulse
3. Respirations
4. Blood Pressure
5. Pain – the fifth vital sign
TEMPERATURE
v Body Temperature- balance between heat produced by the body and heat loss from the body
v Types of Body Temperature
• Core Temperature
ü Temperature of the deep tissues of the body such as abdominal and pelvic cavity.
• Surface temperature
ü Temperature of skin, SQ tissue and fat. Rises and falls in response to the environment.
v Processes Involved in Heat Loss
• Radiation - transfer of heat from surface to surface of one object to surface of another w/o contact
• Conduction - transfer of heat from one surface to another through direct contact
• Convection - dispersion of heat by air currents
• Evaporation - vaporization of moisture from the respiratory tract, mucosa of the mouth and skin
v Factors Affecting Body Temperature
• Age
• Diurnal variation (circadian rhythms)
ü Highest temp: 4pm to 6pm
ü Lowest temp: 4am — 6am
• Exercise
• Hormones (progesterone raises body temp)
• Stress
• Environment
v Alterations in Body Temperature
• Pyrexia/Hyperthermia/Fever
ü Body temperature is above the usual range
• Hyperpyrexia
ü Very high fever, 41°C (105.8°F) and above
• Hypothermia
ü Core body temperature is below the lower limit of normal
ü May be caused by excessive heat loss, inadequate heat production or impaired hypothalamic
thermoregulation
v Types of Fever
• Intermittent fever - body temperature alternates at regular intervals
between periods of fever and normal or subnormal temperature
• Remittent fever - wide range of temp fluctuations more than 2°C for over 24 hrs, all of which are above
normal
• Relapsing fever - short febrile periods of a few days are interspersed with periods of 1-2 days of normal
temperature
• Constant fever - body temperature fluctuates minimally but always remains above normal.
• Fever spike (Staircase) —temperature rises to fever level rapidly following a normal temperature then
returns to normal within a few hours
ASSESSING BODY TEMPERATURE

v Oral
ü Considered to be the most convenient and most accessible
ü Wait for 30 mins. before taking oral temperature if the client has taken cold or hot drinks/food or smoked
ü Contraindicated to patients with;
ü Oral lesions/ surgery
ü Dyspnea
ü Cough
ü Nausea and vomiting
ü Presence of oro-nasal pack, NGT, ET
ü Seizure prone
ü Very young children
ü Unconscious
ü Restless, disoriented, confused
• Clean the thermometer before use (from bulb to stem), and after use (from stem to bulb)
• Place the bulb of the thermometer on either side of the frenulum
• Take oral temperature for 2-3 mins.
• Normal range: 36°C to 37.5°C
v Rectal
• Considered to be very accurate
• Contraindicated to patients with:
o Anal or rectal conditions/surgery
o Diarrhea
o Quadriplegia and Myocardial Infarction
• Wear clean gloves and assist the client to assume lateral/sim's position
• Lubricate thermometer before insertion
• Instruction the client to take a slow deep breath during insertion
• Never force the thermometer if resistance is felt
• Insert 15 cm (6 in.) in adults and 11 cm for children
• Hold the thermometer in place for 2 mins.
• Normal range: 36°C to 37.8°C
v Axillary
• Safest and non-invasive
• Pat dry the axilla. Rubbing causes friction that may increase surface temperature
• The bulb is placed in the center of the axilla
• Place the arm tightly across the chest to keep the thermometer in place and leave it for 9 mins.
v Tympanic membrane
• Frequent site for estimating core body temperature
• Pull pinna back and upward (adults)
• Supine, head stabilized; pull pinna straight back and slightly downward for children <3 y/o
• Put child on adult's lap; pull pinna straight back and upward for children >3 y/o
• Point the probe slightly anteriorly, toward the eardrum
• Insert the probe slowly using a circular motion until snug
Conversion of Fahrenheit to Centigrade
• 5/9 (°F - 32) = °C
Conversion of Centigrade to Fahrenheit
• (°C x 9/5) + 32 = °F
TEPIDSPONGE BATH (TSB)

v When will you start TSB? If there is 1°C to 2°C increase in body temperature
v Temperature of water: 32°C
v How to apply: Done by patting
• Rationale: To avoid friction, which increases temperature
v Do NOT use ALCOHOL when applying TSB
• Rationale: Alcohol dries the skin and leads to irritation
PULSE
v Wave of blood created by contraction of the left ventricle of the heart
v Cardiac output is the volume of blood pumped into the arteries by the heart. Normal CO is 5 L of blood per
minute
v CO = Stroke Volume X Heart Rate
v Factors Affecting the Pulse
• Age
• Gender (male < female)
• Exercise
• Fever
• Medications
• Hypovolemia
• Stress
• Position changes
• Pathology
v Pulse Sites
• Temporal- used when radial pulse is not accessible
• Carotid- used during cardiac arrest and
• Radial- readily accessible
• Apical- routinely used for infants and children up to 3 y/o
• Brachial- used to measure BP and used during cardiac arrest in infants)
• Femoral- used in cardiac arrest/shock and determine leg circulation)
• Popliteal- used to determine circulation on the lower leg
• Posterior tibia and Dorsal Pedal- used to determine circulation to the foot
Assessment of the Pulse
v Pulse Rate
• Normal pulse rate for adult is 60-100 beats/min
• Tachycardia- excessively fast heart rate (over 100 beats/min)
• Bradycardia- heart rate in adult that is less than 60 beats/min
v Rhythm
• The pattern of the beats and the intervals between beats.
• Irregular rhythm is referred to as dysrhythmia or arrhythmia
v Pulse Volume (Amplitude) — force of blood with each beat
• A normal pulse can be felt with
moderate pressure of the fingers
• Full bounding pulse is a forceful volume that is obliterated with difficulty
• A pulse that is readily obliterated with pressure from fingers is referred to as weak or thready
v Arterial Wall Elasticity
• A healthy, normal artery feels straight, smooth, soft and pliable
v Pulse Deficit
• Discrepancy between the apical and radial pulse
v Scale in Pulse Assessment
• 0 - Absence or cannot be felt
• 1+ - Weak or thread
• 2+ - Normal
• 3+ - Bounding
RESPIRATIONS (The Act of Breathing)

v Involves three processes:
• Ventilation- movement of air in and out of the lungs
ü Inhalation (inspiration)
ü Exhalation (expiration)
• Diffusion- exchange of gases from higher pressure to an area of lower pressure. It occurs at the alveolocapillary
membrane
• Perfusion-availability and movement of the blood for transport of gases. Nutrients and metabolic waste products
v Two types of Breathing
• Costal (thoracic)- involves the external intercostal muscles and other accessory muscles
• Diaphragmatic (abdominal)- involves the contraction and relaxation of the diaphragm
v Respiratory center
• Medulla Oblongata- primary respiratory center. CO2 is the primary chemical stimuli for breathing
• Pons contains pneumotaxic center that is responsible for rhythmic quality of breathing, and apneustic center that
is responsible for deep prolonged inspiration
• Carotid and Aortic Bodies contains peripheral chemoreceptors that are sensitive to 02 and CO2 level in the
blood
v Assessing Respirations
• Normal rate is 12-20 breaths/min
• Depth is observed through the movement of the chest and describe. as normal, deep or shallow
• Rhythm refers to the regularity of the expirations and inspirations
• Quality or character refers to respiratory effort and sound of breath
v Factors Affecting Respiratory Rate
• Exercise
• Stress
• Environment
• Increased altitude
• Medications

TERMINOLOGIES
v Tachypnea- quick, shallow breaths (>20cpm)
v Bradypnea- abnormally slow breathing (<12cpm)
v Apnea- cessation of breathing
v Hyperventilation- rapid, deep breathing
v Hypoventilation- shallow respirations
v Cheyne-Stokes- very deep to very shallow breathing followed by temporary apnea
v Kussmaul's- rapid, deep and labored breathing
v Dyspnea- difficult and labored breathing
v Orthopnea- ability to breathe only in upright sitting or standing position
v Stridor- shrill, harsh sound heard during inspiration
v Stertor- snoring or sonorous respiration
v Wheeze- high-pitched musical squeak or whistling sound occurring on expiration
v Bubbling- gurgling sounds heard as air passes through moist secretions in the respiratory tract
v Biot's (cluster) respirations - Shallow breaths interrupted by apnea
BLOOD PRESSURE (BP)

v Pressure exerted by blood as it flows through the arteries
v Systolic pressure: BP as a result cg ventricular contraction
v Diastolic pressure: BP when ventricles are at rest
v Pulse pressure: difference between systolic and diastolic pressure
v Hypertension- blood pressure that is persistently above normal
v Hypotension- blood pressure that is belch. Normal
v Orthostatic Hypotension- blood pressure that falls when the client sits or stands
Determinants of BP
• Pumping Action of the Heart- when the pumping action of the heart is weak, the BP decreases
• Peripheral Vascular Resistance- peripheral resistance can increase BP
• Blood Vessel Diameter – decreased blood vessel diameter (vasoconstriction) can increase BP
• Blood Volume- when blood vol. decreases, BP decreases
• Blood Viscosity- BP increases when blood is viscous
v Factors Affecting BP
- Age - Gender
- Exercise - Medications
- Stress - Obesity
- Race - Diurnal variations
- Disease process
Classification of Blood Pressure
CATEGORY SYSTOLIC BP MMHG DIASTOLIC BP MMHG
Normal <120 and <80

Prehypertension 120-139 or 80-89
Hypertension, stage 1 140-159 or 90-99
Hypertension, stage 2 >160 or >100
v Korotkoff’s Sound
Phase 1: first faint, clear tapping or thumping sounds are heard
Phase 2: heard sounds have a muffled, whooshing or swishing sound quality
Phase 3: sounds become crisper and more intense, softer thumping sound
Phase 4: sound become muffled and have a soft, blowing quality
Phase 5: period of silence
ASSESSING BLOOD PRESSURE

v Ensure the equipment’s needed. Use appropriate size of BP cuff
v Ensure that the client has rested. Allow 30 mins to pass if the client had engaged to exercise, had smoked or
ingested caffeine before taking BP.
v Position the client in sitting or supine position
v Position the arm at the level of the heart, left arm is preferably used
v Wrap the cuff evenly around the upper arm, 1 inch above the antecubital space
v Determine palpatory BP first before auscultatory BP
v Position the stethoscope appropriately
v Inflate the cuff until sphygmomanometer reads 30 mmHG above the point where the brachial pulse disappeared
v Release the valve of the cuff at the rate of 2-3mmHG per second
v As the pressure falls, identify the manometer reading at the Korotkoff’s phases
v Deflate the cuff rapidly and completely
v Wait 1-2 mins before making further determinations
Errors in BP Assessment
ü False Low BP
ü Bladder cuff to wide
ü Arm above level of the heart
• False High BP
ü Bladder cuff too narrow
ü Loose cuff
ü Arm below the level of the heart
ü Arm unsupported
ü Insufficient rest
PAIN
v Pain is an unpleasant sensory and emotional experience associated with actual and potential tissue damage.
v Pain is referred to as the “fifth vital sign” (American Pain Society, 2003).
TYPES OF PAIN
v Acute Pain – lasts from seconds to 6 months
v Chronic Pain – constant or intermittent pain that lasts for 6 months or longer.
o Persistent, non-malignant
v Cancer-related Pain
CHARACTERISTICS OF PAIN (PQRST)

v Provoking Factors
o What are you doing at the time of onset?
v Quality
o How does the pain feel?
e.g., throbbing, burning, aching, stabbing
v Radiation
o Where is the pain?
o Is there pain anywhere else?
o Referred pain – Pain that radiates to other areas of the body
v Severity/Intensity
o Pain rating using a standard scale
o Mild to Severe
o Pain score: 0 to 10
v Time
o How long have you had the pain?
o Acute/Chronic
ASSESSMENT OF PAIN
v Descriptive Pain Intensity Scale
o No Pain to Worst Possible Pain
v Numeric Pain Scale
o 0 to 10
v Visual Analogue Scales
o No pain to Pain as bad as it could be

v Faces Pain Scale •

I
D
o Suitable for children to describe pain

Source: www.painbc.ca
Source: www.painbc.ca
PHYSICAL HEALTH EXAMINATION

v Conducted from head to toes (cephalo-caudal technique)
v Determine the state of awareness of the client at the beginning of the physical examination
v The most important consideration during physical examination is to prepare the client physical and psychologically
v Protect the client’s privacy during the entire procedure. Invasive procedures cause feelings of embarrassment
v Prepare the needed articles and equipment before the start of the procedure to conserve time, effort, and prevent
fatigue in the client
Modes of Examination
• Inspection – assessing the patient using the sense of sight
• Palpation – examining the body using the sense of touch by using the fat pads of the fingers
ü Light (superficial) palpation should always precede by deep palpation
ü For light palpation, the nurse extends the dominant hand’s fingers parallel to the skin surface and presses gently
while moving the hand in a circle
• Percussion – tapping the body parts to produce sound
Percussion Sounds and Tones

SOUND INTENSITY QUALITY EXAMPLE OF LOCATION
Flatness Soft Extremely dull Muscle and bone
Dullness Medium Thud-like Liver and Heart
Resonance Loud Hollow Normal lung
Hyper resonance Very loud Booming Emphysematous lung
Tympany Loud Musical Stomach filled with gas (air)
v Auscultation — listening to the body sounds with the use of stethoscope
Normal Breath Sounds

Type Description
Vesicular Soft-intensity,low-pitched,"gentle sighing" sounds created by air moving through
smaller airways (bronchioles and alveoli)
Broncho- vesicular Moderate-intensity and moderate-pitched "blowing" sounds created by air moving
through larger airway (bronchi)
Bronchial (tubular) High pitched loud, “harsh” sounds created by air moving through the trachea
POSITIONS
v Dorsal recumbent - Back lying position with knees flexed and hips externally rotated (examines head and
neck, axillae, anterior thorax, lungs, breasts, heart, abdomen, extremities, peripheral pulse, vital signs and
vagina)
v Dorsal (supine) - Back lying position with legs extended (examines head and neck, axilla, anterior thorax,
lungs, breasts, heart, extremities, peripheral pulse)
v Sitting - Seated position; back unsupported and leg hanging freely (Head and neck, axillae, anterior and
posterior thorax, lungs, breasts, heart, vital signs, upper and lower extremities, reflexes)
v Lithotomy - Back lying position with feet supported in stirrups, hips in line with edge of the table (examines
female genitals, rectum and female reproductive tract)
v Sim's - Side lying with lowermost arm behind the body and uppermost leg flexed (examines rectum and
vagina)
v Prone - Face-lying position, with or without a small pillow (examines posterior thorax)
Special Nursing Consideration
v The sequence of methods for physical examination is as follows: (IPPA)
• Inspection
• Palpation
• Percussion
• Auscultation
v The sequence for examination of the abdomen is as follows: (IAPePa)
• Inspection
• Auscultation
• Percussion
• Palpation
v Palpate the painful quadrant of the abdomen last
v No abdominal palpation among clients with tumor of the liver or kidneys
v During abdominal examination, it is important to flex the knees to relax the abdominal muscles
v The sequence of examining the abdomen is as follows; right lower quadrant èright upper quadrant
è left upper quadrant left lower quadrant
• The best position when examining the chest is sitting/upright
• The best position when examining the back standing position
• To palpate the neck for lymphadenopathy or thyroid gland enlargement, the nurse stands behind
the client
• If ophthalmoscopy is done, darken the room for illumination
• If a female client is examined by a male, female nurse must be in attendance to ensure that the
procedure is done in ethical manner
SKIN CARE
v Common Problems of the skin
• Abrasion
ü Superficial layers of the skin are scrapped or rubbed away
ü Area appears red or with localized
bleeding or serous weeping
ü Should be kept clean and dry
• Excessive dryness
ü Skin is scaly and rough
ü Encourage the client to increase oral fluid intake
ü Apply moisturizing cream or lotion and avoid using of alcohol
• Acne
ü Inflammatory condition of the skin which occurs in and around the sebaceous gland
ü Avoid food with high fat content and reduce emotional stress and anxiety
ü Avoid pricking or squeezing of pimples
• Erythema
ü Redness of the skin which may be associated with rashes, exposure to sun and elevated body temperature
ü Wash the skin thoroughly to
minimize the microorganism
ü Apply antiseptic spray or lotion to relieve pruritus
• Hyperhidrosis is excessive perspiration
• Bromhidrosis isfoul-smelling perspiration
Vitiligo are patches of hypo pigmented skin caused by destruction of melanocytes in the area
TYPES OF SKIN LESION

v Primary
• Macule — flat, circumscribed area of color with no elevation; <1cm (Freckles)
• Patch — same as macule but >1 cm, port wine birth mark)
• Papule — circumscribed elevation, <0.5 cm diameter (nevus, acne)
• Plaque — same as papule but >0.5cm)
• Nodule — solid mass that extends into the dermis (pigmented)
• Tumor — solid mass larger than nodule
• Vesicle — circumscribed elevation serous fluid or blood <1cm blister. chicken pox)
• Bulla — large fluid filled sac
• Pustule — vesicle or bulla filled with past
• Wheal— elevated, localized, collection of edema fluids
• Cyst — elevated, thick-wall lesions containing fluid or semisolid matter
• Telangiectasia- dilated capillary with fine purplish lines
• Petechiae – pinpoint red spots
v Secondary scale
• Scale – thickened epidermal cells that take off
• Crust – dried serum or pus on the skin surface
• Erosion – loss of all parts of the epidermis
• Excoriation – superficial linear or hallowed out rust area exposing dermis. Ex. Scratch
• Atrophy – decrease in the volume of epidermis
• Scar – formation of connective tissue
• Ulcer – an excavation extending in to dermis or below
BED BATH
v Purpose of bed bath
• Remove microorganisms, body secretions and excretions and dead skin cells
• Improve circulation
• Promote relaxation and comfort
• Prevent or eliminate body odor and promote self-esteem
• Promote sense of well being
• Assess client's skin and body parts
• Provide activity and exercise
v Guidelines during bed bath
• Inform the client and explain the procedure
• Provide privacy
• Turn off electric fan or air con to prevent chilling
• Encourage to void before the procedure
• Place the bed in flat position if permissible
• Move the client to one side of the bed
• Remove the patient's gown and cover patient with bath blanket
• Use warm water (110-115°F)
• Make bath mitt with the wash cloth
• Wash the body parts as follows;
ü Eyes, face, ears, neck
ü Farther arm
ü Nearer arm
ü Hands
ü Chest and abdomen
ü Farther leg
ü Nearer leg
ü Feet
ü Back and buttocks
ü Perineum
• Wash and dry one body part at a time
• Rinse soap thoroughly
• May apply cream, lotion or powder on the skin
• Change gown and do bed making
• Do after care of the equipment and articles Document relevant data

Considerations when bathing a client in bed:
ü Cleanse eyes with water only, wiping from inner to outer cantus. Use separate corner of mitt for each eye
ü Determine if client would like to use soap on face
ü Wash, rinse and dry the arms and legs using long, firm strokes from distal to proximal areas
ü Assess bath water temperature (43°C to 46°C) using dorsal part of the hand or elbow and change water
as necessary
PRESSURE ULCER
v Any lesion caused by unrelieved pressure that result in damage to underlying tissues
v Risk Factors
• Friction and shearing
• Immobility
• Inadequate nutrition
• Fecal and urinary incontinence
• Decreased mental status
• Diminished sensation
• Excessive body heat
• Advanced age
• Chronic medical conditions
v Stages of Pressure Sore Formation
Stage I — non-blanchable erythema of intact skin
Stage II — partial thickness skin loss involving epidermis and possible dermis (abrasion, blister or shallow crate)
Stage III — full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to,
but not through underlying fascia. Ulcer presents a deep crater
Stage IV — full-thickness skin loss with extensive destruction, tissue necrosis or damage to muscles, bone or
supporting structures such as tendon or joint capsule
v Prevention of Pressure Ulcers
• Provide adequate and balanced nutrition
• Clients should be assisted to take at least 2500 ml of fluids a day unless contraindicated
• Provide sufficient protein, vit. A, B1, B5, C and zinc
• Provide smooth, firm and wrinkle free
foundation on which client sits or lies
• Reduce shearing force by elevating the bed not more than 30 degrees
• Never use baby powder and cornstarch in preventing friction
• Apply cream or lotion on dry skin and protective films such as transparent dressing and alcohol free barrier films
• Avoid massage over bony prominences
• Change position every 15 mins to 2 hours
• Use lifting devices such as trapeze in
lifting a patient instead of dragging
• Keep the skin clean and dry
• Ongoing assessment for early Signs and symptoms of pressure sores
v Treatment of Pressure Ulcers
• Minimize direct pressure on the ulcer
• Clean the ulcer with every dressing
change, hydrocolloid dressing is used
• Clean and dress the ulcer using surgical asepsis
• Obtain a sample of drainage for culture and sensitivity
• Gently cleanse the wound using alcohol-free cleanser. Do not use hydrogen peroxide
• Black wounds requires debridement
ü Sharp debridement uses scalpel to separate and remove dead tissues
ü Mechanical debridement uses moist-to-moist dressing
ü Chemical debridement uses collagenase enzyme agents
ü Autolytic debridement uses dressings that contains wound moisture

ADMINISTRATION OF MEDICATIONS
v Before giving any medication, the nurse must:
• Know the drugs prescribed dose, methods of administration, actions, expected therapeutic effect, possible
interactions with other drugs and adverse effects.
• Know and use the institution’s administration procedures for the client's welfare and nurse’s legs, protection.
• Review the physician's order for completeness: the client's name, date of the order, name of the drug, dose,
route, time of administration, and the physician's signature.
• Discuss the medication and its actions with the client; re-check the medication order if the client disagrees with
the dose.
• Check the physician's order against the client's medication administration record (MAR) for accuracy.
v To ensure the client's safety, the nurse adheres to the Ten Rights of medication administration:
• Right drug
• Right dose
• Right client
• Right route
• Right time
• Right documentation
• Right approach
• Right to know about the drug
• Right to refuse
• Right drug history
v Commonly used administration route are oral (usually absorbed in the GIT), topical (applied to the skin or
mucous membranes), and parenteral (administered by injection with a needle).
v Medication can also be instilled into the eye or ear or administered by suppository.
v Medication may be given on a regular schedule, as a one-time dose, or as needed
Essential parts of Drug Order
• Full name of the client
• Date and time the order is written
• Name of the drug to be administered
• Dosage of the drug
• Frequency of administration
• Route of administration
• Signature of the person writing the order
Types of Medication Action
• Therapeutic Effect: Primary effect
• Side effect
ü Secondary effect - Predictable, maybe harmless or potentially harmful
v Adverse effect: More severe side effect and may justify the discontinuation of the drug
v Toxic effect results from over dosage, or buildup of the drug in the blood because of impaired metabolism or
excretion
v Idiosyncratic effects — unexpected and maybe individual to a client
v Allergic Reaction: Immunologic reaction
TYPES OF MEDICATION ORDER:

v Stat - An order for a single dose of medication to be given immediately
v Single Dose – medication to be given once at a specified time
v Standing Order – may or may not have termination date may be carried out indefinitely until an order is written
to cancel it or may be carried out for a specified number of days
v PRN – permits the nurse to give a medication. When, in the nurse's judgment, the client requires it
ROUTES OF DRUG ADMINISTRATION

v ORAL
• Considered to be the most convenient, usually less expensive, and safe because skin is not broken
• Disadvantages includes:
ü Drugs may have unpleasant taste
ü Inappropriate to client with nausea and vomiting and cannot swallow Drugs may stain the teeth

ü Drug may irritate the gastric mucosa
ü Drugs may be aspirated by seriously ill patient
v Never crush enteric coated or sustained release tablets
Drug forms for oral administration:
ü Solid – capsules, pills, tablets or powder
ü Liquid – syrup, suspension, emulsion, elixir,
Ø Syrup – sugar based liquid medication
Ø Suspension – water-based liquid medication, shake the bottle before use
Ø Emulsion- oil-based Medication
Ø Elixir - alcohol-based medication, allow 30 mins to elapse
v SUBLINGUAL
• Drug that is placed under the tongue where it is dissolved
• Drug is rapidly absorbed
• If swallowed, may be inactivated by the gastric juice
v BUCCAL
• Medication is held in the mouth against re mucus membrane of the cheek until the drug is dissolved
• Medication should not be chewed,
swallowed or placed under the tongue
• Swallowed drug may be inactivated by the gastric juices
v TROPICAL
• Application of the medication to a circumscribed area of the body
• Dermatologic preparation – applied to the skin
• Instillation and immigration- applied into the body cavities or orifices such urinary bladder, eyes, ears, nose,
rectum and vagina
• Inhalations- administrated in the respiratory tract by a nebulizer or positive pressure breathing apparatus
v Parenteral
• Administration of medication via needle
• Routes are as follows:
ü Subcutaneous – into the subcutaneous tissue, just below the skin
ü Intramuscular – into the muscle
ü Intradermal – under the epidermis (into the dermis)
ü Intravenous – into a vein
ü Intra-arterial – into to artery
ü Intracardiac – into the heart muscle
ü Intraosseous – into a bone
ü Intrathecal – into spinal canal
ü Epidural – into epidural space
ü Intrapleural – into the pleural space
v Intradermal Injection
• Administration of the drug into the dermal layer of the skin beneath the epidermis
• The sites are the inner lower arm, upper chest and back, beneath the scapulae, and buttocks
• Indicated for allergy and tuberculin testing and for vaccinations
• Use needle gauge #25-27 that is ¼ to 5/8 inch long
• Needle at 10 to 15 degree angle level up
• Inject a small amount of drug slowly to form a wheal or bleb
• Do not massage the site of injection
v Subcutaneous Injection
• Drugs that are administered Subcutaneously are vaccines, preoperative medications, narcotics, insulin,
heparin
• Sites are the outer aspects of the upper arm, anterior aspect of the thighs, abdomen, scapular area of
the upper back, and buttocks
• Rotate sites of injection to minimize tissue damage
• Gauge 25, 5/8 inch needle is used for adults of normal weight and is injected at 45 degree angle
• 3/8 inch needle is used at 90degree angle for obese patients
• A child may need 1/2 inch needle and is inserted at 45 degree angle
• For insulin injection, do not massage to prevent rapid absorption

v Intramuscular injection
• Needle length is 1, 1 1/2 inches
• Use needle gauge 20,21,22,23 depending on the type of muscle and age of the client
• Do not inject on injured tissues, or in area where nodules, lumps, abscesses, tenderness or other
pathology are present
• Avoiding hitting the major blood vessels bone or sciatic nerve to prevent complications
• Sites of injection are dorsogluteal, deltoid, ventrogluteal, vastus lateralis and rectus femoris
• Vastus lateralis is the site of choice for IM injections for infants 1 year and younger
v Intravenous Medication
• Medication enters the client’s bloodstream directly by way of vein
• It is appropriate when medications are too irritating to tissues to given by other routes
• Observe reaction
• It can be given through the ff method:
ü Large volume infusion of IV fluids
ü Intermittent IV infusion (piggyback)
ü Volume controlled infusion
ü IV push or bolus
ü Intermittent injection ports
v Calculating Dosages
• Oral Medication: solid
Desired dosage = quantity of drugs
Stock dosage
• Oral/ parenteral Medication: liquids

Desire dose x dilution = quantity of drugs
Stock dose
• Pediatric Doses
(Clark’s rule)
Wt . in lbs. x usual adult dose = safe child dose
150
(Fried’s rule)
Age in mos. X usual adult dose = child’s dose (CD)
150
(Young ‘s rule)
Age in years x usual adult dose = CD
Age in years + 12
PREPARING MEDICATIONS FROM AMPULES

v Check the medication order
v Check the label of the ampule carefully against the MAR to make sure that correct medication is being prepared
v Follow the three checks for administering medications. Read the label on medication (1), when it is taken from
the cart (2), before withdrawing the medication and (3) after withdrawing the medication
v Check for expiration date
v Perform hand hygiene
v Flick the upper stem of the ampule several times
v Use an ampule opener or place a piece of sterile gauze or alcohol wipe between your thumb and the ampule neck
or around the ampule neck and break off the top by bending it toward you to ensure the ampule is broken away
from yourself and away from others
v Place the ampule on a flat surface
v Insert the needle into the center of the ampule. Hold the ampule slightly on its side if necessary to obtain more
than the ordered amount of medication
v Replace the filter needle with a regular needle, tighten the cap at the hub of the needle and push solution into
the needle
PREPARING MEDICATIONS FROM VIAL

v Mix the solution if necessary by rotating the vial between palms of the hands, not by shaking
v Remove the protective cap and clean the rubber cap with antiseptic wipes by rubbing it in circular motion
v Attach a filter needle to draw up premixed
liquid medications from multi dose vials
v Draw up into the syringe the amount of air equal to the volume of the medication to be withdrawn
v Insert the needle into the upright vial through the center of the rubber cap
v Inject the air into the vial keeping the bevel of the needle above the surface of the medication
v Withdraw the prescribed amount of
medication using either of the following:
• Hold the vial down, move the needle tip so that it is below the fluid level and withdraw the medications.
Avoid drawing up the last drop of the vial, or
• Invert the vial, ensure the needle tip is below the fluid level; and gradually withdraw the medication
v Hold the syringe and vial at eye level to determine that the correct dosage of drug is drawn into the syringe. Eject
air remaining at the top of the syringe into the vial
v When the correct volume of medication plus a little more (eg. 0.25 ml) is obtained, withdraw the needle using the
scoop method, thus maintaining its sterility
v If necessary, tap the syringe barrel to dislodge any air. bubbles present in the syringe
v If giving injection, replace the filter needle, if used, with a regular or safety needle of the correct gauge and
length
MIXING MEDICATIONS USING ONE SYRINGE

v Check the medication administrative record
v Prepare the medication ampule or vial for drug withdraw
v Inspect the appearance of the medication for clarity
v If using insulin, thoroughly mix the solution in each vial prior administration
v Clean the tops of vial with antiseptic swabs
v Mixing medication from two vials

• Take the syringe and draw up a volume _ of air equal to the volume of medications to be withdrawn from
both vials A and B
• Inject a volume of air equal to the volume of medication to be withdrawn into vial A. Make sure the needle
does not touch the solution
• Withdraw the needle from vial A and inject the remaining air into vial B
• Withdraw the required amount of medication from vial B
• Using a newly attached sterile needle, withdraw the required amount of medication from vial A. Avoid
pushing the plunger as that will introduce medication B into vial A
v Mixing medication from one vial to one ampule
• Prepare and withdraw the medication from the vial because ampules do not require addition of air prior to
withdrawal
• Withdraw the required amount of medication from the ampule
v Mixing insulin’s
• Inject 30 units of air into the NPH vial and withdraw the needle (there should be no insulin in the needle)
The needle should not touch the insulin
• Inject 10 units of air into regular insulin vial and immediately withdraw 10 units of regular insulin and
always withdraw regular insulin first
• Reinsert the needle into the NPH insulin vial and withdraw 30 units of NPH insulin
PARENTAL FLUID AND ELECTROLYTE REPLACEMENT

v IV fluid therapy is essential when client s are unable to take food and fluids orally
v An efficient and effective method of supplying fluids directly into the intravascular fluid compartment and
replacing electrolyte loses
v Types of intravascular solution
• Isotonic solution – often used to restore vascular volume
ü 0.9% NaCl (normal saline)
ü Lactated ringer’s (balance electrolyte solution)
ü 5 % dextrose in water (D5W)
• Hypotonic solution- have a lesser concentration of solutes
ü 0.45% NaCl (half normal saline)
ü 0.33 % NaCl (one–third normal saline)
• Hypertonic solution- have greater concentration of solutes than plasma
ü 5 % dextrose in normal saline (D5NS)
ü 5% dextrose in 0.45 % NaCl (D5 ½ NS)
ü 5 % dextrose in lactated ringers (D5LR)
• Lactate is metabolized in the liver to form HCO3 (Bicarbonate, an alkaline compound)
• Saline and balanced electrolytes are commonly used to restore vascular volume particularly after trauma or
surgery
• Lactated ringer’s is an alkalinizing solution that maybe given to treat metabolic acidosis
• Volume expanders are used to increase the blood volume following severe blood loss or loos of plasma.
Examples are dextran, plasma and albumin
Venipuncture sites
• Site chosen for venipuncture varies with the client's age, length of time of infusion, type of solution, and the
condition of the veins
• For adults, veins in the arm and hand are commonly used
• For infants, veins in the scalp and dorsal foot are often used
• Larger veins are preferred for infusions that need to be given rapidly and solutions that could be irritating
• Metacarpal, basilic and cephalic veins are commonly used for intermittent or continuous infusions
• Central venous catheter is inserted when long term IV therapy or parenteral nutrition or Iv medications that are
damaging to the vessels are given
Guidelines in Vein Selection
• Use distal veins of the arms first
• Use the client's non-dominant hand/arm whenever possible
• Select a vein that is:
ü Easily palpated and feels soft and full
ü Naturally splinted by bone
ü Large enough to allow adequate circulation around the catheter
• Avoid using veins that are:
ü In areas of flexion
ü Highly visible because they tend to roll away from the needle
ü Damaged by previous use, phlebitis, infiltration or sclerosis
ü Continually distended by blood or knotted or tortuous
ü In a surgically compromised or injured extremities
INTRAVENOUS EQUIPMENT
v Solution containers are available in various sizes (50, 100, 250, 500, 1000 ml) and smaller containers are usually
used to administer medications
v Solution must be sterile and in good condition that is, clear
v Cloudiness is evidence that the solution is already contaminated
v Check the expiration date of the solution
Infusion sets
• Insertion spike is kept sterile and inserted into the solution container
• Drip chamber permits a predictable amount of fluid to be delivered
• Roller valve or screw clamp compresses the lumen of the tubing controls the flow rate
• Protective cap maintains the sterility of the end of the tubing
• Most infusion sets include one or more injection ports for administering IV medications or secondary infusions
• Over the needle (angiocath) are commonly used for adults. Plastic catheter fits over a needle used to pierce the
skin and the vein wall. Once inserted to the vein, the needle is withdrawn and discarded
• Butterfly or wing-tipped needles with plastic flaps which hold needle tightly together to secure it during insertion

COMPUTATION OF INTRAVENOUS INFUSION
Drops per minute
Total infusion volume (mL) x drop factor
Total Time of infusion (hours) 60 min
Milliliters per minute

Total infusion volume (mL) = mL/min
Total infusion time (min)
COMPLICATIONS OF IV INFUSION
v Infiltration — needle is out of the vein and fluids accumulate in the surrounding tissues
Signs:
ü Swelling
ü Coldness, Pallor
ü Pain around infusion site
Management:
ü Disconnect the IV infusion and restart at a different site
ü Limit the movement of the extremity
v Circulatory overload — results from administration of excessive volume of IV fluids
Signs:
ü Engorged neck veins
ü Hypertension
ü Dyspnea
Management:
ü Slow the rate of the infusion
ü Notify the doctor
ü Monitor V/S and rate of intravenous fluid
v Superficial thrombophlebitis — due to overuse of a vein, irritating solutions or drugs, clot formation or large
bore catheters
Signs:
ü Local tenderness
ü Acute tenderness
ü Redness, warmth Slight edema of the vein above the insertion site
Management:
ü Discontinue the infusion immediately
ü Apply warm, moist compress to the affected site
ü Avoid further use of the vein
ü Restart the infusion at a different site
v Air Embolism — air manages to get into the circulatory system
Management:
ü Position the patient on left side lying
ü Notify the physician especially if the patient experiences sudden pain or difficulty of breathing
v Infection — invasion of pathogenic organisms into the body
v Signs:
v Fever, malaise, pain
v Swelling at the site of infusion
v Discharge at the IV insertion site
Management:
ü Use aseptic technique when starting an infusion
ü Change the dressing regularly
ü Always wash hands before handling the tubing
ü Administer antibiotic as ordered
v Speed shock — may result from administration of IV push medications rapidly
Signs:
ü Pounding headache
ü Fainting, chills
ü Rapid pulse rate, back pains
ü Apprehension, dyspnea
Management:
ü Refer to the physician and monitor V/S and rate of infusion
ü Use proper tubing specially to all pediatric clients
BLOOD TRANSFUSION
v Introduction of whole blood or blood Components in o the venous circulation
Blood Products for Transfusion
Product Use
Whole blood For extreme cases of acute hemorrhage
Packed RBC Used to increase oxygen-carrying capacity of the blood
Autologous RBC Used for blood replacement following planned elective surgery
Platelets Used in clients with bleeding disorders or platelet deficiency
Fresh frozen plasma Expands blood volume and provides clotting factor
Albumin and plasma protein fraction Blood volume expanders and provides plasma protein
Clotting Factors and cryoprecipitate Used for clients with clotting factor deficiencies
ADMINISTERING BLOOD
v When BT is ordered, obtain the blood from the bank before starting the infusion
v Once blood/blood product is removed from the refrigerator, there is limited amount of time to administer it
(e.g. Packed RBC should not hang for more than 4 hours after being removed from the ref)
v Verify that the unit is correct
v Blood is usually administered through a #18- #20 gauge intravenous needle or catheter
v Y-type blood transfusion set with an inline or add on-filters used when administrating blood.
ONLY 0.9NaCl (NSS) should be administered with blood. Dextrose + blood products will result to hemolysis
v Transfusion should be completed within 4 hours
v Blood tubing is changed after 4-6 units per agency policy
INITIATING, MAINTAINING AND TERMINATING BLOOD TRANSFUSION

v Introduce self and verify clients identity
v Explain the procedure and purpose to the client
v Instruct the client to report promptly any sudden chills, nausea, itching, rash, dyspnea, back pain, or other
unusual symptoms
v Obtain the correct blood component for the client
v Check the doctors order with requisition
v Check the requisition form and the blood bag label, specifically client’s name, identification number, blood
type and Rh group, blood donor number and expiration date of the blood. Return outdated or abnormal
blood-to-blood bank.
v With another nurse, compare the laboratory blood record with:
• Clients name and identification number
• Serial number on the blood bag label
• ABO group and Rh type on the blood bag label
• Expiry date
v Make sure that blood is left at room temperature for no more than 30 minutes before starting the infusion
v Verify the client identity
v Set up the infusion set
• Ensure that the blood filter inside the drip chamber for the blood components to be transfused
• Put on gloves
• Close all clamps on the Y-set
• Insert spike on 0.9 % saline solution and hang the container
• Prime the tubing
• Start the saline tubing
• Start the saline solution
• Attach the blood tubing primed with normal saline to the intravenous catheter
• Open the saline and main flow rates
• Allow a small amount of solution, to infuse to make sure there are no problems with the flow or with
venipuncture
v Prepare the blood bag
• Invert the blood bag gently several times to mix the cells with plasma
• Expose the port on the blood bag by pulling back the tabs
• Insert the remaining Y-set spike into the blood bag
• Suspend the blood bag and close the upper clamp below the IV saline solution
• Open the clamp on the blood arm of the y-set and prime the tubing
v The blood will run with saline-filled drip chamber
v Readjust the flow rate with the main clamp
v Observe the client closely for the first 5 to 15 minutes
v Run the blood slowly for the first 15 minutes at 10 drops per minute
v Note adverse reaction
v Remind the client to call a nurse immediately if any unusual symptoms are felt during transfusion
v If any reaction occurs, stop the BT and take appropriate nursing action
v Monitor the client
• Check v/s fifteen minutes after initiating the transfusion
• If there are no reactions, establish the required flow rate
• Assess the clients V/S every 30 minutes or more often
• If the blood is discontinued send the blood bag and tubing to the laboratory for investigation
Termination of the Transfusion

v Put on clean gloves
v If the primary IV is to be continued flush the maintenance line with saline solution
v Disconnect the blood tubing system and re-establish the IV infusion using new tubing
v Discard the administration set according to agency practice. Blood bag and administration set should be bagged
and labelled before being sent for decontamination
v Removes gloves
v Monitor vital signs
v Follow agency protocol for appropriate disposition of the blood bag
v Document relevant data
Transfusion reaction
v Hemolytic reaction- incompatibility between client’s blood and donor ‘s blood
• Clinical manifestations: chills, fever, headache, backache, dyspnea, cyanosis, chest pain, tachycardia,
hypotension
• Nursing interventions includes:
ü Stop the transfusion
ü Maintain vascular and Access with normal saline
ü Notify the physicians immediately
ü Monitor vital signs
ü Monitor fluid intake and output
ü Send the remaining blood, blood set, sample of the client's blood to the laboratory
v Febrile reaction — sensitivity of the client's blood to white blood cells, platelets or plasma proteins
• Clinical manifestations: fever, chills, warm, flushed skin, headache, anxiety, muscle pain
• Nursing interventions
ü Stop the transfusion immediately
ü Give antipyretics as ordered
ü Notify the physician
ü KVO (keep vein open) with normal saline
Allergic reaction (mild) — sensitivity to infused plasma protein
• Clinical manifestations: flushing, itching, urticaria, bronchial wheezing
ü Stop or slow the transfusion
ü Administer antihistamine as ordered

Allergic reaction (severe) — antibody-antigen reaction
• Clinical manifestations: dyspnea, chest pain, circulatory collapse, cardiac arrest
ü KVO with NSS
ü Notify the physician immediately
ü Monitor V/S
ü Administer medications/oxygen as ordered
Circulatory overload — blood administered faster than the circulation can accommodate
• Clinical signs: cough, dyspnea, crackles, distended neck veins, tachycardia, hypertension
• Nursing interventions:
ü Place the patient upright with feet dependent
ü Stop or slow the infusion
ü Administer diuretics and oxygen as ordered
Sepsis — contaminated blood is administered
• Clinical signs: high fever, chills, vomiting, diarrhea, hypotension
ü KVO with NSS
ü Administer IV fluids, antibiotic
ü Obtain blood specimen for culture
ü Send the remaining blood and tubing to the laboratory
ASEPSIS AND INFECTION CONTROL

v Nosocomial infection
• Associated with the delivery of health
care services in a health care facility
• Can be develop during client's stay in
the facility or manifest after discharge
• Endogenous — microorganisms that cause infection originates from the client themselves
• Exogenous — microorganisms that caused infection originates from the hospital environment and/personnel
• Latrogenic infection - direct result of diagnostic or therapeutic procedures
DISINFECTING AND STERILIZING

v Disinfectant
• Chemical preparation (phenol / iodine compounds) used on inanimate objects
• Frequently caustic and toxic to tissue
v Antiseptics are chemical preparation used on skin and tissues
• Bactericidal (destroys bacteria)
• Bacteriostatic (prevents growth & reproduction of some bacteria)
Types of Disinfection
• Concurrent Disinfection — On going practices that are observed in the care of the client, his supplies, his
immediate environment to limit/control the spread of microorganisms
• Terminal Disinfection — practices to remove pathogens from the client's belongings and his/her immediate
environment after his/her illness is no longer communicable
COMMONLY USED ANTISEPTICS AND DISINFECTANTS

v Isopropyl and Ethyl alcohol
• Kills bacteria, TB, fungi, virus
• Used on hands & vial stoppers
v Chlorine (bleach)
• Kills bacteria, TB bacteria, spores, fungi, virus
• Used to clean blood spills
v Hydrogen peroxide
• Kills bacteria, TB, spores, fungi, virus; used on surfaces
v Iodophors
• Kills bacteria, TB, spores, fungi, virus
• Used on equipment, intact skin & tissues (if diluted)
v Phenol
• Kills bacteria, TB, fungi, virus; used on surfaces
v Chlorhexidine
• Kills bacteria, viruses; used on hands
v Triclosan (Bacti-stat)
• Kills bacteria; uses on hands, intact skin
STERILIZATION
v Process that destroys all microorganisms, including spores & viruses
• Moist heat (steam)
ü Steam under pressure (higher than boiling point) autoclave
ü Pressure: 15 — 17 pounds
ü Temp: 121°C — 123°C
• Gas
ü Use ethylene oxide
ü Has good penetration & effective for heat-sensitive items
ü Disadvantage: toxic to humans
• Radiation
ü UV light /rays do not penetrate deeply
ü Used to sterilize food, drugs and other items that are sensitive to heat
ü Ionizing radiation is expensive
CDC (COMMUNICABLE DISEASE CONTROL), HICPAC (HOSPITAL INFECION CONTROL PRACTICES

ADVISORY COMMITTEE) ISO STANDARD PRECAUTIONS
v Used in the care of all hospitalized persons regardless of their diagnosis or possible infection status
v Blood, all body fluids, secretions and excretions (except sweat), non-intact skin and mucous membranes
v Universal precaution + body substance isolation (BSI)
v Designed to reduce risk of transmission of microorganisms from recognized and unrecognized sources
• Wash hands after contact with blood, body fluids, secretions, excretions & contaminated objects whether or not
gloves are worn
ü Immediately after removing gloves
ü Non- antimicrobial soap for routine hand washing
ü Antimicrobial / antiseptic agent for control of specific outbreaks of infection
• Wear clean gloves when touching blood, body fluids, secretions, excretions & contaminated items (soiled gowns)
ü Clean gloves can be unsterile unless their use is intended to prevent entrance of microorganism into the body
ü Remove gloves before touching non - contaminated items & surfaces
ü Wash hands immediately after removing the gloves
• Wear mask, eye protection, or face shield if splashes or sprays of blood, body fluids, secretions or excretions can
be expected
• Wear clean, non-sterile gown to protect clothing from splashes/sprays of blood, body fluids, secretions or
excretions
ü Remove a soiled gown carefully to avoid the transfer of microorganisms to others
ü Wash hands after removing the gown
• Handle client care equipment that is soiled with blood, body fluids, secretions or excretions carefully to
prevent transfer of microorganism to others & environment
ü Make sure reusable equipment is
ü Cleaned and reprocessed correctly Dispose of single-use equipment correctly
• Handle, transport and process linen that is soiled with blood, body fluids, secretions & excretions in a
manner to prevent contamination of clothing, and the transfer of microorganisms to others & environment
• Prevent injuries from used scalpels, needles, or other equipment & place in puncture-resistant containers

TRANSMISSION-BASED PRECAUTIONS
Airborne Precaution
• Clients known or suspected of having serious illnesses transmitted at a distance of more than 3 feet by
airborne droplet nuclei smaller than 5 microns
• Ex: Measles (rubeola), Varicella, (including zoster), Pulmonary tuberculosis
• Use standard precaution as well as the following:
ü Place client in a private room that has a negative air pressure 6-12 air changes/hr, and either discharge
of air to the outside or a filtration system for the room air
ü If a private room is NOT available, place client with another client who is infected with the same
microorganism
ü Wear a respiratory device (N95 respirator) when entering the room of a client who is known or
suspected of having PTB
ü Susceptible people should not enter the room of a client who has rubeola (measles) or varicella
(chickenpox)
ü Limit movement of client outside the room to essential purposes. Place a surgical mask on the client
during transport
v Droplet Precautions
• Clients known or suspected of having serious illness transmitted by particle droplets greater than 5 microns
• Example: diphtheria, mycoplasma pneumonia, pertussis, mumps, rubella, streptococcal pharyngitis,
pneumonia, scarlet fever in infants & young children, pneumonic plague
ü Place client in private room
ü If a private room is NOT available, place client with another client who is infected with the same microorganism
ü Wear a mask if working within 3 feet of the client
ü Limit movement of client outside the room to essential purposes. Place a surgical mask on the client
v Contact Precautions
• Clients known or suspected of having serious illness transmitted by direct client contact or by contact with items in the
client's environment
• E.g. GI, respiratory, skin, or wound infections or colonization with multi-drug resistant bacteria, Clostridium difficile, E.
coli, Shigella, Hepatitis A, RSV, herpes simplex virus, impetigo, pediculosis, scabies
ü Place client in private room
ü If a private room is NOT available, place client with another client who is infected with the same
microorganism
Ø Wear gloves as described in Standard Precautions
Ø Change gloves after contact with infectious material
Ø Remove gloves before leaving client's room
Ø Wash hands immediately after removing gloves. Use an antimicrobial agent
Ø After hand washing, do not touch possibly contaminated surfaces or items in the room
ü Wear a gown when entering a room if there is a possibility of contact with infected surfaces or item, or if the
client is incontinent, has diarrhea, a colostomy, or wound drainage not contained by a dressing
Ø Remove gown in the client's room
Ø Make sure uniform does not contact possible contaminated surfaces
ü Limit movement of client outside the room
ü Dedicate the use of non-critical client care equipment to a single client or to clients with the same infecting
microorganisms
• For clients infected with the coronavirus that causes Severe Acute Respiratory Syndrome (SARS), Standard,
Contact and Airborne Precautions are indicated
DISPOSAL OF SOILED EQUIPMENT AND SUPPLIES

v To prevent inadvertent exposure of health care workers to articles contaminated with body substance
v To prevent contamination of the environment
v Bagging
• Articles contaminated with infective material such as pus, blood, body fluids, feces or respiratory secretions needs
to be enclosed in sturdy bag impervious to microorganisms before they are removed from the client.
• Uses label or bag of particular color that designates them as infective
• Double-bagging are done if it is not sturdy and impervious to microorganisms
v Linens
• Handle soiled linens as little as possible and with the least agitation possible before placing it in the laundry
hamper
v Laboratory Specimens
• Placed in a leak-proof container with a secure lid with a biohazard label
v Dishes
• Require no special precautions
v Blood pressure equipment
• Needs no special precautions unless it becomes contaminated with infective material
v Disposable needles, syringes and sharps
• Placed in a puncture-resistant container
ü Color coded receptacles
o Black — non-biodegradable
o Orange — radio-active items
o Red — punctured resistant
o Green — biodegradable
o Yellow — infectious items
OXYGENATION
v Oxygen is a clear, odorless gas that constitutes approximately 21% of the air we breathe, is necessary for proper
functioning of living cells.
v Absence of oxygen can lead to cellular, tissue and organ death
ALTERATIONS IN RESPIRATORY FUNCTIONS

v Hypoxia — a condition of insufficient oxygen anywhere in the body, from the inspired gas to the tissues
v Hypoxemia — refers to reduced oxygen in the blood
v Hypoventilation — inadequate alveolar ventilation
v Hypercapnia — accumulation of carbon dioxide in the blood
v Altered Breathing Pattern
• Eupnea — normal respiration
• Tachypnea — rapid rate
• Bradypnea— abnormally slow respiratory rate
• Apnea — cessation of breathing
• Kussmaul's breathing — deep, rapid breathing
• Cheyne-stokes respirations — from very deep to very shallow breathing followed by temporary apnea
• Biot's respirations — shallow breaths interrupted by apnea
• Orthopnea — inability to breathe except in upright or standing position
• Dyspnea — difficult or uncomfortable breathing
PROMOTING OXYGENATION
v Deep Breathing and Coughing
• To facilitate removal of secretions from the airways
• Coughing raises secretions high enough where the client can expectorate or swallow them
• Breathing exercises are indicated to patients with restricted lung expansion
CLIENT TEACHING ON ABDOMINAL (DIAPHRAGMATIC) AND PURSED-LIP BREATHING

v Assume a comfortable semi-sitting position or lying position in bed with one pillow
v Flex the knees to relax the muscles of the abdomen
v Place the patient's hand on abdomen just below the ribs
v Concentrate on feeling of rise/expansion of the abdomen; stay relax and avoid arching of the back
v Then purse lips as if about to whistle and breathe out slowly and gently without puffing out the cheeks
v Concentrate on feeling the abdomen fall or sink, and tighten (contract) the abdominal muscles while breathing
out to enhance effective exhalation
v Use this exercise whenever feeling short of breath and increase gradually 5 to 10 minutes four times a day

CLIENT TEACHING ON CONTROLLED AND HUFF COUGHING
v Inhale deeply and hold your breath for few seconds
v Cough twice. First cough loosens the mucus, while the second expels the secretions
v For huff coughing, lean forward and exhale sharply with a "huff' sound
v Inhale by taking rapid short breaths in succession to prevent mucus from moving back into smaller airways
v Rest
v Try to avoid episodes of coughing because these may cause fatigue and hypoxemia
INCENTIVE SPIROMETRY
v Also referred to as sustained maximal inspiration devices (SMIs), measures the flow of air inhaled through the
mouthpiece
Used for the following:
• Improve pulmonary ventilation
• Counteract the effects of anesthesia hypoventilation
• Loosen respiratory secretions
• Facilitate respiratory gaseous exchange
• Expand collapsed alveoli
Instructions in Using Incentive Spirometer

• Hold or place the spirometer in an upright position
• Exhale normally
• Seal the lips tightly around the mouthpiece
ü Take in a slow, deep breath to elevate the balls or cylinder and then hold the breath for 2 seconds initially,
increasing to 6 seconds (optimum), to keep the balls or cylinder elevated if possible
v For a flow-oriented device, avoid brisk, low volume breaths that snap the balls to the top of the chamber. Greater
lung expansion is achieved with a very slow inspiration. Sustained elevation of the balls or cylinder ensures
adequate ventilation of the alveoli
v If you have difficulty breathing only in the mouth, a nose clip can be used
v Remove the mouthpiece and exhales normally
v Cough after the incentive effort. Deep ventilation may loosen secretions, and coughing can facilitate their removal
v Relax and take several normal breaths
before using the spirometer again
v Repeat the procedure several times and then four or five times hourly
v Clean the mouthpiece with water and shake it dry
PERCUSSION, VIBRATION AND POSTURAL DRAINAGE

v Dependent nursing interventions performed according to a primary care provider's order
v The sequence for PVD is usually postural drainage, percussion, vibration, removal of secretions by
coughing or suctioning
v Each position is usually assumed for 10-15 mins
v The nurse should auscultate the client's lung, compare the findings to the baseline data and document the
amount, color and character of expectorated secretions after PVD
Percussions
• Sometimes called clapping, is a forceful
striking of the skin with cupped hands
• When hands are used, fingers and thumb are held together and flexed slightly to form a cup
• Percussion over congested lung areas can mechanically dislodge tenacious secretions from the bronchial walls
The following are steps in percussion:
ü Cover the area with a tower or gown to reduce discomfort
ü Ask the client to breathe slowly and
deeply to promote relaxation
ü Alternately flex and extend the
wrist rapidly to slap the chest
ü Percuss each affected lung segment for 1-2 mins.
ü Percussion is avoided over the breasts, sternum, spinal column and kidneys,
Vibration
• Series of vigorous quivering-produced vibration by hands that are placed flat against the client's chest wall
• Used after percussion to increase the turbulence of the exhaled air and thus loosen thick secretions
• Often done alternately with percussion
Following are steps in vibration:
ü Place hand, palm down on the chest area to be drained, one hand over the other with the fingers together and
extended. Hands may be placed side by side.
ü Ask the client to inhale deeply and exhale slowly through the nose or pursed lips
ü During the exhalation, tense all the hand and arm muscles, and using mostly the heel of the hand. Vibrate
(shake) the hands, moving them downward. Stop vibrating when the client inhales
ü Vibrate during five exhalations over one affected lung segment
ü After each vibration and Encourage the client to cough and expectorate
secretions into the sputum container
v Postural Drainage
• Drainage by gravity of secretions from various lung segments
• Wide variety of position is necessary to drain all segments of the lungs, but not all positions are required for
every client
• Lower lobes require drainage frequently because the upper lobes drain by gravity
• Client may be given bronchodilator or
nebulization to loosen secretions
• Scheduled 2-3 times daily depending on the degree of lung congestion
• Best time includes before breakfast. lunch, in the late afternoon and before bedtime
• Assess vital signs particularly the pulse and respiratory rate
OXYGEN THERAPY
v Clients who have difficulty ventilating all areas of their lungs. Those whose gas exchange is impaired, or people
with heart failure may benefit from 02 therapy
v Safety Precautions
• Place “NO SMOKING" sign on the client's door, at the foot or head of the bed and on the oxygen equipment
• Make sure that electric devices are in good working order to prevent short-circuit sparks
• Avoid materials that generate static electricity such as woolen blankets and synthetic fabrics. Cotton blankets
should be used
• Avoid the use of volatile, flammable materials such as oils, greases, alcohols, ether and acetones
• Be sure that electric monitoring equipment, suction machines and portable diagnostic machines are all electrically
grounded
• Make known the location of fire extinguishers. and make sure personnel are trained in their use
OXYGEN DELIVERY SYSTEM

Cannula
• Most common and inexpensive device
• Delivers relatively low concentration of 02 (24-45%) at flow rates of 2-6 L/min
• Inability to deliver higher 02 concentrations and irritation and drying of mucous membrane are limitations of
nasal cannula
Face Mask
• Simple face mask — delivers 02 concentration from 40-60% at liter flows of 5-10 L/min
• Partial rebreather mask — delivers 02 concentration at 60-90% at liter flows of 6-10 L/min. Allows the client
to rebreathe about the first third of the exhaled air
• Nonrebreather mask — delivers the highest 02 concentration — 95-100% - at liter flows of 10-15 L/min
• Venturi mask— delivers 02 concentrations varying from 24-40 or 50% at liter flows of 4-10 L/min. Delivers
precise 02 concentration and liter flow
Face Tent
• Can replace masks when masks are poorly tolerated by clients
• Provide varying 02 concentrations (3050%) at 4-8 L./min.
• Client's facial skin must be kept dry

TRACHEOSTOMY
v An opening into the trachea through the neck
v A tube is usually inserted through the
opening and an artificial airway is created
v A curved tracheostomy tube is inserted to
extend through the stoma into the trachea
TRACHEOSTOMY CARE
v Introduce self and verify client's identity Perform hand hygiene
v Provide privacy
v Assist the client in semi-fowler's or fowler's position
v Open the tracheostomy kit or sterile basin and other sterile supplies needed
v Suction the tracheostomy tube if needed
v Put on sterile gloves
v Suction the tracheostomy tube to remove secretions and ensure patent airway
v Rinse the catheter
v Unlock the inner cannula (counter clockwise) and remove it gently by pulling it out toward you in line with the
curvature place the inner cannula in the soaking solution
v Removed soiled dressing and change gloves
v Clean the inner cannula by using brush or pie cleaners
v Inspect the inner cannula for cleanliness by holding it at eye level and looking through it into the light
v Rinse the inner cannula thoroughly in the sterile normal saline
v After rinsing and gently tap the cannula against the inside edge of the sterile saline container Use a pipe cleaner
folded in half to dry only the inside of the cannula, do not dry the outside
v Replace the inner cannula, securing it in place
v Insert the inner cannula in the direction of its curvature
v Lock the cannula in place by turning the lock into position to secure the flange of the inner cannula to the outer
cannula
v Clean the incision site and tube flange using sterile applicators or gauze dressings moistened with normal saline.
Clean the incision site. Use each applicator or gauze dressings only once and then discard
v Hydrogen peroxide maybe used to remove crusty secretions. Thoroughly rinse the cleansed area
v Clean the flange of the tube with the same manner
v Thoroughly dry the client's skin and tube flanges
v Use a commercially prepared tracheostomy dressing of non-raveling material or refold a 4in x 4in gauze dressing
into a V shape. Avoid using cotton-filled gauze square or cutting the 4in x 4in gauze
v Place the dressing under the flange of the tracheostomy tube
v Ensure that the tracheostomy tube is securely supported while applying the dressing
v Change the tracheostomy ties
v Tape and pad the tie knot
v Place a folded 4in x 4in gauze square under the tie knot and apply tape over the knot
v Check the tightness of the ties
v Document all relative data
SUCTIONING
v Aspirating secretions through a catheter connected to a suction machine or wall suction outlet
v Sterile technique is recommended for all suctioning to avoid introducing pathogens into the airway
v Whistle-tipped catheter is less irritating to respiratory tissue Open-tipped catheter is more effective for
removing thick mucus plugs
v Yankauer suction catheter is used for oropharyngeal
v Hyperinflation — giving the client breaths that are 1-1.5 times the tidal volume set on the ventilator through
ventilator circuit or via manual resuscitation bag
v Hyperoxygenation — done with a manual resuscitation bag or through the ventilator and is performed by
increasing the 02 flow (usually to 100%) before suctioning and between suction attempts
v Suction Catheter Sizes:
• Adults: Fr 12-18
• Children: Fr 8-10
• Infant: Fr 5-8
•
OROPHARYNGEAL, NASOPHARYNGEAL AND NASOTRACHEAL SUCTIONING
v Introduce self and verify the client's identity Perform hand hygiene
v Provide privacy
v Position a conscious person who has functional gag reflex in Semi-Fowler's position with the head turned to
one side for oral suctioning or neck hyper extended for nasal suctioning
v Position unconscious client in lateral position facing you
v Place towel or moisture-resistant pad over the pillow or under the chin
v Set the pressure on the suction gauge and turn on the suction
• Wall unit: Adult-100-120 mmHg Child — 95-110 mmHg
Infant — 50-95 mmHg
• Portable unit: Adult-10-15 mmHg Child —5-10 mmHg Infant —2-5 mmHg
v For oropharyngeal suctioning:
• Moisten the tip of the catheter with sterile or water saline
• Pull the tongue forward if necessary
• Do not apply suction during insertion
• Advance the catheter about 10-15 cm. (4-6in.) along one side of the mouth into the pharynx
• It may be necessary during oropharyngeal suctioning to apply suction to secretions that collect in the vestibule of
the mouth and beneath the tongue
v For nasopharyngeal and nasotracheal
• Open the lubricant
• Open the sterile suction package
• Setup the cup or container
• Pour sterile water or saline in the container
• Put on sterile gloves
v Measure the distance between the tip of the nose and earlobe or about 13cm. (5in.) for an adult and mark the
position on the tube with the fingers
v Test the pressure of the suction and the patency of the catheter
v If needed, apply or increase supplemental 02
v Lubricate the catheter tip
v Insert the catheter the recommended distance into either the nares and advance it along the floor of nasal cavity
v Never force the catheter against an obstruction, if one nostril is obstructed, try the other
v Apply suction for 5-10 secs and gently rotate the catheter. The whole suction attempt should last only 10-15 secs.
v Rinse and flush the catheter and tubing with sterile water or saline
v Relubricate the catheter and repeat suctioning until the air passage is clear
v Allow sufficient time between each suction for ventilation and oxygenation. Limit suctioning to 5 mins total
v Encourage the client to breathe deeply and to cough between suctions
v Obtain a specimen if required
v Assist the client with oral or nasal hygiene
v Assist the client to the position that facilitates breathing
v Dispose of equipment and ensure availability for the next suction
v Assess the effectiveness of suctioning
SUCTIONING OF TRACHEOSTOMY OR ENDOTRACHEAL TUBE

v Introduce self and verify the client's identity
v Provide privacy
v If not contraindicated, place the client in semi-Fowlers position
v If necessary, provide analgesia before suctioning
v Attach the resuscitation apparatus to the 02 source. Adjust the 02 flow to 100%
v Open the sterile supplies
v Place sterile towel across the client's chest below the tracheostomy
v Turn on the suction and set the pressure
v Put on goggles, mask and gown if necessary
v Put on sterile gloves
v Holding the catheter in dominant hand and the connector to non-dominant hand, attach the suction catheter to
the suction tubing
v Using the dominant hand, place the catheter tip in sterile saline solution
v Using the thumb of non-dominant hand, occlude the thumb control and suction small amount of the sterile
solution through the catheter
v If the client does not have copious secretions, hyperventilate the lungs with resuscitation bag before suctioning
ü Using your non-dominant hand. turn on the 02 to 12-15 L/min
ü If the client is receiving 02, disconnect the 02 source from the tracheostomy tube using non-dominant hand
ü Attach the resuscitator to tracheostomy or endotracheal tube
ü Compress the ambubag 3-5 times as the client inhales. This is best done by second person
ü Observe the rise and fall of the client's chest
ü Remove the resuscitation device
v If the client has copious secretions, do not hyperventilate instead keep the regular 02 delivery device and
increase the liter flow to 100% for several breaths before suctioning
v Quickly but gently insert the catheter without applying any suction
v Insert the catheter about 12.5 cm (5in) for adults or until the client coughs or you feel resistance
v Apply suction for 5-10 seconds and rotate the catheter by rolling it between your thumb and forefinger while
slowly withdrawing it
v Hyperventilate the client and suction again
v Reassess the client's oxygenation status and repeat suctioning
v Allow 2-3 mins with 02. as appropriate between suctions when possible
v Flush the catheter and repeat suctioning until the air passage is clear and the breathing is relatively effortless and
quiet
v Dispose the equipment and ensure availability for the next suction
v Assist the client to a comfortable position that aids breathing
ü If the client is conscious (Semi-Fowlers position)
ü If unconscious. Sim's position to aid drainage of secretions in the mouth
ENTERAL FEEDING
v Alternative feeding method to ensure adequate nutrition through the gastrointestinal system methods
v Also referred to as total enteral nutrition (TEN)
v Provided when the client is unable to ingest food or the upper gastrointestinal tract is impaired and the transport
of food to the small intestine is interrupted.
• Nasogastric
• Gastrostomy
• Jejunostomy
ENTERAL ACCESS DEVICE

v Enteral access -is achieved by means of nasogastric or nasointestinal (nasoenteric) tubes, gastronomy or
jejunostomy tubes.
v Nasogastric tube- is inserted through one of the nostrils, down the nasopharynx, and into the alimentary tract.
v Purposes:
• Used for feeding clients who have adequate gastric emptying and who require short-term feedings. It is not
advised for feeding clients without intact gag and cough reflexes.
• To prevent nausea, vomiting and gastric distention following surgery
• To remove stomach contents for laboratory analysis.
• To lavage (wash) the stomach in cases of poisoning or overdose of medications.
v Tubes:
• Levin tubes- a flexible rubber or plastic, single lumen tube with holes near the tip.
• Salem sump tube- double lumen
• Sengstaken-Blakemore tube – triple-lumen tube used to treat bleeding esophageal varices
• Miller Abbot – used for intestinal decompression
• Nasoenteric (or nasointestinal) tube-a longer tube than the naasogastric tube (at least 40 inches for an
adult) is inserted through one nostril down into the upper small intestines.
• Indications are the following:
• Decreased level of consciousness
• Poor cough or gag reflex
• Endotracheal intubation
• Recent extubation
• Inability to cooperate with the procedure
• Restlessness or agitation
• Inability to cooperate with the procedure
• Restlessness or agitation
Enteral Feeding
v Intermittent feedings- is the administration of 300 to 500 mL of enteral formula several times per day.
v Continuous feedings- is generally administered over a 24-hour period using an infusion pump that guarantees
a constant flow rate.
v Cyclic feedings- are continuous feedings
that are administered in less than 24 hours
v The bag and tubing should be replaced every 24 hours
INSERTING A NASOGASTRIC TUBE
PROCEDURE RATIONALE
Assist the client to a high fowler’s position and support his It is often easier to swallow in this position and gravity
head on pillow. helps the passage of the tube
Assess the client’s nares and select the nostril that has the This length approximates the distance from the nares to
greater airflow. Use the tube to mark off the distance from the stomach
the tip of the client’s nose to tip of the earlobe up to the
xyphoid process.
Lubricate the tip of the tube well with water soluble A water-soluble lubricant dissolves if the tube accidentally,
lubricant or water to ease insertion enters the lungs. An oil-based lubricat such as petroleum
jelly will not dissolve and could cause respiratory
complication (eg lipid pneumonia) if it enters the lungs.
Ask the client to hyperextend neck and gently advance the Hyperextension of the neck reduces the curvatures of the
tube towards the nasopharynx nasopharyngeal junction.
Direct the tube along the floor of the nostril and toward Directing the tube along the floor avoids the projections
the ear on that side. (turbinate’s) along the lateral wall
Slight pressure and twisting motion are sometimes Tears are natural body response and provide the client
required to pass the tube into the nasopharynx and some with tissue as needed.
client’s eyes may water at this point.
If the tube meets resistance, withdraw it, relubricate it, The tube should never be forced against resistance
and insert it in the other nostril because of the danger of injury.
Ask the client to tilt the head forward and encourage the Tilting the head forward facilitates passage of the tube
client to drink and swallow into the posterior pharynx and esophagus rather than
If the client continues to gag and the tube does not The tube may be coiled in the throat
advance with each swallow, withdraw it slightly and
inspect the throat
Place the tape over the bridge of the client's nose and
Taping in this manner prevents the tube from pressing
bring the split ends either under and around the tubing against and irritating the edge of the nostril
Attach a piece of adhesive tape to the tube, and pin the The tube is attached to prevent it from dangling and
tape to the gown pulling

PROCEDURE RATIONALE
Assist the client to a fowlers position (at least 30 degrees Prevents aspiration of fluid into the lungs
elevation) in bed or a sitting position, if it is contradicted right-
side lying position is acceptable
Aspirates all contents and measure the amount before Evaluate the absorption of the last feeding
administering feeding
If 100 ml is withdrawn, check with the agency policy before Feeding is delayed when the specified amount
proceeding to reinstill the gastric contents into the stomach if remains in the stomach and Removal of the contents
this is the agency policy order could disturb the clients electrolyte balance
Warm feeding to room temperature This minimizes the risk of contaminants entering the
feeding bag or syringe.
Aspirate stomach contents and check the pH Testing pH is a reliable way to determine location of
a feeding tube. Gastric contents are commonly pH1
to 5
Aspirate can also be tested for biliburin Lungs-almost zero stomach -1.5 mg/dl intestine over
10mg/dl
Nasogastric tube position can be confirmed by spray Nasogastric tubes are radiopaque
Place a stethoscope over the clients epigastrium and

inject 10 to 30 ml of air into the tube while listening
to the wooshing/gurgling sound
GASTROSTOMY AND JEJUNOSTOMY
v Are used for long term nutritional support, generally more than 6 to 8 weeks
v Tubes are placed surgically or by
laparoscopy through the abdominal wall in to the stomach or into the jejunum.
Feeding:
• After feeding, ask the client to remain in the sitting position or slightly elevated right lateral position for at least
30 minutes. This minimizes the risk for aspiration
• Assess status of peristomal skin. Gastric or jejuna] drainage contains digestive enzymes that can irritate the skin.
Parenteral Nutrition
• Also referred to as Total Parenteral Nutrition or Intravenous Hyperalimentation
• Gastrointestinal tract is nonfunctional because of an interruption in its continuity or because its' absorptive
capacity is impaired.
• Through central venous catheter into the superior vena cava.
• Parenteral -composed of dextrose. Water, fat, proteins, electrolytes, vitamins and trace elements.
• Hypertonic- injected into high -flow central veins, diluted by the client's blood.
• Means of achieving an anabolic state in clients who are unable to maintain a normal nitrogen balance (severe
malnutrition severe burns, bowel disease disorders)
• Infection control is of utmost importance during TPN therapy
• Infusions are started gradually to prevent hyperglycemia
• When TPN therapy is to be discontinued, the TPN infusion rates are decreased slowly to prevent
hyperinsulinemia and rebound hypoglycemia
• Weaning may take 48 hours but can occur in 6 hours as long as the client receives adequate carbohydrates either
orally or intravenously.
BOWEL/FECAL ELIMINATION
Characteristics of Normal and Abnormal Feces
CHARACTERISTICS NORMAL ABNORMAL
Color Adult: brown Infant: yellow Clay or
White, Black or
Tarry, Red, Pale, orange or green
Consistency Formed, soft, Hard, Dry Diarrhea
Semisolid, moist
Shape Cylindrical about Narrow, pencil
2.5 cm in diameter in adults Shaped: string-like stool
Amount Varies with diet (100-400 g/day)
Odor Aromatic Pungent
Constituents Small amounts of undigested roughage, Pus, mucus, parasites, blood, large
Sloughed dead bacteria and epithelial quantities of fat, foreign objects
cells. Fat, protein, dried constituents of
digestive juices
FECAL ELIMINATION PROBLEMS

v Constipation - defined as fewer than three bowel movements per week
v Fecal impaction - a mass or collection of hardened feces in the folds of the rectum, results from prolonged
retention and accumulation of fecal material
v Diarrhea - refers to passage of liquid feces and an increased frequency of defecation, results from rapid
movement of fecal contents through the large intestines
v Bowel incontinence — refers to the loss of voluntary ability to control fecal and gaseous discharges through
the anal sphincter
v Flatulence — the presence of excessive flatus in the intestines and leads to stretching and inflation of the
intestines
ENEMA
v Is a solution introduced to the rectum and large intestines
v The main action are to distend the intestines and to irritate the mucosa thereby increasing peristalsis and the
excretion of feces and flatulence
TYPES OF ENEMA
v Cleansing Enema
• Done to prevent the escape of feces during surgery
• Prepares the intestines for certain
diagnostic test such as colonoscopy
• Remove feces ininstances of
constipation or impaction
• High enema is given to cleanse as much of the colon as possible. Client changes from left lateral to dorsal
recumbent to right lateral position so that the solution can follow the large intestine. Container is held 12-18
inches above the rectum
• Low enema is used to clean the rectum and sigmoid colon only. Solution container should be no higher than 12
inches
Carminative Enema
• Given primarily to expel flatus
• For an adult, 60-80 ml of solution is instilled
Retention enema
• Introduces oil or medication into the rectum and sigmoid colon
• Solution is retained for a long period (13 hours)
• Acts to soften the feces and to lubricate the rectum and anal canal
Return Flow Enema
• Used occasionally to expel flatus
• Alternating flow of 100-200 ml of fluid into and out of the rectum and sigmoid colon, this process is done 5-6
times until flatus is expelled
• Replace the solution several times as it becomes thick with the feces
Solutions Used in Enema
• Hypertonic solution (Fleet phosphate enema) — draws water into the colon
ü Introduced 90-120 ml of solution and remains 5-10 mins to take effect
• Hypotonic — distends colon, stimulates peristalsis and soften the stool
ü 500-1000 ml of tap water in given and remains 15-20 mins in the colon
• Isotonic — distends colon, stimulates peristalsis and soften the stool
ü 500-1000 ml of tap water in given and remains 15-20 mins in the colon

• Soapsuds — irritates the mucosa and distends the colon
ü 500-1000 ml (3-5 ml of soap to 1000 ml water) is given and remains 10-15 mins
• Oil (mineral, olive, cottonseed) —lubricates the feces and colonic mucosa
ü 90-120 ml is given and remains 1-3 hour
SIZE AND INSERTION OF RECTAL TUBE

v Adult — Fr. 22-32 inserted 3-4 inches in the anal canal
v Children — Fr. 14-18 inserted 2-3 inches in the anal canal
v Infant — Fr. 12 inserted 1-1.5 inches in the anal canal
ADMINISTRATION ENEMA
v Check the doctor's order
v Provide privacy
v Promote relaxation to relax the anal sphincter
v Lubricates 5 cm. (2 in.) of the rectal tube
v Run some solution through the connecting tubing to expel air
v Insert 3-4 in. of rectal tube smoothly and slowly into the rectum
v Slowly administer the enema solution If abdominal cramps occur, lower the container or clamp the tube to stop
the flow for 30 sec. then restart the flow at a slow rate
v After introduction of the solution, press the buttocks together to inhibit the urge to defecate
v Assist the client to defecate. Ask the client who is using the toilet not to flush it. The nurse must observe the
return flow
v Do perianal care
v Document the relevant data
BOWEL OSTOMIES
• An opening for the colon onto the skin
• The purpose of bowel ostomies is to divert and drain fecal material
Classifications
Permanence
• Temporary colostomies
ü Traumatic injuries
ü Inflammatory conditions of the bowel
ü Allow the distal diseased portion of the bowel to rest and heal
• Permanent colostomies
ü Rectum or anus is non-functional
ü Birth defect
ü Disease such as cancer of bladder
Anatomic Location
• Ileostomy
ü Empties from the distal end of the small intestine
ü Liquid fecal drainage
ü Cannot be regulated
ü Some digestive enzymes which are damaging the skin
ü Wear appliance continuously
ü Special precautions to prevent skin breakdown
ü Odor is minimal because fewer bacteria is present.
• Cecostomy- empties from cecum (the first part of the ascending colon)
• Ascending colostomy- empties from the ascending colostomy
ü Drainage is liquid
ü Cannot be regulated
ü Digestive enzymes are present
ü Odor is a problem
• Transverse colostomy- empties from the transverse colon
ü Malodorous, mushy drainage
ü Usually no control
• Descending colostomy- empties from the descending colon
ü Increasingly fluid fecal drainage.
• Sigmoidostomy- empties from the sigmoid colon
ü Normal or formed consistency
ü Frequency of discharge can be regulated
ü Odor can be controlled May not have to wear an appliance
TYPES OF STOMA ACCORDING TO SURGICAL CONSTRUCTION

v Single stomata (end/terminal)
• One end of bowel is brought out through an opening onto the anterior abdominal wall
v Loop Colostomy
• A loop of bowel is brought out onto the abdominal wall and supported by a plastic bridge, or a piece of rubber
tubing
v Divided Colostomy
• Consists of two edges of bowel brought out onto the abdomen but separated from each other
v Double-barreled Colostomy
• Resembles a double-barreled shotgun
• Proximal and distal loops of bowel are sutured together and both ends are brought up onto the abdominal wall
PROMOTING REGULAR DEFECATION

v Privacy
v Provide as much privacy as possible
• Timing
• The client should be encouraged to
defecate when the urge is recognized.
• Discuss when mass peristalsis normally
occurs and provide time for defecation.
• Other activities should not interfere with the defecation time
v Nutrition and Fluids
• For Constipation
ü Increase daily fluid intake, and instruct the client to drink hot liquids and fruits juices. Especially prune juice.
Include fiber in the diet
• For Diarrhea
ü Encourage oral intake of fluids and bland foods.
ü Eating small amounts can be helpful
ü Highly spiced foods and high fiber foods can aggravate diarrhea.
• For Flatulence
ü Limit carbonated beverages. the use of drinking straws and chewing gum-all of which increase the ingestion of
air. Gas forming foods should be avoided. (cabbage, beans, onions, cauliflower)
STOMA AND SKIN CARE

v Skin is kept clean by washing off any excretion and drying thoroughly.
v Closed pouches are often used by people who have a regular stoma discharge (empty pouch 1 to 2 times a day)
v Odor control (use of bathroom, appropriate kind of appliance. odor-barrier material) Ostomy appliances can be
applied for up to 7 days
v If the skin is erythematous, eroded denuded or ulcerated, the pouch should be changed every 24 to 48 hours to
allow appropriate treatment of the skin
COLOSTOMY IRRIGATION
v Form stoma management used only for client who have a sigmoid or descending colostomy
v Purpose
• Distend the bowel sufficiently top stimulate peristalsis which stimulates evacuation. When a regular evacuation
pattern is achieved, the wearing of a colostomy pouch is unnecessary
CHANGING A BOWEL DIVERSION OSTOMY APPLIANCE

Assess the following:
v Stoma color- the stoma should appear red, and slightly moist. Very pale or darker-colored stomas with a dusky
bluish or purplish hue indicate impaired blood circulation to the area. Notify the surgeon immediately.
v Stoma size and shape- protrude slightly from the abdomen. New stomas normally appear swollen, but swelling
generally decreases over 2 or 3 weeks or for as long as 6 weeks.
v Stomal bleeding- slight bleeding initially when the stoma is touched is normal but other bleeding should be
reported.
v Status of peristomal skin- any redness and irritation of the peristomal skin- the 5 to 13 cm (2 to 5 in) of skin
surrounding the stoma-should be noted.
v Amount and type of feces- inspect for abnormality like pus and blood. Empty if ostomy bag is 1/3 full.
v Complaints - burning sensation under the skin burrier may indicate skin breakdown
Procedures Rationale
Assess fullness of the bag The weight of an overly full bag may loosen the skin
barrier and separate it from the skin
Avoid times close to meal or visiting hours Ostomy odor and stool may reduce appetite or embarrass
the client
Avoid times immediately after meals or the It may stimulate bowel evacuation
administration of any medications
Empty the contents of a drainable pouch through the Emptying before removing the pouch prevents spillage of
bottom opening into a bedpan or a toilet stool onto the clients skin
Use warm water, Soap is sometimes not advice because it can be irritating
Mild soap and a washcloth to clean the skin and stoma. to the skin
Do not use deodorant or moisturizing soaps They may interfere with the adhesives in the skin barrier
Dry the area thoroughly by patting with a towel Excess rubbing can abrade the skin
Place a piece of tissue or gauze over the stoma and This absorbs any seepage from the stoma while the
change it as needed ostomy appliance is being change
Make the opening of the barrier no more than 1/8 to ¼ This allows space for the stoma to expand slightly when
inch larger than the stoma functioning and minimizing the risk of stool contacting
peristomal skin
Center the one-piece skin barrier and apply over the The heat and pressure help activate the adhesives in the
stoma, and gently press it onto the client skin for 30 skin barrier
seconds.
URINARY ELIMINATION
v Characteristics of normal and abnormal urine
• Amount in 24 hours (adult)
ü Normal: 1200-1500 ml
• Color, clarity
ü Normal: straw, amber, transparent
ü Abnormal: dark amber, cloudy, dark orange, red or dark brown, viscid, thick
• Odor
ü Normal: faint aromatic
ü Abnormal: offensive
• Sterility
ü Normal: no microorganism present
ü Abnormal: microorganism present
• pH level
ü Normal: 4.5-8
ü Abnormal: over 8 and under 4.5
• Specific gravity
ü Normal: 1.010-1.025
ü Abnormal: over 1.025 and under 1.010
• Glucose
ü Normal: not present
ü Abnormal: present
• Ketone bodies (acetone)
ü Normal: not present
ü Abnormal: present
• Blood
ü Normal: present
ü Abnormal: occult (microscopic) bright red
PROBLEMS IN UNIRARY ELIMINATION

v Altered Urine Production
• Polyuria- production of abnormal large amounts of urine
• Oliguria- low urine output usually less than 500 ml/day or greater than 30 ml/hr for an adult
• Anuria- refers to lack of urine production (<100ml/day)
v Altered urine frequency
• Frequency- voiding at frequent intervals more than 4-6 times per day
• Nocturia- voiding two or more times at night
• Urgency- sudden strong desire to void
• Dysuria- voiding that is either painful or difficult
• Urinary hesitancy- delay and difficulty in initiating voiding
• Enuresis- involuntary urination in children beyond 4-5 years old
• Urinary incontinence- involuntary urination
ü Total incontinence - continuous and unpredictable loss of urine
ü Stress incontinence – leakage of less than 50 ml of urine as a result of sudden increase in intra-
abdominal pressure, ex. Sneezing, coughing etc.
ü Urge Incontinence- follows a sudden strong desire to urinate and leads to involuntary detrusor
contraction
ü Functional incontinence- involuntary unpredictable passage of urine
ü Reflex incontinence – involuntary loss of urine occurring at somewhat predictable intervals when
specific bladder volume is reached
• Retention – accumulate of urine in the bladder with associated inability of the bladder to empty itself
URINARY CATHETERIZATION
v Introduction of catheter into the urinary bladder
v Straight catheter is a single-lumen tube with small eye or opening from the insertion tip. This is used for short
term and for men with prostatic hypertrophy because it is less traumatic on insertion.
v Two-way Foley catheter (retention) is a double lumen catheter. The larger lumen drains the urine from the
bladder and the smaller lumen is used to inflate the balloon to hold the catheter in place within the bladder and
used for long term.
v Three-way Foley catheter is used for clients who requires continuous or intermittent bladder irrigation, which
has third lumen through which sterile irrigating fluid can flow into the bladder.
PURPOSE OF URINARY CATHETERIZATION

v To relieve bladder distension
v To instill medication into the bladder
v To irrigate the bladder
v To measure the urine output accurately
v To collect sterile urine specimen
v To measure residual urine. Residual urine is the amount of urine retained in the bladder after forceful voiding
v To maintain continence to incontinent patients
v To promote healing of the genito-urinary structures postoperatively
v To empty the bladder in preparation for diagnostic procedures and surgery
ADMINISTRATION OF URINARY CATHETER

v Verify the doctor’s order and identify the client
v Explain the procedure and purpose of the procedure to the client
v Provide privacy
v Practice strict asepsis
v Do perineal care before the procedure
v Use appropriate size of catheter to prevent trauma
• Male: Fr. 16-18
• Female: Fr. 12-14
v Position the patient
• Male: supine, thighs slightly abducted or apart
• Female: dorsal recumbent position
v Have adequate lighting to visualize urethral meatus properly
v Don sterile gloves and inflate the balloon of the catheter with air to check that it is intact then deflate again
v Locate the urinary meatus properly
• Male: at the tip of the glans penis
• Female: between the clitoris and the vaginal orifice
v Lubricate the catheter to reduce friction and prevent trauma
v Cleanse urinary meatus with antiseptic solution
v Insert the catheter gently and instruct the client to take slow deep breath to relax the sphincter or strain as if
attempting to void to open the urinary meatus
v Advance the catheter 2 inches farther after the urine begins to flow
v If the catheter accidentally slips into vagina, leave it there until new catheter is inserted in the meatus
v Length of catheter insertion
• Male: 6-9 inches
• Female: 3-4 inches
v During the insertion of catheter in male, hold the penis at 90 degree angle or perpendicular to the body to
straighten the urethra and facilitate catheter insertion
v If the purpose of catheterization is to relieve bladder distension, practice gradual decompression to prevent
shock. Only 750-1000ml of urine are to be drained at a time
v For retention catheterization, inflate the balloon with 5 ml sterile NSS.
v Gently pull on the catheter, if resistance is felt, the catheter balloon is properly inflated in the bladder
v Anchor the catheter properly:
• Male: laterally or upward over the lower abdomen to prevent penoscrotal pressure
• Female: inner aspect of the thigh, providing enough “give” so it will not pull when the legs move
v Attach the drainage bag to the bed frame, ensuring that tubing does not fall into dependent loops
v Keep the client comfortable
v Do after care equipment and articles
v Document the catheterization procedure
REMOVAL OF INDWELLING CATHETER

v Check the doctor’s order
v Wash hands. Remove the tape that secures the catheter to the client’s body
v Don clean gloves
v Deflate the balloon by drawing out all the liquids via inflation port to prevent trauma to the urethra as the
catheter is removed
v Instruct the client to inhale then kink and remove the catheter slowly and carefully as the client exhales
v After removal of the catheter, allow the urine to drain into collection bag. Measure and record the amount of
urine in the bag
v Assess client’s perineum and meatus for any sign of redness or irritations
v Assist patient to do perineal care
v Discard contaminated equipment and articles in appropriate containers
v Make relevant documentation
v Voiding should be expected within 6-8 hours from the time of removal of the catheter
v If the patient has not voided in 8 hours, assess for urinary retention
v If the client has difficulty establishing voluntary control of voiding, notify the physician
SAFE USE OF STRECHER

v Lock the wheels of the bed and stretcher before the client transfers in or out of them.
v Fasten safety straps across the client on a stretcher, and raise the side rails.
v Never leave a client unattended on a stretcher unless the wheels are locked and the side rails are raised on both
sides and/or the safety straps are securely fastened across the client.
v Always push a stretcher from the end where the client’s head in the positioned. This position protects client’s in
the event of a collision.
v If the stretcher has two swivel wheels and two stationary wheels:
• Always position the client’s head at the end with stationary wheels and
• Push the stretcher from the end with the stationary wheels. The stretcher is maneuvered more easily
when pushed from this end.
v Maneuver the stretcher when entering the elevator so that the client’s head goes in first.
TRANSFERRING OF PATIENT FROM BED TO WHEELCHAIR

v Before transferring a client, assess the following:
• The client’s body size
• Ability to follow instructions
• Activity tolerance
• Muscle strength
• Joints mobility
• Presence of paralysis
• Level of comfort
• Presence of orthostatic hypotension
• The technique with which the client is familiar
• The space in which the transfer will need to be maneuvered (bathrooms, for example, are usually
cramped)
• The number of assistants (one or two) needed to accomplished the transfer safety
• The skill and strength of the nurse(s)
v IMPLEMENTATION
• Introduce yourself, verify the client’s identity and explain the procedure
• Observe infection control measure
• Provide privacy
• Lower the bed to its lowest position so that the client’s feet will rest flat on the floor. Lock the wheels of
the bed.
• Place the wheelchair parallel to the bed as close to the bed as possible.
• Put the wheelchair on the side of the bed that allows the client to move toward his or her stronger side.
• Lock the wheels of the wheelchair and raise the footplate
• Prepare and assess the client
• As the client to move forward and sit on the edge of the bed, lean forward slightly from the hips and
place the foot of the stronger leg beneath the edge of the bed and put the other foot forward
• Place the client’s hands on the bed surface or on your shoulders so that the client can push while
standing.
• Position yourself correctly.
ü Stand directly in front of the client. Lean the trunk forward from the hips. Flex the hips, knees,
and ankles. Assume a broad stance, placing one foot forward and one back. Mirror the placement
of the client’s feet, if possible
ü Encircle the client’s waist with your arms, and grasp the transfer belt at the client’s back with
thumbs pointing downward
ü Tighten your gluteal, abdominal, leg and arm muscles
• Assist the client to stand, and then move together toward the wheelchair (on the count of three, move
together with the patient)
• Assist the client to sit and ensure safety
• Ask the client to push back into the wheelchair seat
• Lower the footplates, and place the client’s feet on them
• Apply a seat belt as required
v NURSING CONSIDERATION
• Angling the Wheelchair – for clients who have difficulty walking, place the wheelchair at a 45-degree
angle to the bed
ü Rationale: this enables the client to pivot into the chair and lessens the amount of the body
rotation required
• Transferring a Client with an Injured Lower Extremity- When the client has an injured lower extremity,
movement should always occur toward the client’s unaffected (strong) side. For example, if the client’s
right leg is injured and the client is sitting on the edge of the bed preparing to transfer to a wheelchair,

position the wheelchair on the client’s left side. In this way, the client can use the unaffected leg most
effectively and safely.
LOSS, GRIEVING AND DEATH

vLOSS
• Is an actual or potential situation in which something that is valued is changed or no longer available. People
can experience the loss of the body image, a significant other, a sense of wellbeing, a job, personal
possessions, or beliefs. Illness and hospitalization often produce losses
• Types of loss
ü Actual loss – recognized by others
ü Perceived loss – experienced by one person but cannot be verified by others
ü Anticipatory loss – experienced before the loss actually occurs
ü Situational loss – loss of one’s job, the death of a child, or the loss of functional ability because of
acute illness or injury
ü Developmental loss — losses that occur in the process of normal development such as the departure
of grown children from the home retirement from a career. and the death of aged parents
• Sources of Loss
ü Loss of an aspect of oneself — a body part, a physiologic function, or a psychologic attribute
ü Loss of an object external to oneself
ü Separation from an accustomed environment
ü Loss of a loved or valued person
v Grief, Bereavement and Mourning
• Grief — total response to the emotional experience related to loss
ü Manifested in thoughts. feelings, and behaviors associated with overwhelming distress or sorrow
ü Essential for good mental and physical health. It permits the individual to cope with the loss gradually and to
accept it as part of reality
• Bereavement — subjective response experienced by the surviving loved ones after the death of a person with
whom they have shared a significant relationship
• Mourning — behavioral process through which grief is eventually resolved or altered: it is often influenced by
culture, spiritual beliefs and custom
v Types of Grief Responses
• Abbreviated grief — brief but genuinely felt. This can occur when the lost object is not significantly important to the
grieving person or may have been replaced immediately by another, equally esteemed object
• Anticipatory grief — experienced in advance of the event such as the wife who grieves before her ailing husband dies
• Disenfranchised grief — occurs when a person is unable to disclose the loss to other persons
ü Situations in which this may occur often relate to a socially unacceptable loss that cannot be spoken about, such
as suicide, abortion or relationships that are socially unsanctioned such as extramarital and homosexual
relationships
• Complicated Grief — unhealthy grief that is pathologic in nature. Exist when the strategies to cope with the loss are
maladaptive
• Different forms of complicated grief
• Unresolved or chronic grief is extended in length and severity. The same signs are expressed as with normal grief,
but the bereaved may also have difficulty expressing the grief, may deny the loss, or may grieve beyond the expected
time
• Inhibited grief - many of the normal symptoms of grief are suppressed, and other effects including somatic are
experienced instead
• Delayed grief - occurs when feelings are purposely or subconsciously suppressed until a much later time
• Exaggerated grief - survivor who appears to be using dangerous activities as a method to lessen the pain of grieving
Kubler-Ross Stages of Grieving
STAGE BEHAVIORAL RESPONSE NURSING INTERVENTION
Refuses to believe that loss is happening. May Verbally support client but do not reinforce
Denial assume artificial cheerfulness to prolong denial denial
Client or family may direct anger at nurse or -Help client understand that anger is a
staff about matters that normally would not normal response to feelings of loss and
Anger bother them powerlessness. Avoid withdrawal or
retaliation
-Deal with needs underlying any angry
reaction
Seeks to bargain to avoid loss -Listen attentively, and encourage client to
Bargaining talk to relieve guilt and irrational fear. If
appropriate. Offer spiritual support
Grieves over what has happened and what - Allow client to Express sadness
cannot be - Communicate nonverbally by sitting quietly
Depression
without expecting conversation
- Convey caring by touch
-Comes to terms with loss- May have -Help family and friends understand client's
decreased interest in surroundings and support decreased need to socialize
Acceptance
people May wish to begin making plans - Encouraged client to participates much as
possible in the treatment program
DYING AND DEATH

Signs of Impending Clinical Death
v Loss of Muscle Tone
• Relaxation of the facial muscles (e.g., the jaw may sag)
• Difficulty speaking
• Difficulty swallowing and gradual loss of the gag reflex
• Decreased activity of the gastrointestinal tract, with subsequent nausea.
Accumulation of flatus abdominal distention and retention of feces especially if narcotics or tranquilizers are
being administered
• Possible urinary and rectal incontinence
due to decreased sphincter control
• Diminished body movement
v Slowing of the Circulation
• Diminished sensation
• Mottling and cyanosis of the extremities
• Cold skin, first in the feet and later in the hands ears and nose (the client, however, may feel warm if there is a
fever)
• Slower and weaker pulse
• Decreased blood pressure
v Changes in Respirations
• Rapid shallow, irregular, or abnormally slow respirations
• Noisy breathing, referred to as the death rattle, due to collecting of mucus in the throat
• Mouth breathing. dry oral mucous membranes
v Sensory Impairment
• Blurred vision
• Impaired senses of taste and smell
Nursing Interventions for a Dying

v Patients Helping the patients die with dignity
• Restore and support feelings of control — allow clients to choose the location of care times of appointment with
health care providers, activity schedule, etc.
• Support the client's will and hope
• Focus on client's need
• Help the client accept his or her loses
v Meeting the Physiologic Needs of the Dying Clients
• Provide personal hygiene measures
• Controlling pain
• Relieving respiratory difficulties
• Assisting with movement, nutrition, hydration and elimination
• Provide measures related to sensory changes
v Provide Spiritual Support
• Ensure that the client's spiritual needs are attended
• Facilitate expressions of feeling, prayer, meditation, reading, and discussion with appropriate clergy or a
spiritual adviser
v Supporting the Family
• Use therapeutic communication to
facilitate their expression of feelings
• Provide empathetic and caring presence
• Explain what is happening and what the family can expect
• Repeat the provided information
because they may not absorb it due to stress and grieving
• Encourage the family to participate in
the physical care of the dying person
• After the client dies, encouraged the family to view the body
Definitions and Signs of Death

v Heart-lung death — cessation of pulse, respirations and blood pressure
v Cerebral death (higher brain death) —occurs when higher brain center, the cerebral cortex is irreversibly
destroyed
v Indications of death
• Total lack of response to external stimuli
• No muscular movement, especially breathing
• No reflexes
• Flat encephalogram (brain waves)
v Postmortem Care
• Rigor Mortis
ü Stiffening of the body that occurs about 2 to 4 hours after death
ü Results from a lack of adenosine triphosphate (ATP), which causes the muscles to contract, and in turn
immobilizes the joints
• Algor Mortis
ü Gradual decrease of the body's temperature after death
ü Body temperature falls about 1°C (1.8°F) per hour until it reaches room temperature
• Livor Mortis
ü Discoloration of the body which appears in the lowermost or dependent areas of the body
Nursing Interventions for the Body After Death
v Post-mortem care should be carried out according to hospital policy
v Check the client's religion and make every
attempt to comply with their religious law
v Make the environment as clean and pleasant as possible and to make the body appear natural and comfortable
v All equipment, soiled linen. and supplies should be removed from the bedside
v Some agencies require all tubes in body remain in place
v Placed the body in a supine position with the arms either at the sides, palms down, or across the abdomen
v One pillow is placed under the head and shoulders to prevent blood from discoloring the face by settling in it
v Eyelids are closed and held in place for a few seconds so they remain closed
v Dentures are usually inserted to help give the face a natural appearance. The mouth is then closed
v Wash the soiled areas of the body
v Place absorbent pads under the buttocks to take up any feces and urine release
v Place a clean gown on the client and —brushed/combed the hair
v Removed all jewelries except wedding band that is taped to the finger
v Top bed linens are adjusted neatly to cover the client to the shoulders
v Provide soft lighting and chairs to the family
v Put deceased's wrist identification tag that is left on and additional identification tags are applied
v Body is wrapped in a shroud, a large piece of plastic or cotton material used to enclose a body after death
v Place an identification tag outside the shroud
v Take the body into the morgue
LABORATORY AND DIAGNOSTIC EXAMINATIONS
v Critical element of assessment
v Invasive or non-invasive
v Procedures that involve physical inspection of body structures and evidence of their function
PHASES OF DIAGNOSTIC TESTS

• Focus: Client preparation

Pre-Test
• Thorough assessment and data collection
• Focus: Specimen collection & performing or assisting with certain diagnostic
testing
Intra-test • Standard precautions&
sterile technique are utilized.
• Provision of emotional & physical support
• Provide nursing care and follow-up
• Monitor vital signs
• Assess for possible
complications
Post-Test
• Provide comfort
• Specimen care
• Accurate documentation
• Prompt referral & reporting of result
NEUROLOGICAL STUDIES
Computed Tomography Scan
v Makes detailed images of structures within the body
v Uses a narrow x-ray beam to scan body parts in successive layers
v Contrast dye may be used
Uses
• Differentiate benign and malignant tumors
• Detect aortic aneurysms:infarctions:
hydrocephalus: presence of stenosis
• Evaluate cysts masses. abscesses, renal
calculi, GI bleeding and obstruction, trauma
• Monitor and evaluate the effectiveness of
medical, radiation or surgical therapies
Contraindications
• Allergies to shellfish or iodinated dye
• Claustrophobic
• Pregnant client
• Chronically dehydrated
• Renal failure
Nursing Responsibilities
• Secure informed consent
• Assess allergies if dye is used
• NPO for at least 8 hours (to prevent aspiration)
• Assess VS before and after the procedure
• Remove any metal objects
• Check BUN & Creatinine
Post Test
• Observe for delayed allergic reactions (rash. urticaria. tachycardia. hyperpnea. palpitations. NN)
• Increase fluid intake to help eliminate the contrast medium
• Assess kidney functions
• Instruct client to apply cold compress to the puncture site (reduces discomfort)
• Instruct client to resume usual diet. Medications or activity as directed by the health care provider.
Magnetic Resonance Imaging (MRI)

v Uses a powerful magnetic field to obtain images of different areas of the body.
v Can be performed with or without contrast medium.
Uses
• Detect and locate presence of tumors
• Detect CVA, cerebral infarct or hemorrhage
• Evaluate the cause of seizures
• Evaluate demyelinating disorders
• Evaluate solid. cystic and hemorrhagic components of lesions
• Monitor and evaluate effectiveness of medical/surgical interventions, chemotherapy and radiation therapy.
Contraindications
• Presence of metal in their body
• Patients with pacemakers
• Intrauterine devices
• Claustrophobic
• Pregnant client
• Assess for allergies in contrast medium
• Obtain a list of medications the client is taking
• Explain to the client that no pain will be experienced during the test. However there may be moments of slight
discomfort.
• Tell the client to expect to hear loud banging from the scanner and possibly to see flickering lights in the visual field.
• Explain that IV line may be necessary
• Remove dentures, jewelry, hairpins, credit cards, and other metallic objects
• Instruct the client to remain still throughout the procedure (movement produces unreliable results)
• Instruct patient to take slow. deep breaths if nausea occurs during the procedure
Post Test
• Observe for delayed allergic reactions
• Instruct client to immediately report
symptoms such as fast heart rate difficulty breathing, skin rash, itching. decreased urinary output
• Apply cold compress to the punctured site
• Increased oral fluid intake to facilitate the excretion of the dye
Positron Emission Tomography (PET) Scan

• Uses positron emissions from specific radionuclides to produce detailed functional (physiologic) images within the
body.
Uses
• Detect Parkinson's disease and Huntington's disease
• Detect the effectiveness of the therapy as evidenced by biochemical activity of normal and abnormal tissues
• Differentiate between tumor recurrence and radiation necrosis
• Identify cerebrovascular accident or aneurysm
• Identify focal seizure
Contraindication
• Pregnant clients unless the potential benefits of the procedure far outweigh the risks to the fetus and mother
• Note any recent procedures that can interfere with test results including examinations using iodine-based contrast
medium or barium.
• Obtain a list of medications the client is taking
• Client should restrict food for 4 hours
• Restrict alcohol, nicotine or caffeine-containing drinks for 24 hours
• Withhold medications for 24 hours before the test
• Remove dentures, jewelry. hairpins, credit cards and other metallic objects
• Record baseline vital signs and assess neurologic status.
• Observe standard precautions
• The client may be blindfolded or asked to use earplugs to decrease auditory and visual stimuli.
• Monitor the client for complications related to the procedure (allergic reaction. anaphylaxis, bronchospasm)
Post Test
• Increased oral fluid intake for 24 to 48 hours unless contraindicated
• Cold compress to the punctured site
• Flush the toilet immediately after each voiding
• No other radionuclide test should be scheduled for 24 to 48 hours after the procedure.
• Resume diet fluids, medications or activity,
as directed by the health care provider.

• Advise the client to immediately report symptoms such as fast heart rate, difficulty breathing skin rash, itching, or
decreased urinary output
Electroencephalography
• Represents a record of the electrical activity generated in the brain.
• Obtained through electrodes applied on the scalp or through microelectrodes placed within the brain tissue
• Provides an assessment of cerebral electrical activity
• Non-invasive
Uses
• Confirms brain death
• Detect cerebral ischemia
• Detect intracranial cerebrovascular lesions
• Detect seizure disorders
• Determine presence of tumors, abscesses blood clots and infection
• Evaluate the effect of drug intoxication on the brain
• Evaluate sleeping disorders
Results
• Normal Findings
ü Normal occurrences of alpha, beta theta and delta waves (rhythms. varying depending on the client's age)
ü Normal frequency. amplitude and characteristics of brain waves
• Abnormal Findings
ü Abscess
ü Brain death
ü Cerebral infarct
ü Encephalitis
ü Head injury
ü Hypocalcemia / hypoglycemia
ü Intracranial hemorrhage
ü Meningitis
ü Migraine headaches
ü Narcolepsy
ü Seizure disorders
ü Sleep apnea
Factors that may impair the results of the examination
• Inability of the client to cooperate or remain still during the procedure because of age significant pain, or mental
status. Drugs and substances such as sedatives anticonvulsants, anxiolytics and alcohol and stimulants such as
caffeine and nicotine.
• Hypoglycemic or hypothermic states
• Hair that is dirty, oily or sprayed or treated with hair preparations.
• Make sure a written and informed consent has been signed prior to the procedure and before administering any
medications.
• Inform the client that the procedure performed to measure electrical activity of the brain.
• Obtain a list of the medications the client taking
• Inform the client that he/she may be asked to alter breathing pattern
• Instruct the client to clean the hair and refrain from using hair sprays, creams of solutions before the test
Refrain from drinking caffeine-containing beverages for 8 hours before the procedure
• Anti-seizure agents,tranquilizers, stimulants and depressants should be withheld 24 to 48 hours before an EEG.
• Inform the client that the standard EEG takes 45 to 60 minutes
• Sleep EEG requires 12 hours
• Inform the client that EEG does not cause electric shock.
• Limit sleep to 5 hours for an adult and 7 hours for a child at night before the study.
• Remind the client to relax and not to move any muscles or parts of the face or head.
• Recordings are made with the client at rest and with eyes closed
• Procedures may be done to bring out abnormal electrical activity or other brain abnormalities
Post Test
• Remove electrodes from the hair and remove paste by cleansing with oil
• Promote safety by raising the side rails Instruct the client to resume medications as directed by the health care
provider.
• Instruct the client to report any seizure activity
• Recognize anxiety related to test results, and be supportive of perceived loss of independent function. Discuss the
implications of abnormal test results on the client's lifestyle. Provide teaching and information regarding the clinical
implications of the test results, as appropriate.
• Explain the importance of adhering to the therapy regimen and the use of any ordered medications.
• Reinforce information given by the client's health care provider regarding further testing, treatment or referral to
another health care provider
• Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression
of the disease process and determine the need for a change the therapy.
Lumbar Puncture
Also termed as Lumbar/Spinal Tap
Insertion of a needle into the lumbar subarachnoid space to withdraw CSF. Between L3 and L4 or L4 and L5
v Color
• Normal: clear and colorless
• Abnormal: pink, blood-tinged or grossly bloody CSF (subarachnoid hemorrhage)
v Position: Knee-chest position / C-shaped position I Fetal position I Shrimp
v Position Three test tubes - Collection (9 to 12 mL)
USES:
• Obtain CSF for examination
• Measure and reduce CSF pressure
• Determine the presence or absence of blood in the CSF
• Administer medications intrathecally (into the spinal canal)
Contraindications
• This procedure is contraindicated if infection is present at the needle insertion site_
• Degenerative joint disease or coagulation defects
• Extreme caution in patients with increased intracranial pressure
Results
Increase:
• Protein - Meningitis, Encephalitis
• Lactic acid - Bacterial, tubercular, fungal meningitis
• Myelin Basic Protein - trauma, stroke, tumor, multiple sclerosis, subacute, sclerosing panencephalitis
• RBC count - Hemorrhage
Decrease:
• Glucose - Bacterial and Tubercular Meningitis
• Obtain history of client's immune and musculoskeletal system
Obtain a list of the medications the client is taking.
• There are no food, fluid or medication restrictions unless by medical direction Ensure that anticoagulant therapy has
been withheld for the appropriate amount of days prior to the procedure.
Post Test
• Observe puncture site for bleeding, CSF leakage or hematoma formation.
• Monitor vital signs and neurologic status and for headache every 15 minutes for 1 hour, then every 2 hours for 4
hours, and then as ordered by health care practitioner.
• If permitted, administer fluids to replace lost CSF
• Position:
ü Prone (to relieve headache)
ü Supine (if more than 20 ml CSF was removed)
ELECTRONEUROGRAPHY
• It is performed to identify peripheral nerve injury, to differentiate primary peripheral nerve pathology from muscular
injury and to monitor response of the nerve injury to treatment.
Indication
• Confirm the diagnosis of peripheral nerve damage or trauma
Normal: No evidence of peripheral nerve injury or disease.
Abnormal
• Carpal tunnel syndrome
• Diabetic neuropathy
• Guillain-Barre Syndrome
• Herniated Disk Disease
• Muscular Dystrophy
• Myasthenia Gravis
• Poliomyelitis
• Make sure a written and informed consent has been signed prior to the procedure and before administering any
medications.
• Inform the client that the procedure is performed to measure electrical activity of the muscles
• Obtain a history of neuromuscular and neurosensory status
• There are no food, fluid, or medication
restrictions unless by medical direction
• Instruct the client to void before the procedure
• Position: supine / sitting
• Shave the extremity in the area to be stimulated
Post-Test
• When the procedure is complete, remove the electrodes and clean the skin where the electrodes were applied. -
• Monitor electrode sites for inflammation.
• Residual pain = warm compress & take analgesics
• Instruct the patient to resume usual diet, medication, and activity, as directed by the health care practitioner.
Electromyography (EMG)
Other Terms: • Electrodiagnostic study/ Neuromuscular Junction Testing
• Measures skeletal muscle activity during rest. Voluntary contraction and electrical stimulation.
Indications
• Assess primary muscle diseases affecting striated muscle fibers or cell membrane
• Detect anterior poliomyelitis, amyotrophic lateral sclerosis. Amyotonia and spinal tumors
• Detect Guillain-Barre syndrome, Herniated Disc, or Spinal Stenosis
• Differentiate secondary muscle disorders caused by polymyositis, sarcoidosis, hypocalcemia, thyroid toxicity.
tetanus and other disorders
• Monitor and evaluate progression of myopathies or neuropathies
Results
v Normal Finding
• Normal muscle electrical activity during rest and contraction states
v Abnormal Findings
• Amyotrophic lateral sclerosis
• Bell's palsy
• Beriberi
• Carpal tunnel syndrome
• Diabetic Peripheral Neuropathy
• Guillain-Barre syndrome
• Multiple sclerosis
• Muscular dystrophy
• Myasthenia gravis
• Myopathy
• Polymyositis
• Radiculopathy
• Traumatic injury
Contraindications
• Extensive skin infection
• Anticoagulant therapy
• Infection at the sites electrode placement
• Make sure a written and informed consent has been signed prior to the procedure an before administering any
medications
• Inform the patient that the procedure performed to measure electrical activity of the muscles.
• Obtain a history of neuromuscular an neurosensory status
• Obtain a list of medications the client is takin especially medications known to affect bleeding including
anticoagulants, aspirin and other salicylates
• Instruct the client to refrain from smoking and drinking caffeine-containing beverages for hours before the
procedure.
• Under medical direction, the client should avoid muscle relaxants, cholinergics, and anticholinergics for 3 to 6 days
before the test.
• Assess for the ability to comply with directions given for exercising during the test.
• Ask the client to remain very still and relaxed and to cooperate with the instructions giver to contract muscles
during the procedure.
• Place the client in a supine or sitting position depending on the location of the muscle to be tested.
• Administer mild analgesic (adult) or sedative (children), as ordered, to promote a restful state before the
procedure
• Explain to the client that he/she will expect sensation similar to that of an intramuscular injection as the needle is
inserted into the muscle.
Post Test
• Monitor electrode sites forbleeding
hematoma or inflammation.
• Inform the client that the muscles may a for short time after the procedure.
• Residual pain = Apply warm compresses an take analgesics
• Instruct the client to resume usual die medication and activity as directed by the health care practitioner.
RESPIRATORY DIAGNOSTIC STUDIES

Chest X-ray
• It is obtained to determine the size, contour and position of the thoracic organs such as heart, lungs, rib cage, etc.
Uses
• Aid in the diagnosis of diaphragmatic hernia, lung tumors, metastasis
• Evaluate known or suspected pulmonary disorders, chest trauma, cardiovascular disorder and disorder and skeletal
disorders
• Evaluate positive PPD or Mantoux test
• Monitor resolution, progression or maintenance of disease
• Monitor effectiveness of the treatment regimen
Contraindications
• Pregnant client, unless the potential benefits of the procedure far outweigh the risks to the fetus and mother
• Inform the client that if e procedure assesses cardiopulmonary status
• Obtain a list of the medications the client is taking
• Review the procedure with the client.
• There are no food, fluid or medical restrictions unless by medical direction.
• Instruct the client to remove dentures, jewelry, hairpins, credit card and other metallic object.
• Place the client in the standing position in the front of the x-ray film or detector
• Ask the client to inhale deeply and hold his or her breath while the x-ray images are taken, and then to inhale after
the images are taken.
BRONCHOSCOPY
v Direct visualization of the larynx, trachea and bronchi through either a flexible fiberoptic bronchoscope or a rigid
bronchoscope.
Use
• To examine tissues or collect secretions
• To determine the location and extent of the pathologic process and to obtain a tissue sample for diagnosis
• To determine whether a tumor can be resected surgically
• To diagnose bleeding sites
Contraindications
• Bleeding disorders, with uremia and cytotoxic chemotherapy
• Pulmonary hypertension
• Cardiac conditions
• Disorders that limit extension of the neck
• Severe obstructive tracheal conditions
• Secure informed consent.
• Food and fluid are withheld for 6 hours before the test
• Administer preoperative medications
Remove the \dentures and other oral prostheses
• Local / general anesthesia may be used depending on the type of bronchoscopy
Post Test
• NPO until the cough/gag reflex returns
• For elderly patients, nurse assesses for confusion and lethargy
• Offer ice chips and fluids once cough reflex returns
• Monitor client's RR
• Observe for signs of hypoxia, hypotension, tachycardia, dysrhythmias, hemoptysis and dyspnea.
• Instruct the client and significant others to report any shortness of breath or bleeding immediately.
Pulse Oximetry
v It is a non-invasive study that provides continuous readings of arterial blood oxygen saturation using a sensor site
Area of application
• Earlobe
• Fingertip
• Forehead
• Toes
• Nose
Use
• Determine effectiveness of pulmonary gas exchange function
• Monitor oxygenation during testing for sleep apnea
• Monitor response to pulmonary drug regimens
Results
v Normal Findings
• Greater than or equal to 95%
v Abnormal Findings
• Abnormal gas exchange
• Hypoxemia with levels less than 95%
• Impaired cardiopulmonary function
• Inform the patient that the procedure is used to monitor oxygenation of the blood.
• Obtain history of the client's respiratory and cardiovascular system
• Instruct the client not to smoke for 24 hours before the procedure
• If finger is used, instruct the client not to grip treadmill rail or bedrail tightly
• No food, fluid or medication restrictions, unless by medical direction
• Ensure that the patient does not have false fingernails and that nail polish has been removed.
• Massage or apply a warm towel to the upper earlobe or finger (increases blood flow)
• Place the photodetector probe over the finger in such a way that the light beams and sensors are opposite to each
other.
• Perform the procedure in an area away from direct, intense light sources.
Thoracentesis
v Aspiration of fluid or air from the pleural space
v Takes about 20 minutes
v Position: Sitting while leaning over the table
Uses
• Removal of fluid and air from the pleural cavity
• Aspiration of pleural fluid for analysis, pleural biopsy, and instillation of medication into the pleural space

Pleural Effusion
• Shave the site before the procedure
• Cough suppressant may be given before the procedure
• Sedative or analgesia may be given since discomfort may be expected during needle insertion
• No food or fluid restriction unless by medical direction
• Anticoagulants and aspirin may be withheld.
• Have emergency equipment readily available (in case of laryngospasm)
Post Test
• Position: sitting or side-lying (unaffected side) for 1 hour
• Assess pulse rate and respiratory rate and skin color
• Don't remove more than 1.000 ml of fluid from the pleural cavity within the first 30 minutes
• Observe changes in the client's cough, sputum, respiratory depth, and breath sounds and note complaints of chest
pain
• Observe the thoracentesis sit for bleeding, inflammation or hematoma formation
• Nausea & pain: administer antiemetic and analgesic medications as ordered by the physician
Arterial Blood Gases (ABG)
• Used to evaluate respiratory function and provide a measure for determining acid-base balance.
Use
• Assess conditions of asthma, COPD. embolism
• Assist in the diagnosis of respiratory failure
• Determine acid-base status, type of imbalance and degree of compensation
NORMAL VALUE
pH 7.35 — 7.45
PaO2 80 — 100 mm Hg
PaCO2 35 — 45 mm Hg
HCO3 22 — 26 mEq/L
Base excess -2 to +2 mEq/L
O2 saturation 95 — 100 %
Radial artery: most common site
If radial artery will be used, perform Allen’s test
• Ensures that the client has adequate collateral circulation (ulnar artery)
• Extend client's wrist over a rolled towel
• Ask the client to make a fist
• Use the 2" and 3rd fingers to locate the
pulses on the palmar surface of the wrist
• Nurse compresses the radial and ulnar arteries simultaneously
• After the client opens the fist, the nurse releases pressure on the ulnar artery
• If blood is restored within 6 seconds, the circulation to the hand may be adequate enough to tolerate placement of
radial artery catheter.
Ultrasonic Doppler: Most accurate method for assessing arterial perfusion of the hand
• Inform the client that the test is used to assess acid-base balance and oxygenation level of the blood.
• Obtain history of the client's respiratory system and any bleeding disorders
• Inform the client that the specimen collection usually takes 10 to 15 minutes
• Prepare an ice slurry in a cup or plastic bag to have ready for immediate transport of the specimen to the laboratory
• Instruct client to breathe normally and to avoid unnecessary movement
Post Test
• Pressure should be applied to the puncture site for at least 5 minutes (unanticoagulated client) and for at least 15
minutes (client receiving anticoagulant)
• Observe puncture site for bleeding or hematoma formation
• Observe client for signs or symptoms of respiratory disturbances
• Educate client on breathing exercises
PULMONARY FUNCTION STUDIES
• Performed to assess respiratory function and to determine the extent of dysfunction
Use
• Useful in monitoring the course of a client with an established respiratory disease and assessing the response to
therapy
• Screening test in potentially hazardous industries
• Detect COPD and/or restrictive pulmonary diseases that affect the chest wall
• Evaluate pulmonary disability for legal or insurance claims
• Evaluate the respiratory system to determine the client's ability to tolerate procedures such as surgery or diagnostic
studies
LUNG VOLUMES & CAPACITIES
Tidal volume Volume inhaled and exhaled during normal quiet breathing
N: 500 mL
Inspiratory Reserve Volume Maximum amount of air that can be inhaled over and above a normal breath
N: 3000 mL
Residual Volume Amount of air remaining in the lungs after maximal exhalation N: 1,200 mL
Vital Capacity Total amount of air that can be exhaled after a maximal inspiration
N: 4, 600 mL
Inspiratory Capacity Total amount of air that can be inhaled following a normal quiet exhalation
N: 3, 500 mL
Volume left in the lungs after normal exhalation
Functional Residual Capacity
N: 2. 300 mL
Total Lung Capacity Total volume of the lungs at the maximum inflation
N: 5. 800 mL
• Inform the client that the procedure assesses the function of the lungs
• Client should refrain from smoking or eating a heavy meal for 4 to 6 hours prior to the study
• Client should avoid bronchodilators for at least 4 hours before the study
• Position: sitting
• Instruct the client to inhale deeply and then quickly exhale as much air as possible into the mouthpiece
Post Test
• Assess the client for dizziness or weakness after the testing
• Instruct the client to resume usual diet and medications as directed by the health care practitioner
• Allow the client to rest as long as needed to recover
MANTOUX TEST
Other Terms: Purified Protein Derivative (PPD), Tuberculin Skin Test
Done to determine past or present exposure to Mycobacterium tuberculosis.
Intradermal injection
This is read after 48 to 72 hours.
Uses
• Evaluate cough, weight loss, fatigue, hemoptysis, and abnormal x-rays to determine if the cause of symptoms is
tuberculosis
• Evaluate known or suspected exposure to tuberculosis, with or without symptoms
• Inform the client that the test is used to indicate exposure to tuberculosis here are no food, fluid, or medication
restrictions, unless by medical direction Emphasize the client that the area should not be scratched or disturbed after
the injection and before the reading.
• Mantoux Test Preparation:
ü Prepare PPD or old tuberculin in a tuberculin syringe with a short, 26-gauge needle attached.
ü Prepare the appropriate dilution and amount for the most commonly used intermediate strength (5 tuberculin
units in 1 ml)
ü Inject the preparation infra-dermally at the prepared site as soon as it is drawn up into the syringe.
• Evaluation: at least 10 mm induration (positive exposure for regular patients)
at least 5 mm induration (positive exposure for HIV clients)
PULMONARY ANGIOGRAPHY

v X-ray visualization of the pulmonary vasculature after injection of an iodinated contrast medium into pulmonary
artery.
Uses
v Detect acute pulmonary embolism
v Detect arteriovenous malformations, tumors, aneurysm, congenital defects
v Determine the cause of recurrent or severe hemoptysis
Contraindications
• Bleeding disorder
• Elderly, chronically dehydrated before the test
• Renal failure
• Note any recent procedures that can interfere with test results, including examinations using iodine-based contrast
medium
• Inform the client that a burning and flushing sensation may be felt throughout the body during injection of the
contrast medium
• Client may experience an urge to cough, flushing, nausea or a sally metallic taste
• NPO for 8 hours
• Avoid any anticoagulant medication prior to the procedure
• Remove dentures, jewelry, hairpins, credit cards and other metallic objects
• Have emergency equipment readily available
• The client has a history of severe allergic reactions to any substance or drug, administer ordered prophylactic
steroids or antihistamines before the procedure.
• Position: Supine
• Mark the site of the client’s peripheral pulses before angiography using pen
• Instruct the client to take slow, deep breaths if nausea occurs during the procedure
Post Test
• Monitor vital signs and neurologic status every 15 minutes for 1 hour, then every 2 hours for 4 hours, and as
ordered.
• Observe for delayed allergic reactions,
as rash, urticaria, tachycardia, hyperpnea hypertension, palpitations, nausea, et. Vomiting.
• Advise the patients to immediately re, symptoms such as fast heart rate, difficulty breathing, skin rash, itching, or
decreased urinary output.
• Instruct the client to apply cold
• Maintain bed rest for 4 to 6 hours
GASTROINTESTINAL STUDIES
Upper GI
Barium swallow
v Other terms:
• Esophagram
• Esophagography
Use
• Confirm the integrity of esophageal anastomoses in the postoperative patient.
• Detect esophageal reflux, tracheoesophageal, fistulas, and varices.
• Determine the cause of dysphagia heartburn or regurgitation
• Determine the type and location of foreign
bodies within the pharynx and esophagus
Contraindications
• Intestinal obstruction or suspected esophageal rupture, unless water- soluble iodinated contrast medium is used
• Suspected tracheoesophageal, fistula, unless barium is used.
• Inform the patient that the procedure assesses the esophagus.
• Explain to the client that some pain may be experienced during the test, and there may be moments of
discomfort

• Inform the client that the procedure is performed in a radiology department, usually by physician and support
staff takes approximately 15 to 30 mins.
• NPO for 8 hours prior to the procedure
• Instruct to remove jewelry and other metallic objects
• The client is asked to swallow a barium solution with or without a straw.
Post Test
• Instruct the client to resume usual diet, fluids, medications or activity as directed by the health care practitioner
• If iodine is used, monitor for reaction to iodinated contrast medium
• Monitor for fluid and electrolyte imbalance
• Instruct the patient that stools will be white or light in color for 2 to 3 days.
• Report to the physician if stool does not return to normal color
Lower GI
BARIUM ENEMA
• Radiologic examination of the colon, distal small bowel and occasionally the appendix
• Visualization can be improved by using air or barium as the contrast medium
Uses:
• Determine the cause of rectal bleeding, pus or mucus in feces
• Evaluate suspected inflammatory process congenital anomaly, motility disorder
• Evaluate unexplained weight loss, anemia or change in bowel pattern
• Identified and locate benign or malignant polyps or tumors
Contraindications
• Allergy to shellfish or iodinated dye
• Pregnant or suspected of being pregnant, unless the potential benefits of the procedure far outweigh the risks to
the fetus and mother.
• Intestinal obstruction, acute ulcerative colitis, acute diverticulitis, megacolon, or suspected rupture of the colon.
• Inform the client that the procedure assesses the colon
• Ensure that this procedure is performed before an upper gastrointestinal study or barium swallow.
• Low-residue and clear-liquid diet 2 days before the procedure
• NPO 8 hours
• Laxatives are given before the procedure
• Remove jewelries, credit cards and other metallic objects
Post Test
• Instruct the patient to resume usual diet, fluids, medications, or activity as directed by the health care
practitioner,
• Monitor for delayed allergic reaction (rash, urticaria, tachycardia, hyperpnea, hypertension, palpitations, nausea
or vomiting
• Carefully monitor the client for fatigue and fluid and electrolyte imbalance
• Laxatives are then again given after the procedure to aid in the elimination of barium
• Instruct the patient that stools will be white or light in color for 2 to 3 days.
• Increase oral fluid intake
PROCTOSIGMOIDOSCOPY
v Viewing of the rectum and distal sigmoid colon
Uses:
• Diagnosis of diverticular disease
• Diagnosis of Hirschprung’s disease
• Determine the cause of pain and rectal prolapse
• Determine the cause of rectal itching, pain, or burning
• Reduce volvulus of the sigmoid colon
• Remove hemorrhoids by laser therapy
• Screen for colon cancer
Contraindications
• Clients with bleeding disorders, especially disorder associated with uremia and cystotoxic chemotherapy
• Clients with cardiac conditions or arrhythmias

• Clients with bowel perforation, acute peritonitis, ischemic bowel necrosis, toxic megacolon, diverticulitis, recent
bowel surgery, severe cardiac or pulmonary disease.
• Informed the client that the test is primarily used to examine the rectum and the distal portion of the colon.
• Low residue diet several days before the procedure
• Position: left lateral decubitus position/ knee-chest position
• WOF: abdominal pain, tenderness or distention; pain on defecation; fever
• Encourage the client to drink several glasses of water to help replace fluid lost.
Colonoscopy
v Allows inspection of the mucosa of the entire colon, ileocecal valve and terminal ileum using a flexible fiberoptic
colonoscope inserted through the anus and advanced to the terminal ileum.
v Procedure may take up to 1 hour.
Uses
• Assess GI function in a patient with a personal or family history of colon cancer, polyps, or ulcerative colitis
• Confirm diagnosis of colon cancer and inflammatory bowel disease
• Determine cause of lower GI disorders, especially when barium enema and proctosigmoidoscopy are inconclusive
• Evaluate stools that show a positive occult blood test, lower GI bleeding, or change in bowel habits
• Remove colon polyps
• Reduce volvulus and intussusception
Contraindications
• Bleeding disorders or cardiac conditions
• Bowel perforation, acute peritonitis, acute colitis, ischemic bowel necrosis, toxic colitis, recent bowel surgery.
advanced pregnancy, severe cardiac are Pulmonary disease, recent myocardial infarction
• Colon anastomosis within the past 14 to 21 days.
• Inform the patient that the procedure assesses the colon.
• Note intake of oral iron preparations within 1 week before the procedure because these cause black, sticky feces that
are difficult to remove with bowel preparation.
• Instruct the patient to eat a low- residue diet for several days before the procedure
• Advise client to limit the intake of liquids for 24 to 72 hours before the examination.
• Laxative may be ordered two nights before the examination (Fleet or Saline enema)
• Have emergency equipment readily available
• Position: Sim’s position / Left side with knees flexed
• Administer opioid analgesic or a sedative to provide moderate sedation and relieve anxiety during the procedure
Post Test
• Monitor the patient for signs of respiratory depression.
• Maintain on bed rest until fully alert.
• Observe for signs and symptoms of bowel perforation (rectal bleeding, abdominal pain or distention, fever, focal
peritoneal signs)
• Observe the client for indications of chest pain, abdominal pain or tenderness, or breathing problems.
• Inform the patient that belching, bloating, or flatulence is the result of air insufflation.
• WOF: severe pain, fever, difficulty breathing, GI bleeding.
Fecalysis
Guaiac stool exam
• Used to assess gastro-intestinal bleeding
• Increase fiber diet 48 to 72 hours
• False Positive Results
ü Red meat (beef, lamb, liver, and processed meats)
ü Raw vegetables or fruits (radishes, turnips horseradish, and melons)
ü Aspirin or other NSAIDS, iron preparations and anticoagulants
• False Negative Results
ü If client has taken more than 250 mg per day of Vitamin C up to 3 days before the test.
• Taken in 3 consecutive days (3 stool specimens)
Stool for Ova and Parasites
• Specimen should be sent immediately (fresh and warm) usually done to detect amoebiasis
Stool for Lipids
• To assess stool for steatorrhea
• Include fats in the diet.
• Avoid alcohol for 3 days (alcohol metabolize fats)
• Avoid mineral oil and other oily medications.
• 72-hour stool specimen is collected.
CARDIOVASCULAR STUDIES
Electrocardiogram (ECG)
v Records electrical activity of the heart on paper
Uses
• Assess congenital heart disease
• Assess myocardial infarction or ischemia
• Assess function of heart valves
• Detect arrhythmias, pericarditis, and electrolyte imbalances
• Inform the client that the procedure assesses cardiac function.
• Inform the client that there will be no discomfort in the procedure.
• Procedure will take 15 minutes approximately.
• Record baseline vital signs
• Shaving may be done to areas which are highly occupied with hair growth
Post test
• Monitor vital signs and compare with baseline values
• Report the following immediately: chest pain, change in pulse rate or shortness of breath
Echocardiography (2D Echo)
v Non-invasive ultrasound procedure
v Uses high-frequency sound waves
v Allows visualization of the size, shape, position, thickness, and movement of cardiac structures
Uses
• Detect arterial tumors
• Detect subaortic stenosis
• Detect ventricular or atrial mural thrombi Evaluate congenital heart disorders
• Evaluate endocarditis
• Monitor prosthetic valve function
• Evaluate the presence of shunt flow and continuity of the aorta
• Evaluate unexplained chest pain, electrocardiographic changes and abnormal chest x-ray
Nursing responsibilities
• Inform the client that the procedure assesses cardiac function
• Remove jewelry, body rings and other metallic objects
• Instruct the client to remain still throughout the procedure because movement produces unreliable results
Holter monitor
v Other terms:
• Holter electrocardiography
• Ambulatory monitoring
• Ambulatory electrocardiography
v Records electrical cardiac activity on a continuous basis for 24 hours
v Non invasive
v Involves use of a portable device worn around the waist or over the shoulder that records electrical impulse on a
magnetic tape
Uses
• Detect arrhythmias that occur during normal activities
• Evaluate activity intolerance related to
oxygen supply and demand imbalance
• Evaluate chest pain, dizziness, syncope and palpitations
• Evaluate the effectiveness of anti-arrhythmic medications
• Evaluate pacemaker function
• Inform the client that the procedure evaluates how the heart responds to normal activity or to a medication
regimen.
• Avoid contact with electrical devices that can affect the strip tracings (shavers, toothbrush, massager, blanket)
and to avoid showers and tub bathing.
• Wear loose-fitting clothes
• Instruct the client regarding recording and pressing the button upon experiencing pain or discomfort
Post Test
• Report immediately: fast heart rate or difficulty breathing
• Compare the activity log and tape recordings for changes during monitoring period
• Educate the client regarding access to counseling services
Cardiac Stress testing

Other Terms:
• Exercise electrocardiogram
• Graded Exercise Tolerance Test
• Exercise Stress Test
• Treadmill Test
v Non-invasive
v Measures cardiac function during physical stress
Uses
v Determine the following:
• CAD
• Cause of chest pain
• Functional capacity of the heart after an MI or heart surgery
• Effectiveness of anti-anginal or anti-arrhythmic medications
• Dysrhythmias that occur during physical exercise
• Specific goals for a physical fitness program
Contraindications
• Severe aortic stenosis
• Acute myocarditis / pericarditis
• Severe hypertension
• Suspected left main CAD
• Heart Failure
• Unstable angina
• NPO 4 hours before the test
• Avoid stimulants such as tobacco and caffeine
• Instruct not to take any certain cardiac medications before the test if ordered by the physician
• Attire: clothes which are suitable for exercising and sneakers or rubber-sole shoes
• Women are advised to wear bra that provides adequate support
• Educate client on the equipment that will be used as well as the sensation and experiences that the client may
have during the test
• Instruct the client to report symptoms such as dizziness, sweating, breathlessness or nausea during the test
(these are normal as speed increases)
• Test are terminated if pain or fatigue is severe
Post test
• Report any angina pain or other discomforts experienced after test
• Instruct the client regarding special dietary intake and medication regimen
Cardiac Catheterization
v It is an invasive diagnostic procedure in which radiopaque arterial and venous catheters are introduced into
selected blood vessels of the right and left sides of the heart.
Uses
• Diagnose CAD
• Assess coronary artery patency
• Determine the extent of atherosclerosis
• Determine whether revascularization procedure
• Diagnose pulmonary arterial hypertension
• Treat stenotic heart valves via percutaneous balloon valvuloplasty
Complications
• Comorbid conditions -- including diabetes, heart failure, pre-existing renal disease, hypotension or dehydration.
• Elderly
Nursing Interventions
• Instruct to fast, usually for 8 to 12 hours, before the procedure.
• Advise that it will involve lying on a hard table for less than 2 hours.
• Reassure that IV medications are given to maintain comfort.
• Inform about sensations that will be experienced during the catheterization
• Explain to the client that an occasional pounding sensation (palpitation) may be felt in the chest
• Ask to cough and to breathe deeply.
• Encourage to express fears and anxieties.
Post Procedure
• The catheter access site is observed for Bleeding or hematoma formation.
• Temperature, color and capillary refill of the affected extremity are frequently evaluated.
• Assess the apical and peripheral pulses for change sin rate and rhythm
• Bed rest is maintained for 2 to 6 hours after the procedure
• Head of the bed no greater than 30 degrees
• Provide analgesics
• Instruct to report chest pain and bleeding or sudden discomfort from the catheter insertion sites
• Oral and IV hydration is used to increase urinary output and flush the contrast agent from the urinary tract.
• Provide client's safety by assisting him/her when getting out of bed for the first time after the procedure.
ENDOCRINE STUDIES
Radioactive Iodine Uptake
v Measures the ability of the thyroid gland to concentrate and retain circulating iodide for synthesis of thyroid
hormone
v Used for evaluation of thyroid function.
Uses
• Evaluate hyperthyroidism and/or hypothyroidism
• Evaluate neck pain
• Evaluate as part of a complete thyroid evaluation for symptomatic clients
o Swollen neck
o Extreme sensitivity to heat or cold
o Jitter
o Sluggishness
• Evaluate thyroiditis, goiter or pituitary failure
• Monitor response to therapy for thyroid disease
Contraindication
the fetus and mother
• Inform the client that the procedure assesses thyroid function
• Inform the client that the procedure may take approximately 15 to 30 minutes.
• Instruct the client to remove dentures,
• jewelry, hairpins, credit cards and other metallic objects
• NPO for 8 to 12 hours before the procedure but the client may eat 4 hours after the test begins, unless otherwise
indicated.
• Administer the I-123 orally
• Wear gloves during the radionuclide
• administration and while handling the client's urine
• drugs that may elevate results: barbiturates, estrogen, lithium
• Drugs that may decrease results. Lugol's solution, SSKI, anti-thyroid, antihistamines
Post Test
• Instruct the client to resume usual diet, as directed by the health care practitioner
• Increase OFI for 24 hours, unless contraindicated
• Educate client that radionuclide is eliminated from the body within 24 hours
• Flush toilet immediately for three times after each voiding following the procedure
• Wash hands meticulously with soap and water after each voiding for 24 hours after the procedure.
Thyroid Scan
v Other Terms:
• Thyroid Scintiscan
• Iodine Thyroid Scan
• Technetium Thyroid Scan
v Assesses thyroid size, assisting in differential diagnosis of masses in the neck, base of the tongue and ruling out
possible ectopic thyroid tissue.
v Performed after oral administration of radioactive iodine-123 or 1-131, or
intravenous injection of technetium-99m.
Uses
• Assess palpable nodules
• Assess the presence of enlarged thyroid gland
• Detect malignant or benign thyroid tumors
• Detect causes of neck or substernal masses
• Detect forms of thyroiditis
• Inform the client that the procedure assesses thyroid function and structure
• NPO for 8 to 12 hours prior to the procedure
• Remove jewelries, dentures and other metallic objects
• Administer sedative to a child or to an uncooperative adult, as ordered
• Oral I-123 should be administered 24 hours before scanning or IV technetium-99m 20 minutes before scanning
Post Test
• Increase OFI for 24 to 48 hours unless contraindicated
• Flush toilet immediately after each voiding following the procedure
• Wash hands after each voiding
Thyroid Stimulation Hormone Assay

v Other term: Thyrotropin
Uses
• Assist in the diagnosis of congenital hypothyroidism
• Assist in the diagnosis of hypo/hyperthyroidism.
• Inform the client that the procedure may take approximately 5 to 10 minutes
• Inform the client that there may be some discomfort during the venipuncture
• Observe venipuncture site for bleeding or hematoma formation
Result

Increased Congenital hypothyroidism

Primary hypothyroidism
Thyroid hormone resistance thyroiditis
Decreased Excessive thyroid hormone replacement
Grave’s disease primary hyperthyroidism
Free Thyroxine Concentration

v Used to evaluate signs of hypothyroidism or hyperthyroidism
v Also used to monitor response to therapy for hypo/hyperthyroidism
Result
Increased Hyperthyroidism
Hypothyroidism treated with T₄
Decreased Hyperthyroidism
Hyperthyroidism treated with tri-
iodothyronine (T₃)
Pregnancy (late)
Vanillylmandelic Acid (VMA) Test
v Vanillylmandelic acid is a major metabolite of epinephrine
v 24-hour urine specimen
Uses
• Assist in the diagnosis of neuroblastoma, ganglioneuroma or pheochromocytoma
• Evaluate hypertension of unknown e cause
• Inform the client that all urine must be saved during the 24-hour period.
• Abstain from smoking for 24 hours before the test
• Avoid foods high in amines for 48 hours (bananas, avocados, beer, aged cheese, chocolate, cocoa, coffee)
• Avoid foods or fluids high in caffeine for 48 hours before the test
• Avoid any food or fluids containing vanilla or licorice
• Avoid the following medications for 2 weeks: aspirin, pyridoxine, levodopa, amoxicillin, carbidopa
• Avoid excessive exercise and stress during the 24-hour collection of urine
Total Plasma Catecholamine Concentration

v Assist in the diagnosis of neuroblastoma, ganglioneuroma or dysautonomia
v Assist in the diagnosis of paragangliomas
v Assist in the diagnosis of pheochromocytoma
v Evaluate hypertension of unknown origin
RESULT
Diabetic acidosis Ganglioblastoma
Ganglioneuroma Hypothyroidism MI
Increased Neuroblastoma Pheochromocytoma
Decreased Autonomic Nervous System
Dysfunction
Orthostatic Hypotension Parkinson's
Disease
• Normal-sodium diet for 3 days before testing
• Abstain from smoking tobacco 24 hours
• Avoid consumption of foods high in amines for 48 hours
• NPO for 10 to 12 hours
Post Test
• Assess client for increased pulse and blood pressure, hyperglycemia, shakiness and palpitations
• Observe venipuncture site for bleeding or hematoma formation.
Oral Glucose Tolerance Test (OGTT)
v Done to evaluate abnormal fasting or postprandial blood glucose levels that do not clearly indicate diabetes
v Identify impaired glucose metabolism
v Detection of gestational diabetes mellitus

• NPO for 8 to 12 hours
• Take regular diet for at least 3 days before the test
• Avoid smoking before and during the test
• Series of blood specimen will be collected after ingestion of glucose
Glycosylated Hemoglobin
v Most accurate indicator of DM
v Reflects serum glucose levels up to 3 months
v Use: Assess long-term glucose control in diabetics
RESULT
Increased Diabetes (poorly controlled or uncontrolled)
Chronic blood loss
Decreased Chronic renal failure
Conditions that decrease red blood cell lifespan
Hemolytic anemia
Fasting Blood Glucose

v NPO for 8 to 12 hours before specimen collection
v Initial test for diabetes
v Normal: 70 — 110 mg/dL
2-hour Postprandial Blood Sugar Test

v Measures the blood glucose levels 2 hours after the client ingests food
HEPATOBILIARY SYSTEM
Paracentesis
v Removal of fluid from the peritoneal cavity through a puncture or a small surgical incision through the abdominal
wall under sterile conditions
• Void before the procedure
• Position: sitting
• Maintain client's privacy
• Observe the client closely for signs of distress
• Observe for signs of hypotension and hypovolemic shock
• Place a small sterile dressing over the site of the incision
Post Test
• Observe for hypotension and hypovolemic shock
• Observe for scrotal edema
• Monitor VS
• Measure abdominal girth
Liver Biopsy
v Removal of small amount of liver tissue usually through needed aspiration
v Permits the examination of liver cells
Uses
• Evaluate diffuse disorders of the parenchyma
• Diagnose space-occupying lesions
• Ascertain that results of coagulation tests and compatible donor blood are available
• Obtain baseline vital signs
• Position: Supine; expose right side of the client's abdomen
• Ascertain that results of coagulation tests and compatible donor blood are available
• Position: Supine; expose right side of the client's abdomen
• Instruct to inhale and exhale deeply several times and finally exhale and hold breath at the end of expiration
• Instruct client to resume breathing after the physician aspirates and withdraws the needle
Post Procedure
• Position: client is turned on the right side for several hours
• Place a pillow under the costal margin
• Avoid coughing or straining
• Monitor VS
• Avoid heavy lifting and strenuous activity for one week
Liver Function Test

Serum Aminotransferase Studies (AST and ALT)
AST
N: 10-40 units (4.8-19 U/L)
RESULTS
Increased Liver or Biliary
Disorder
MI
CVA
Pregnancy
Decreased DKA
Salicylates
ALT
N: 5-35 units (2.4-17 U/L)
RESULTS
Increased Liver Disorder
Muscular Dystrophy
Renal Failure Shock
Salicylates
Decreased
Pigment Studies
RESULTS
Serum bilirubin (direct) 0 - 0.3 mg/dL
Serum bilirubin (total) 0 - 0.9 mg/dL
Urine urobilinogen 0.05 - 2.5 mq/24 hr
Fecal urobilinogen 50 - 300/24 hr
• These studies measure the ability of the liver to conjugate and excrete bilirubin.
• Results are abnormal in liver and biliary tract disease and are associated with jaundice clinically
Protein Studies
RESULTS
Total serum protein 7.0 - 7.5 g/dL
Serum albumin 4.0 - 5.5 g/dL
Serum globulin 1.7 - 3.3 g/dL
Albumin / globulin (A/G ratio) A > G or 1.5: 1 - 2.5:1
GENITO-URINARY STUDIES
RENAL CONCENTRATION TESTS
Specific Gravity • N: 1.010 - 1.025

Evaluates ability of the kidneys to
concentrate solutes

Urine Osmolality 300-900

mOsm/kg/24 h
This test may disclose early defects
in renal function
SERUM TESTS
Creatinine level 0.6 - 1.2 mg/dL
Measures effectiveness of renal function
BUN 7 - 18 mg/dLServes as index of renal
function
Kidney, Ureter and Bladder Study (KUB)

• Provides information regarding the structure,
size and position of abdominal organs
Uses
• Determine the cause of acute abdominal pain or palpable mass
• Evaluate:
ü Effects of lower abdominal trauma
ü Known or suspected intestinal obstruction
ü Presence of renal, ureter, or other organ calculi
ü Suspected abnormal fluid, air, or metallic object
• Inform the client that the procedure assesses the status of the abdomen
• Remove jewelries and other metallic objects
• Explain to the client that little or no pain is expected during the test
• Bowel preparation (laxative in the evening and enema in the morning as ordered)
Cystoscopy
• Provides direct visualization of the urethra, urinary bladder and ureteral orifices
Uses
• Coagulate bleeding areas
• Determine possible source of persistent urinary tract infections
• Determine source of hematuria of unknown cause
• Dilate urethra and ureters
• Evaluate the function of each kidney
• Evaluate the extent of prostatic hyperplasia
• Identify and remove polyps
• Done under local, general or spinal anesthesia
• NPO for 8 hours
• For local anesthesia, allow only clear liquids 8 hours before the procedure
• Obtain baseline Vital Sign
• Instruct to void before the procedure
• Position: lithotomy
Post Test
• Bed rest until vital signs are stable
• Urine may be blood-tinged for the first and second voiding after the procedure
• Report: persistent flank or suprapubic pain, fever and chills
• Dysuria, blood-tinged urine and urinary frequency can be expected after the procedure
• Increase OR after the procedure
• Monitor fluid intake and UO for 24 hours after the procedure
• Warm sitz bath

RETROGRADE URETEROPYELOGRAPHY
• Uses a contrast medium introduced through a catheter during cystography and radiographic visualization to view
the renal collecting system.
Uses
• Evaluate:
ü Effects of urinary system trauma
ü Known or suspected ureteral obstruction
ü Placement of a ureteral stent or catheter
ü Presence of calculi in the kidneys, ureters or bladder
Contraindications
• Allergies to shellfish or iodinated dye.
• Elderly and other clients who are chronically dehydrated before the test
• Renal failure
• Renal insufficiency
• Multiple myeloma who may experience decreased kidney function
• Discontinue anticoagulant therapy and other salicylate substances
• Local anesthesia may be used
• NPO for 8 hours
• Assess for iodine allergy
• Remove dentures, jewelry, hairpins, and other metallic objects
• Record baseline vital signs and assess
neurologic status
Post Test
• Observe for delayed allergic reactions
• Apply cold compress to the puncture site
• Monitor for signs and symptoms of sepsis and severe pain
Endoscopic Retrograde Cholangiopancreatography (ERCP)

• Permits direct visualization of structures that laparotomy previously could be seen only during
Uses
• Evaluate the presence and location of ductal stones
• Assess jaundice of unknown cause to differentiate biliary tract obstruction from liver disease
• Perform therapeutic procedures, such as sphincterotomy and placement of biliary drains
Results
• Normal Findings
ü Normal appearance of the duodenal papilla
ü Patency of the pancreatic and common bile ducts
Abnormal Findings
• Duodenal papilla tumors
• Pancreatic cancer
• Pancreatic fibrosis
• Pancreatitis
• Sclerosing cholangitis
Contraindications
the fetus and mother.
• Inform the client that the procedure assesses the biliary ducts
• Ensure that this procedure is performed before an upper gastrointestinal study or barium swallow
• Assess for completion of bowel preparation
according to the institution's procedure
• Instruct the client to remove jewelry, including watches, credit cards, and other metallic objects.
• Administer ordered sedation
• An x-ray of the abdomen is obtained to determine if any residual contrast medium is present from previous
studies.
• Position: Left lateral position with left arm behind the back and right hand at the side with the neck slightly
flexed.
Post Procedure
• Instruct the client to resume usual diet, fluids, medications, or activity after 24 hours or as directed by the health
care practitioner.
• Do not allow the patient to eat or drink until the gag reflex returns, after which the patient is permitted to eat or
drink until the gag reflex returns, after which the patient is permitted to eat lightly for 12 to 24 hours
• Monitor vital signs and neurologic status every 15 minutes for 1 hour, then every 2 hours for 4 hours, and as
ordered. Take temperature every 4 hours for 24 hours. Compare with baseline values.
• Monitor for reaction to iodinated contrast medium, including rash, urticaria,
• tachycardia, hyperpnea, hypertension,
palpitations, nausea, or vomiting.
• Tell the patient to expect some throat soreness and possible hoarseness.
• Inform the patient that any belching, bloating,
or flatulence is the result of air insufflation.
• Emphasize that any severe pain, fever, difficulty breathing, or expectoration of blood must be reported to the
physician immediately.
HEMATOLOGY STUDIES
Complete Blood Count
v Identifies the total number of white and red blood cells and platelets.
v Measures hemoglobin and hematocrit
NORMAL VALUE
Hemoglobin M: 13 - 18 g/dL
F: 12 -16 g/dL
Red Blood Cell M: 4.7-6.1 million/mm3
F: 4.2 - 5.4 million/mm3
White Blood Cell 4,500 -11,000/mm3
Mean Corpuscular (MCV) 81 – 96 fL
Mean Corpuscular 33-36 g/dL
Hemoglobin
Concentration
Prothrombin Time (PT) 9.5-12 seconds
Partial Thromboplastin Time (PTT)
60-70 seconds
Bone Marrow Biopsy

v Involves the removal of a small sample of bone marrow by aspiration, needle biopsy, or open surgical biopsy for
a complete hematologic analysis
Uses
• Assess how an individual's blood cells are being formed
• Assess the quantity and quality of each type of cell produced within the marrow
• Used to document infection or tumor within the marrow
• Evaluate abnormal results of complete blood count or white blood cell count
• Evaluate hepatomegaly or splenomegaly
• Identify bone marrow hyperplasia or hypoplasia
• Monitor bone marrow response to chemotherapy or radiation therapy
Results
v Increased Reticulocytes:
• Compensated red blood cell (RBC) loss
• Response to Vitamin B12 therapy
v Decreased Reticulocytes:
• Aplastic crisis of sickle cell anemia
v Increased Neutrophils:
• Acute myeloblastic leukemia
v Decreased Neutrophils:
• Aplastic anemia
• Leukemias (Monocytic & Lymphoblastic)
v Increased Lymphocytes:
• Aplastic anemia
• Lymphatic leukemia
• Lymphomas
• Lymphosarcoma
• Mononucleosis
• Viral infections
v Increased Plasma Cells:
• Cirrhosis of the liver
• Connective tissue disorder
• Hypersensitivity reactions
• Infections
• Ulcerative colitis
v Increased Megakaryocytes:
• Hemorrhage
• Increasing age
• Infections
• Myeloid leukemia
• Pneumonia
• Polycythemia vera
• Thrombocytopenia
• Increased Eosinophils:
• Bone marrow cancer
• Lymphadenoma
• Myeloid leukemia
Interfering Factors
• Recent blood transfusions, iron therapy, or administration of cytotoxic agents may alter test results.
• Contraindicated in clients with bleeding disorders.
• Failure to follow dietary restrictions before the procedure may the procedure to be canceled or repeated=
Proximal
• Secure informed consent.
• Inform the client that the test is used to establish a histologic diagnosis of bone marrow and immune system
disease.
• Obtain a history of the client's complaints, including a list of known allergens
• Obtain a history of the client's hematopoietic and immune systems, any bleeding disorders and results of
previously performed
laboratory tests
• Obtain a list of medications the client is taking, including anticoagulant therapy, acetylsalicylic acid, and
nutritional supplements, especially those known to affect coagulation.
• Inform the client that it may be necessary to shave the site before the procedure
• Explain that a sedative and/or analgesia may be administered to promote relaxation and reduce discomfort
• Explain that an intravenous line may be inserted to allow infusion of IV fluids, anesthetics or sedatives
• NPO for at least 4 hours prior to the procedure.
• Have emergency equipment readily available.
• Have the client void before the procedure.
• Assist the client to the desired position depending on the test site to be used.
ü Young children = L4
ü Adults = Sternum or iliac crest
ü Side-lying position = iliac crest or tibial sites
ü Supine = sternum
Post Test
• Instruct the client to resume preoperative diet, as directed by the health care practitioner.
• Monitor vital signs and neurologic status every 15 minutes for 1 hour, then every 2 hours for 4 hours and then as
ordered by the health care practitioner.
• Observe for delayed allergic reactions such as rash, urticarial, tachycardia, hyperpnea, hypertension, palpitations,
nausea or vomiting.
• Observe the biopsy site for bleeding, inflammation or hematoma formation.
• Instruct to report any redness, edema, bleeding or pain at the biopsy site.
• Instruct to report chills or fever.
• Assess for nausea and pain.
• Administer antibiotic therapy if ordered

COMMUNITY HEALTH NURSING

DEFENITION
v It is synthesis of nursing practice and public health applied to promoting and preserving the health of populations
(ANA,1980)
v Focus of the community health nursing is the community as a whole, with nursing care of individuals, families and
groups being provided within the context of promoting and preserving the health of the community (Association of
Community Health Nursing Educators, 1990)
v According to Ruth B. Freeman, it refers to a service rendered by a professional nurse with communities, group,
families, individuals at home, in health centers, in clinics, in schools, in places of work for the:
• Promotion of health
• Prevention of illness
• Care of the sick at home and rehabilitation
Four Levels of Clientele:
• Individuals
• Family
• Population
• Community
Subspecialties:
• School Nursing
• Occupational Health Nursing
• Community Mental Health Nursing
• Public Health Nursing
COMMUNITY – BASED NURSING

v It is a philosophy of care in which the care is provided as clients and their families move among various service
outside of hospitals.
PUBLIC HEALTH NURSING

v It is a special field of nursing that combines the skills of nursing, public health and some phases of social assistance
(World Health Organization)
v Functions as part of the total public health programme for the promotion of health, the improvement of the
conditions, in the social and physical environment, rehabilitation of illness and disability
v According to Dr. C.E Winslow, public health is the science and art of:
• Preventing diseases
• Prolonging life
• Promoting health and efficiency
PUBLIC HEALTH NURSE
v Refers to the nurses in the local/national health departments or public schools whether their official position title is
public Health Nurse or Nurse school nurse
v Starts with a Salary Grade 15
v Roles & Functions
• Planner/Programmer
ü Identifies the health needs, priorities and problems of individuals, families, and community
• Nursing Care Provider
ü Provides nursing care to the sick, disabled in the home, clinic, school, or place of work
• Manager/Supervisor
ü Formulates and implements nursing plan for individual, family, group, community
ü Leads and encourages them to address their health needs and solve their health problems
• Community Organizer
ü Motivates and enhances community participation
ü Initiates and participates in community development activities
• Service Coordinator
ü Collaborates with individuals, families, and groups for health and health services

• Health Educator/Counselor/Trainer
ü Conducts health teaching, training and counseling
ü Trains and educates rural health midwives Acts as a resource speaker on health and health related services
• Health Monitor
ü Monitors the status of the individuals, families and groups through various contacts
• Role Model
ü Sets as good example of healthful, living to the individuals, families, and community
• Change Agent
ü Motivates changes in the health behavior of individual, families and community
• Reported/ Recorder/Statistician
ü Records every nursing interventions
ü Updates existing data base
ü Makes statistical analysis of data for interpretation
• Researcher
ü Uses observation, interview, survey questionnaire, physical exam, and other methods in the assessment of
individuals, families, and community
Qualifications of Public Health Nurses

• Graduate of Bachelor of Science in Nursing and a Registered Nurse
• Good physical and mental health
• Interest and willingness to work in the community
• Capacity and ability to:
ü Relate the practice with on-going community health and health related activities
ü Work cooperatively with other disciplines and members of the community
ü Accept and take actions needed to improve self and service
ü Analyze combination of factors and conditions that influence health of populations
ü Apply nursing process in meeting the health and nursing needs of the community
ü Mobilize resources in the community
• With leadership potential
• Resourcefulness and creativity
• Active membership to professional nursing organizations
PHILIPPINE HEALTH CARE DELIVERY SYSTEM

PUBLIC SECTOR
DEPARTMENT OF HEALTH
Leadership in • Serve as national policy and regulatory institution.
Health • Provide leadership in formulation, monitoring, and evaluation of national policies, plans and
programs.
• Serve as advocate in the adoption of health policies, plans and programs
Enabler and • Innovate new strategies in health
Capacity • Exercise oversight functions and monitoring and evaluation of national health plans,
programs, and policies
• Ensure the highest achievable standards of quality health care, health promotion, and
health protection
Administrator of • Manage selected national health facilities and hospitals with modern and advanced facilities
specific Services • Administer direct services for emergent health concerns that require new complicated
technologies
• Administer health emergency response
VISION
v Filipinos are among the healthiest people in Southeast Asia by 2022, and Asia by 2040
MISSION
v To lead the country in the development of a productive, resilient, equitable and people-centered health system
GOAL
v Health Sector Reform Agenda (HSRA)

• Health Sector reform is the overriding goal of DOH
FRAMEWORK FOR THE IMPLEMENTATION OF HSRA

v FOURmula ONE for Health (2005-2010)
• Goals of the FOURmula One of Health
ü Better Health Outcomes
ü More responsive health systems
ü Equitable health care financing
• Four Elements of the Strategy
1. Health Financing
ü To foster greater, better and sustained investments in health (PHILHEALTH)
2. Health Regulation
ü To ensure the quality and affordability of health goods and services
3. Health Service Delivery
ü To improve and ensure the accessibility and availability of basic and essential health care
4. Good Governance
ü To enhance health system performance at the national and local levels.
LOCAL HEALTH SYSTEM

v RA 7160 – Local Government Code
• All structures, personnel, and budgetary allocations from the provincial health level down to the barangays were
DEVOLVED to the Local Government Units to facilitate health service delivery
v Objectives of Local Health System
• Establish local health system
• Upgrade the health care management and service capabilities of local health facilities
• Promote inter-LGU linkages and cost sharing schemes
• Foster participation of the private sector, non-government organizations and community
v Inter Local Health System
• It is a system of health care similar to a district health system
• System that is being espoused by the DOH in order to ensure quality of health care service
Composition of Inter-Local Health Zone

1. People
ü Ideal health district would have a population size between 100,000 to 500,000 for optimum efficiency and
effectiveness
2. Boundaries
ü Clear boundaries between inter Local Health Zones determine the accountability and responsibility of health
service providers
3. Health Facilities
ü District or provincial hospital and other health services deciding to work together as an integrated health system
4. Health Workers
ü Right unit of health providers is needed to deliver comprehensive health services.
PRIMARY HEALTH CARE (PHC)

v Adopted in the Philippines through:
• Letter of instruction (LOI) 949
ü Signed by President Marcos on October 19, 1979
• Underlying theme: “Health in the Hands of the People by 2020”
v Characterized by partnership and empowerment of the people that shall permeate as the core strategy in the
effective provision of essential health services that are community- based, accessible, acceptable, and sustainable at
a cost, which the community and the government can afford.

v Elements/Components of PHC
E Ducation for health
L Ocally Endemic and Communicable Disease Control and Treatment
E Expanded Program on Immunization
M Aternal and Child Health and Family Planning
E Ssential Drugs
N Utrition
T Reatment (Medical and Emergency Care, Non Communicable Diseases and Mental Health)
S Anitation of the Environment
v Four Cornerstones/Pillars in Primary Health Care
• Active community participation
• Intra and inter-sectoral linkages
• Use of appropriate technology
• Support mechanism made available
v Levels of Primary Health Care Worker

1. Village/Barangay Health Workers
• Refers to trained community health workers or health auxiliary volunteer or a traditional birth attendant or
healer
2. Intermediate Level Health Workers
• General medical practitioners or their assistants.
• E.g. Public Health Nurse, Rural Sanitary Inspectors and Midwiwes, Rural Health Physician
v Levels of Health Care and Health Referral System

1. Primary Level of care
• Devolved to the cities and municipalities
• Health care provided by center physicians, public health nurses, rural health midwiwes, barangay health
workers, traditional healers
EXAMPLES
Barangay Health Stations
Rural Health Unit
Community Hospitals
Health Centers
Puericulture Center
2. Secondary Level of Care

• Secondary care is given by physicians with basic health training
• Serves as a referral center for the primary health facilities
• Capable of performing minor surgeries and perform some simple laboratory examinations
EXAMPLES
Emergency/District Hospitals
Provincial/City Health Services
Provincial/City Hospitals
3. Tertiary Level of Care

• Tertiary care is rendered by specialists in health facilities
• Referral center for the secondary care facilities
• Complicated cases and intensive care requires tertiary care
EXAMPLES
Regional Health Services
Regional Medical Centers and Training Hospitals
National Health Services
Medical Centers
Teaching and Training Hospitals

v Levels of Prevention
1. Primary Prevention
• Focuses on health promotion and disease prevention
EXAMPLES
Immunization
Promotion of Healthy Lifestyle (Proper Diet & Exercise)
2. Secondary Prevention
• Focuses on early detection of disease and prompt treatment for individual experiencing health problems
EXAMPLES
Breast-Self Examination
Diagnostic Test (AFB test)
Cancer Signs & Symptoms (CAUTION US)
3. Tertiary Prevention
• Rehabilitation (prevent further disability)
• Restore client’s optimum level of functioning
EXAMPLES
Mental Health
Crutch Walking
Physical Therapy
COMMUNITY HEALTH NURSING PROCESS

1. Assessment
• This provides:
ü An estimate of the degree to which a family, group or community is achieving the level of health possible for
them
ü Identifies specific deficiencies or guidance needed
ü Estimates the possible effects of nursing interventions
• Health Deficit
ü A gap between actual and achievable health status
ü Failure in health maintenance
ü Already developed the disease or disability, developmental lag.
• Health Threat
ü Condition that promote disease or injury and prevent people from realizing their health potential
• Foreseeable Crisis
ü Anticipated periods of unusual demand on the individual/family in terms of resources and adjustment
• Wellness Potential
ü This refers to states of wellness and the likelihood for health maintenance or improvement to occur
depending on the desire of the family
2. Planning
• Goal Setting
ü Initial step
ü Declaration of purpose/ intent that gives essential direction to action
• Constructing a Plan of Action
ü Choosing from among the possible courses of action
ü Selecting the appropriate types of nursing intervention
ü Identifying appropriate and available resources
• Developing an Operational Plan
ü Establish priorities, phase, and coordinate activities
ü Development of evaluation parameters is done in the planning stage
3. Implementation
• Involves various nursing interventions which have been determined by the goals/objectives that have been
previously set
• Carrying out of nursing procedures
• Documentation is done at this phase
4. Evaluation
• Three Classic Frameworks
ü Structural elements
ü Process elements
ü Outcome elements
MANAGEMENT FUNCTIONS OF THE COMMUNITY HEALTH NURSE

v Planning
• Includes assisting the organization in establishing a vision for the future
• Deciding what must be done and what the organization wants to achieve
v Organizing
• Helps to determine how a manager implements planning to achieve the stated goals
• Major concerns:
ü Analysis of the systems
ü Analysis of functions
ü Assigning job responsibilities
ü Implementation
v Directing
• Includes conveying to the workers what has occurred in the planning and organizing phases
v Coordinating
• Linking people on the health care team together to function in such a way that objectives are achieved
v Controlling
• Process that measures and corrects the activities of the people and establishes standards so that objectives are
met
• Step:
ü Establishing standards
ü Measuring performance criteria
ü Correcting deviations from normal
v Evaluating
• Involves upon actions to determine their effectiveness in order to make decisions regarding future action
• Documenting the progress by comparing achievements against a performance standard
NURSING PROCEDURES
CLINIC VISIT
v Standard Procedures
1. Registration/Admission
• Greet the client and establish rapport
• Prepare family record (New Client)
• Retrieve record (Old Client)
• Elicit and record the client’s chief complaint and clinical history
• Perform physical exam on the client
2. Waiting time
• Give Priority numbers to clients
• Implement “first come, first served” policy except for emergency cases
3. Triaging
• Manage program-based cases
ü Manage according to Protocols
• Refer all non-program based cases to the physician
• Provide first-aid treatment to emergency cases
4. Clinical Evaluation
• Validate clinical history and physical exam
• Nurse arrives at the evidence-based diagnosis and provides rational treatment based on DOH programs
• Inform the client on the nature of the illness, appropriate treatment and prevention and control measures
5. Laboratory and other Diagnostic Examinations
• Identify a designated referral laboratory when needed

6. Referral System
• Refer the patient if he needs further management following the two-way referral system
• Accompany the patient when an emergency referral is needed
7. Prescription/Dispensing
• Give proper instruction on drug intake
8. Health Education
• Conduct one-on-one counseling with the patient
• Reinforce health education and counseling messages
• Give appointments for the next visit
BLOOD PRESSURE MEASUREMENT

1. Preparatory Phase
• Introduce self to client
• Make sure the client is relaxed and has rested for 5 minutes
• Client should not have smoked or ingested caffeine within 30 minutes before BP measurement
• Explain the procedure
• Assist to seated or supine position
2. Applying the BP cuff and stethoscope
• Bare client’s arm
• Apply cuff around the upper arm 2-3 cm above the brachial artery
• Apply cuff snugly with no creases
• Keep the manometer at eye level
• Keep arm level with his/her heart by placing it on a table or a chair arm or by supporting it with examiner’s hand.
If the client is in recumbent position, rest arm at his/her side
• Palpate brachial pulse correctly just below or slightly medial to the antecubital area
3. Obtaining the BP Reading by using Palpatory Method
• While the branchial or radial pulse is located and palpated, close pressure bulb and inflate cuff until pulse
disappears
• Note point at which pulse disappears (palpated systolic BP)
• Deflate cuff fully
• Wait for 1-2 minutes before inflating cuff again
4. Obtaining the BP by Auscultation
• Place earpieces of stethoscope in ears and head (diaphragm) of stethoscope over the branchial pulse
• Use the bell side of the stethoscope; however, for obese persons, use diaphragm
• Watching the manometer, inflate the cuff rapidly by pumping the bulb until it reaches 30mmHg above the
palpated SBP
• Deflate the cuff slowly at a rate 2 to 3 mmHg per beat
• While the cuff is deflating, listen for pulse sounds.
ü 1st Clear tapping sound (Korotkoff Phase I: Systolic BP)
ü Disappearance of sound (Korotkoff Phase V: Diastolic BP
5. Recording of BP and other Guidelines
• For every visit, take the mean of 2 reading, obtained at last 2 minutes apart
• If first visit, repeat procedure with other arm. Subsequent BP readings should be performed on the arm, with a
higher BP reading
HOME VISIT
v Professional family-nurse contact
v Allow the health worker to assess the home and family situations in order to provide the necessary nursing care and
health related activities
v Principles
• Home visit must have a purpose or objective
• Planning should:
ü Make use of all available information
ü Involve the individual and family
ü Give priority to the essential needs

v Purposes
• To give nursing care to the clients
• To assess living conditions of the patient and his family
• To give health teaching regarding the prevention and control of diseases
• To establish close relationship between health agencies and public
• To make use of inter referral system
v Factors influencing Frequency of Home Visits
• Needs of the (most important)
• Acceptance of the family 2nd most important
• Policy of a Specific agency
• Other health agencies involved
• Past services given to family
• Ability to recognize own needs
v Steps in conducting Home Visits
1. Greet the patient and introduce self
2. State the purpose of visit
3. Observe the patient and determine health needs
4. Put the bag in a convenient place then proceed to perform the bag technique
5. Perform the nursing care needed and give health teachings
6. Record all important data, observation, and care rendered
7. Make appointment for a return visit
BAG TECHNIQUE
v A tool by which the nurse will enable her to:
• Perform a nursing procedure with ease and deftness
• Save time and effort
v Public Health Bag
• An essential and indispensable equipment of a public health nurse which she has to carry along during her home
visits
v Principles of bag Technique
• Minimize if not prevent the spread of any infection
• Saves time and effort
• This should show the effectiveness of total care given to an individual or family
• Can be performed in a variety of ways depending on the agency’s policy or home situation or as long as principles
of avoiding transfer of infection is always observed
v Important Points to Consider in the Use of the Bag
• The bag should:
ü Contain all the necessary articles, supplies, and
ü Equipment that will be used to answer emergency needs
ü Be cleaned very often, the supplies replaced, and ready for use any time
ü Be well protected from contact with any article
• Arrangement of contents should be the one most convenient to the user
Epidemiology
v Study of the occurrence and distribution of health conditions such as disease, death, deformities or disabilities on
human populations.
v The nurse measures the frequency and distribution of health conditions using Vital statistics.
Important Concepts related to Epidemiology:

1. The Multiple Causation Theory (the wheel, the web, the ecologic triad)
2. Natural History of Disease
A. Pre-pathogenesis or susceptibility
B. Pathogenesis which has 3 substages:
a. Pre-symptomatic
b. Discernible lesions
c. Advanced Disease
3. Level of Prevention of Health Problems

4. Concept of Causality and Association
The Epidemiological Approach

1. Descriptive Epidemiology
v Concerned with disease distribution and frequency
2. Analytical Epidemiology
v Attempts to analyze causes or determinants of disease through hypothesis testing
3. Intervention or Experimental Epidemiology
v Answers questions about the effectiveness of new methods for controlling diseases or for improving
underling conditions
4. Evaluation Epidemiology
v Attempts to measure the effectiveness of different health services and programs
VITAL STATISTICS
v Refers to the systematic study of vital events such as births, illnesses, marriages, divorces, separation and deaths
v Morbidity (Disease) and Mortality (Death)
• Indicate the state of health of a community and the success of failure og health work
v Uses of Vital Statistics
• Indices of the health and illness status of a community
• Serves as bases for planning, implementing, monitoring and evaluating CHN programs and services
v Sources of Data
• Population census
• Registration of Vital Data
• Health survey
• Studies and researches
v Comparison between Rates and Rations
• Rate - Shown the relationship between vital event and those persons exposed to the occurrence of said event
within a given area and during a specified unit of time
• Ratio – is used to describe the relationship between two numerical quantities or measure of events without
taking particular considerations to the time or place
• Infant Mortality Rate
ü Good index of the general health condition of a community
• Crude Birth Rate
ü A measure of one characteristic of the natural growth or increase of population
• Crude Death Rate
ü A measure of one mortality from all causes which may result in a decrease of population
• Maternal Mortality Rate
ü Measures the risk of dying from causes related to pregnancy, childbirth and puerperium
ü Index of the obstetrical care needed and received by women in a community
• Fetal Death Rate
ü Measures pregnancy wastage
ü Death of the product of conception occurs prior to its complete expulsion, irrespective of duration of
pregnancy
• Neonatal Death Rate
ü Measures the risk of dying 1st month
• Attack Rate
ü More accurate measure of the risk of exposure
• Case Fatality Ratio
ü Index of a killing power of a disease and is influenced by incomplete reporting and poor morbidity data
• Incidence Rate
ü Measures the frequency of occurrence of the phenomenon during a given period of time
ü New cases
• Prevalence Rate
ü Measures the proportion of population which exhibits a particular disease at a particular time
ü New and old cases
FIELD HEALTH SERVICES AND INFORMATION SYSTEM (FHSIS)

v Objectives
• To provide summary of data on health services delivery
• To provide data that can be used for program monitoring and evaluation purposes
• To provide a standardized, facility level database which can be accessed for more in-depth studies
• To ensure that the data are useful and accurate
• To minimize the recording and reporting burden at the service delivery level
v Components
• Family Treatment Record
ü Fundamental building block of FHSIS
• Target Client List
ü Second building block of FHSIS
• Reporting Forms
ü Only mechanism through which data are routinely transmitted from one facility to another
ü Prepared and submitted either monthly or quarterly
• Output Reports
ü Objective in designing the output formats: Make the reports useful for monitoring or management purposes
PUBLIC HEALTH PROGRAMS

FAMILY HEALTH
Maternal Health Program
1. Antenatal Registration
PRENATAL VISITS PERIOD OF PREGNANCY
ST
1 Visit As early in pregnancy as possible
2nd Visit During 2nd trimester
rd
3 Visit During 3rd trimester
Every 2 weeks After 8th month of pregnancy until delivery
2. Tetenus Toxoid Immunization

VACCINE INTERVAL PROTECTION DURATION
TT 1 As early as possible during pregnancy ----------- ---------
TT 2 After 4 weeks 80% 3 years
TT 3 After 6 months 95% 5 years
TT 4 After 1 year 99% 10 years
TT 5 After 1 year 99% Lifetime
3. Micronutrient Supplementation
VITAMIS DOSE SCHEDULE
Vitamins A 10,000 IU Twice a week starting on the 4th month of pregnancy
Iron/Folic acid 60mg/400ug tablet Daily (Starting 5th month of pregnancy up 2 months postpartum)
4. Treatment of Diseases and Other Conditions
5. Clean and Safe Delivery
6. Health Teachings:
• Birth registration
• Importance of breastfeeding
• Newborn screening between 48 hours up 2 weeks after birth
• Schedule when to return for consultation for post-partum visits
ü 1st Visit – 1st week postpartum preferably 3-5 days
ü 2nd Visit – 6 weeks postpartum
7. Support to Breastfeeding
8. Family Planning Counseling
• Proper spacing of birth (3 to 5 years interval)

FAMILY PLANNING (FP)

v Overall Goal: To provide universal access tp family planning information and services wherever and whenever these
are needed
v Aims to reduce:
• Infant deaths
• Neonatal deaths
• Under-five deaths
• Maternal deaths
v Objectives
• Addresses the need to help couples and individuals achieved their desired family size within context of
responsible parenthood
• Ensure that quality FP services are available in DOH retained hospitals, LGU managed health facilities, NGOs and
private sector
v Family Planning Methods
1. Female Sterilization
• Also known as Bilateral Tubal Ligation
• Safe and simple surgical procedure which provides permanent contraception for women who do not want more
children
• Involves cutting or blocking of two fallopian tubes.
Advantages
ü Permanent method of contraception
ü Does not interfere with sex
ü Results in increased sexual enjoyment
ü No effect on breastfeeding
ü No known long term side effects or health risks
Disadvantages
Uncommon complications of surgery:
ü Infection or bleeding
ü Increase risk for ectopic pregnancy
ü Requires physical examination
ü Reversal surgery is difficult
ü Do not protect against sexually transmitted diseases
2. Male Sterilization
• Also known as Vasectomy
• Permanent method wherein the vas deferens is tied and cut or blocked through a small opening in the scrotal
skin
Advantages
ü Very effective in 3 months after the procedure
ü Permanent, safe, simple and easy to perform
ü Can be performed in a clinic
ü Person will not lose his sexual ability and ejaculation
Disadvantages
ü May be uncomfortable due to slight pain and swelling 2-3 days after the procedure
ü Reversibility is difficult and expensive
ü Bleeding may result in hematoma formation
3. Pill
• Contains hormones – estrogen and progesterone
Advantages
ü Safe as proven through extensive studies
ü Convenient and easy to use
ü Reduces gynecologic symptoms such as painful menses and endometriosis
ü Does not interfere with sexual intercourse

Disadvantages
ü Often not used correctly and consistently, lowering its effectiveness
ü Has side effects such as nausea, dizziness or breast tenderness
ü Can suppress lactation
4. Male Condom
• Thin sheath of latex rubber made to fit on a man’s erect penis to prevent the passage of sperm cells and sexually
transmitted disease into the vagina
Advantages
ü Safe and has no hormonal effect
ü Protects against microorganisms during intercourse
ü Encourages male participation in family planning
Disadvantages
ü May cause allergy for people who are sensitive to latex or lubricant
ü May decrease sensation, making sex less enjoyable
5. Injectables
• Contain synthetic hormone, progestin that suppresses ovulation, thickens cervical mucus and changes uterine
lining.
Advantages
ü Reversible
ü No need for daily intake
ü Does not interfere with sexual intercourse
ü Has no estrogen-related side effects
6. Lactating Amenorrhea Method/LAM

• Temporary introductory postpartum method of postponing pregnancy based on physiological infertility
experienced by Breastfeeding women
Advantages
ü LAM is universally available to all postpartum breastfeeding women
ü No other FP commodities are required
ü It contributes to improve maternal and child health and nutrition
Disadvantages
ü Short term FP method which is effective only for a maximum of 6 months
ü The effectiveness of LAM may decrease if a mother and child are separated for extended periods
ü Full or nearly full BF may be difficult to maintain up to 6 months
7. Mucus/Billing Methods
• Abstaining from sexual intercourse during fertile days prevents pregnancy
• Advantages
ü Can be used by any woman of reproductive age as long as she is not suffering from an unusual disease or
condition that results in extraordinary vaginal discharge
• Disadvantages
ü Cannot be used by woman with medical conditions that would make pregnancy dangerous
8. Basal Body Temperature

• Identifies the fertile and infertile period of a woman’s cycle by daily taking and recording of the rise in body
temperature during and after ovulation.
• Before Ovulation: Temperature decreases 0.5 °F
• During Ovulation: Temperature increases 1.0°F
9. Sympto-thermal Method
• Identifies the fertile and infertile days of the menstrual cycle as determined through a combination of
observations made on the cervical mucus, basal body temperature recording and other signs of ovulation

10. Two Day Method

• Simple fertility awareness based method of FP that involves:
ü Cervical secretions as an indicator of fertility
ü Women checking the presence of secretions everyday
Advantages
ü Can be used by women with any cycle length
ü No health related side effects associated
ü Incurs very little or no cost
ü Immediately reversible
ü Promote male partner involvement in FP
Disadvantages
ü Needs cooperation of the husband
ü Can become unreliable for women who have conditions that cause abnormal cervical secretions
11. Standard Days Method

• Couples use color coded cycle beads to mark the fertile and infertile days of the menstrual cycle
Advantages
ü No health related side effects associated with its use
ü Increases self-awareness and knowledge of human reproduction
ü Can be used either to avoid or achieve pregnancy
ü Enhances self-discipline, mutual respect
ü Can be integrated in health and family planning services
Disadvantage
ü Cannot be used by women who usually have menstrual cycle between 26 and 32 days long
v Misconceptions about Family Planning

• Causes abortion
• Will render couples sterile
• Will result to loss of sexual desire
v Roles of Public Health Nurse on FP Program
• Provide counseling
• Provide packages of health services
• Ensure the availability of FP supplies and logistics
CHILD HEALTH PROGRAMS

v Goal: To reduce morbidity and mortality rates (for children 0-9yrs)
v Programs:
• Infant and Young Child Feeding
• Newborn Screening
• Expanded Program on Immunization
• anagement of Childhood illnesses
• Micronutrient Supplementation
• Dental health
• Early Child Development
• Child Health Injuries
INFANT & YOUNG CHILD FEEDING (IYCF)

v Goal: Reduce child mortality rate by 2/3 by 2015
v Objective: To improve health and nutrition status of infants and young children
v Outcome: To improve exclusive and extended breastfeeding and complementary feeding
v Key Messages on Infant and Young Child Feeding
• Initiate breastfeeding within 1hour after birth
• Exclusive for the first 6 months of life
• Complemented at 6 months with appropriate food
• Extend Breastfeeding up to 2 years and beyond
v Exclusive breastfeeding means giving a baby only breast milk, and no other liquids or solids, not even water.
v Complementary feeding- after six months of age all babies require other foods to complement breast milk.
• Complementary foods should be:
ü Timely
ü Adequate
ü Safe
ü Properly fed
• When not to breastfeed:
ü AIDS
LAWS THAT PROTECT INFANT AND YOUNG CHILD FEEDING

1. Milk Code (EO 51)
• Products covered by Milk Code consist of breast milk substitutes, including infant formula; other milk
products, food and beverages, including bottle-fed complementary foods.
2. Rooming-In and Breastfeeding Act of 1992 (RA 7600)
• To promote room-in and to encourage. Protect and support the practice of breastfeeding.
• Compliance to the law is ensured through one of the 10 steps to Mother Baby Friendly Hospitals wherein
the mother and the baby should be together for 24 hours.
3. Food Fortification Law (RA 8976)
• The law requires a mandatory food fortification of staple foods – rice, flour, edible oil and sugar and
voluntary food fortification of processed food or food products
4. Expanded Breastfeeding Act of 2010 (RA 10028)
• Exclusive breastfeeding for the first 6 months.
EPI LAW (PD (996)

v Principles:
• It is safe and immunologically effective to administer all EPI vaccines on the same day at different sites of the
body
• Measles Vaccine should be given as soon as the child is 9 months old. If the child is living in an endemic area,
give the vaccine as early as 6 months. If given at 9 months = 85% protection; if given at one year and older =
95%
• Vaccine schedule should not be restated
• Giving doses less than the recommended interval may lessen the antibody response
• No extra must be given to children/ mother who missed a dose of DPT/Hepa-B/OPV/TT
• Strictly follow the principle of never, ever reconstituting the freeze dried vaccines other than the diluents supplied
with the
• One Syringe, One Needle per child during vaccination
RA 10152 (2011)
v An act providing for mandatory basic immunization services for infants and children.
False Contraindications:
ü Malnutrition
ü Low Grade Fever
ü Mild Respiratory Infections
ü Cough
ü Diarrhea
ü Vomiting
Absolute Contraindications:
ü DPT 2 or DPT 3 to a child who has had convulsions or shock within 3 days the previous dose.
ü Patients with neurologic disease should not be given vaccines containing whole cell pertussis
ü Live vaccines like BCG vaccine must not be given to individuals who are immunosuppressed due to a
malignant disease.

EPI ROUTINE SCHEDULE

VACCINE MINIMUM AGE AT 1ST DOSES INTERVAL
DOSE
BCG At birth 1
Pentavalent 6 weeks 3 4 weeks
OPV 6 weeks 3 4 weeks
HEPA B At birth 1 6 weeks from 1st dose
MEASLES 9 months 1
MMR 12 months 1
IPV 14 weeks 1
VACCINE DOSAGE ROUTE SITE

BCG 0.05 mL ID Right deltoid region
DPT 0.5 mL IM Upper outer portion of thigh (Vastus lateralis)
OPV 2-3 drops Oral Mouth
HEPA B 0.5 mL IM Upper outer portion of thigh (Vastus lateralis)
MEASLES 0.5 mL SQ Outer portion of upper arm
NUTRITION PROGRAM
v Goal: improve quality of life of Filipinos through better nutrition, improved health, and increased productivity
v Common Nutritional Deficiencies
• Vitamin A
• Iron
• Iodine
Programs and Projects:
• Micronutrient Supplementation
• Food Fortification
• Essential maternal and Child Health Service Package
• Nutrition Information, Communication, and Education
• Home, School and Community Food Production
• Food Assistance
• Livelihood Assistance
ORAL HEALTH PROGRAMS

v Goal: Reduce the prevalence rate of dental caries and periodontal diseases from 92% in 1998 to 85% and from
78% in 1998 to 60% by 2010 among general population
Objectives:
• To increase the proportion of orally fit children under 6 years old 80% by 2010
• To control oral health risk among the young people
• To improve the oral health conditions of pregnant women by 20% and older persons by 10% every year until
2010
CLASSIFIACTION OF ORAL INTERVENTIONS
Promotive Service • Health education
Preventive Treatment • Oral examination
• Oral hygiene
• Pit & Fissure Sealant Program
• Fluoride Utilization Program
Curative Treatment • Permanent Filling Gum Treatment
• Atraumatic Restorative Treatment
• Temporary Filling
• Extraction
• Treatment Post Extraction
• Drainage of Localized Oral abscesses

PHILIPPINE REPRODUCTIVE HEALTH

v Overall Goal: Better Quality Life among Filipinos
v Main Objectives
• Reducing Maternal Mortality Rate
• Reducing Child Mortality
• Halting and Reversing spread of HIV/AIDS
• Increasing access to reproductive health information and services
v Elements
• Family Planning
• Maternal and Child Health Nutrition Prevention and Management of Reproductive Tract Infection
• Adolescent Reproductive Health
• Prevention and Management of Abortion and its Complications
• Prevention and Management of Breast and Reproductive Tract Cancers and other Gynecological Conditions
• Education and Counselling on Sexuality and Sexual Health
• Men’s Reproductive Health and Involvement
• Violence against Women and Children
• Prevention and Management of Infertility and Sexual Dysfunction
ENVIRONMENTAL HEALTH AND SANITATION

v Environmental Health
v It is a branch of public health that deals with the study of preventing illness by managing the environment and
changing people’s behavior to reduce exposure to biological and non-biological agents of disease or injury
v Health and Sanitation Laws
• PD 856 – Sanitation Code of the Philippines
• RA 6969- toxic Substances and hazardous and Nuclear Waste Control Act of 1990
• RA 8749- Clean Air Act of 1999
• RA 9003- Ecological Solid Waste Management Act of 2000
• RA 9275- Clean Water Act 2004
v Environmental Sanitation
• Study of all factors in man’s physical environment, which may exercise a deleterious effect on his health well-
being and survival
v The Development of Health through the Environment and Occupation Health Office (EOHO) has set some policies on
the following areas:
1. Approved Types of Water Supply Facilities
• LEVEL 1 (Point Source)
ü Protect well or developed spring with an outlet but without a distribution system
ü Serves around 15 to 25 households
ü Outreach must not be more than 250 meters from the farthest user
ü Yield or discharge is generally from 40 to 140 liters per minute
ü Generally adaptable for rural areas where the houses are thinly scattered
• LEVEL II (Communal Faucet System or Stand –posts)
ü System composed of a source of reservoir, a piped distribution network and communal faucets
ü Located not more than 25 meters from the farthest house
ü Designed to deliver 40-80 liters of water per capital per day
ü Average households: 100
ü One faucet per 4 to 6 households
ü Suitable for rural areas where houses are clustered densely to justify a simple-piped system
• LEVEL III (Waterworks System or Individual House Connections)

ü NAWASA, Maynilad
2. Unapproved type of water facility
• Open drug wells
• Unimproved springs
• Wells that need priming
3. Access to sage and potable drinking water

4. Water quality and monitoring surveillance

• Disinfection of water supply sources is required on the following:
• Newly constructed water supply facilities
• Water supply facility that has been repaired/improved
5. Waterworks/water system and well construction

• Well sites shall require the prior approval of the Secretary of Health or his duly authorized representative
• Well construction shall comply with sanitary requirements of the Department of Health
• Water supply system shall supply safe and potable water in adequate quantity
PROPER EXCRETA AND SEWAGE DISPOSAL PROGRAM

APPROVED TYPE OF TOILET FACILITY
Level I Non-water Carriage Toilet Facility
ü Pit Latrines
ü Reed Oderless Earth Closet
Toilet Facilities requiring small amount of water
ü Poor Flush Toilet
ü Aqua Privies
LEVEL II Water carriage type with Water Flush type with septic vault/tank disposal
facilities
LEVEL III Water carriage types of toilet facilities connected to septic tanks and/or
sewerage system to treatment plant
FOOD SANITATION PROGRAM

v Food Establishments shall be appraised as to the following sanitary conditions:
• Inspection/approval of all food source, containers, transport vehicles
• Compliance to sanitary permit requirements for all food establishment
• Provision of updated Health certificate for food handlers, cooks and cook helpers
ü DOH’s Administrative Order no.1 – 2006 requires all laboratories to use Formalin Ether Concentration
Technique (FECT) instead of the direct fecal smear in the analysis of stools of food handlers.
• Food Establishment shall be rated as follows:

ü CLASS A – Excellent
ü CLASS B – Very Satisfactory
ü CLASS C – Satisfactory
v Four Rights in Food Safety

• Right Source
ü Always buy fresh meat, fish fruits & vegetables
ü Look at the expiry dates of processed food
ü Avoid buying canned goods with dents, bulges, deformation, broken seals and improper seams
ü Boil water for at least 2 minutes (running boiling)
• Right Preparation
ü Avoid contact between raw food and cooked food
ü Always buy pasteurized mild and fruit juices
ü Wash vegetables well if to be eaten raw such as lettuce, cucumber, tomatoes & carrots
ü Wash hands kitchen utensils before and after preparing foods
ü Sweep kitchen floors to remove food droppings

• Right Cooking
ü Cook food thoroughly (temperature on all parts of the food should reach 70 degrees centigrade
ü Eat cooked food immediately
ü Wash hands thoroughly before and after eating
• Right Storage
ü All cooked food should be left at room temperature for not more than two hours
ü Use tightly sealed containers for storing food
ü Store food under hot conditions (at least or above 60°C) or in cold conditions (below or equal to 10°C) if you
can plan to store it for more than 4 to 5 hours
ü Do not overburden the refrigerator by filing it with too large quantities of warm food
ü Food should be reheated to at least 70 degrees centigrade
ü Rule in Food Safety: “When in doubt, throw it out!”
OTHER PRIORITY HEALTH PROGRAMS

SENTRONG SIGLA (SS) CERTIFICATION
Goal: Quality Health Care, Services, and Facilities
Level and Scope of Certification
1. Basic SS Cerfitication
• Minimum input, process and output standards for integrated public health services for 4 core programs,
facility system, regulatory functions and basic curative services
2. Specialty Awards
• Second level quality standards for selected 4 core public health programs
3. Awards for Excellence

• Highest level quality standards for maintaining Level 2 standards for the 4 core public health programs and
level 2-facility system for at least 3 consecutive years.
• The SS Certification validity of certification is every two years.
• Facilities which did not progress to a level of certification but maintained current certification are:
ü Given stickers to confirm the renewal of the validity of seal
ü No other incentives given for mere renewal of SS status
• Facilities that slide back; seal will not be removed but not issued an SS sticker
v Scope and structure of the SS Quality Standards (Level I)

• Primary Function: Provide basic public health services
• Facility and System Standards

ü Ensure that the health facility is appropriately equipped with sufficient manpower, adequate logistics and
organized procedures to efficiently and effectively promote core public health programs
• Integrated Public Health Function Standards

ü Ensure that the health facility and staff promote public health programs and prevent and control public health
problems through direct patient/client care
• Basic Curative Function Standards

ü Ensure that the health facility and staff provide basic curative services that consist of primary level outpatient
and emergency care
• Regulatory Function Standards

ü Ensure that the health facility and staff support and provide an environment to prevent, reduce and control
risks and hazards to the community
v Scope and Structure of SS Quality Standards (Level II)

1. Local Health System Development
Goal: To strengthen local health system development
2. Integrated Public Health Functions covering 5 core public health programs:

• Integrated Women’s Health
• Child Care
• Prevention and Control of Infectious Disease
• Integrated Prevention and Control of Lifestyle Related Diseases
• Environmental Health
HERBAL MEDICINE
v General guidelines for the use of medicinal plants
• Be sure that the right king of plant is used according to the intended purpose
• Use the plant part suggested
• Use according to the dosage and direction recommended
• Use only one kind of medicinal plant at a time
• Stop the use of the plant if there is any untoward reaction or if side effects occur
• If there are no signs of improvement after two or three administration of the drug, consult a physician
• In boiling the plants, use enamel were or clay pots, not aluminum ware. Clean the pots very well before and after
boiling the plant
• Use only the prescribed part of the plant
• Avoid the use of insecticides
v Herbal Plants
1. Lagundi (Vitex negundo)
• For cough and asthma
• Preparations
ü Clean the leaves thoroughly and chop
ü Measure two cups of water and boil on a low fire for 15 minuts
ü Use the table on the amount of leaves to be used
LEAVES
AGE FRESH DRIED
Adult 6 tbsp. 4 tbsp.
7- 12 y/o 3 tbsp. 2 tbsp.
2 – 6 y/o 1 ½ tbsp. 1 tbsp.
• Dosage
ü Divide the solution into three parts. Drink one part each in the morning, noon and night For fever, drink
each part every four hours
2. Yerba Buena (Mentha cordifolia Opiz ex Fresen)

• For pains of the body
• Preparations
ü Cleanse thoroughly and chop the leaves, then boil in two glasses of water for 15 minutes.
ü Do not cover the pot; allow to cool and strain
ü For adults, six tbsp. of fresh leaves or four tbsp. of dried leaves should be used
ü For patients 7-12 years old, use half the adult dose
• Dosage
ü Divide the boiled solution into three parts and drink on part each in the morning, afternoon and evening,
Squeeze the fresh leaves and place on the painful part
3. Sambong (Blumea balsamifera)

• For swelling. Diuresis, anti-urolithiasis
• Preparations
ü Cleanse thoroughly and chop leaves, boil in two glasses of water for 15 minutes

ü Do not cover the pot; keep boiling and strain

ü For adults, use six tbsp. fresh leaves or four tbsp. dried leaves
• Dosage
ü Divide the boiled solution into three parts and drink one part each in the morning, afternoon and
evening, Squeeze the fresh leaves and place on the painful part.
4. Tsaang Gubat (Ehretia microphylla Lam)

• For stomachache
• Preparations
ü Cleanse thoroughly and chop leaves and boil in two glasses of water for 15 minutes
ü Do not cover the pot; keep cooking and strain
ü For adults, six tbsp. of fresh leaves or four tbsp. of dried leaves should be used
ü For patients 7-12 years old, use half the adult dose
• Dosage
ü Divide in two parts and drink one part every four hours
5. Niyug-niyugan (Quisqualis indica)

• For ascaris
• Preparation
ü Use newly-opened, mature and dried nuts
• Administration
ü Eat the seeds two hours after supper
• Dosage
Adult 8-10 seeds
7-12 y/o 6-7 seeds
6-8 y/o 5-6 seeds
4-5 y/o 4-5 seeds
6. Bayabas (Psidium guajava)

• For cleansing or wounds, mouth infections and swollen gums
• Preparations
ü Clean thoroughly and chop leaves
ü Boil two glasses of leaves in four glasses of water on a low fire
• Administration
ü Clean wounds with the solution two times a day. To use as a mouthwash, use a lukewarm solution
7. AKapulko (Cassia alata)

• Infected skin, skin irritation and scabies
• Preparation
ü Squeeze enough leaves
• Administration
ü Apply the juice of the leaves on affected parts twice a day
8. Ulasimang bato (Peperomia pellucida)

• Lower uric skin; for arthritis or gout
• Preparations
ü Salad: Clean leaves thoroughly, Eat three times a day with meals
ü Decoction: Clean leaves thoroughly and boil 1 ½ glasses of leaves in two glasses of water for 15 minutes.
Divide into three parts and take three times a day.
9. Bawang (Allium sativum)

• To lower cholesterol level
• Preparation
ü Saute or boil; may be infused (five minutes); be mixed with vinegar
• Administration and Dosage

ü Eat two clove of garlic with meals three times a day
10. Ampalaya (Momordica charantia)

• For diabetes mellitus (mild-insulin dependent)
• Preparation
ü Clean the leaves thoroughly and chop. Measure two cups of leaves in two glasses of water, Boil for 15
minutes on low fire. Drink ½ glass three times a day before eating
HEALTH EMERGENCY PREPAREDNESS AND RESPONSE PROGRAM

v Goal: Promoting health emergency preparedness among the general public and strengthening the health sector
capability and response to emergencies disaster.
v Legal Mandate
• Presidential Decree No 1566 (1978) – Strengthening the Philippine Disaster Control Capability and Establishing
the National Program on Community Disaster Preparedness
•
• Republic Act No 7160 (Local Gov’t Code of 1991)
ü Transfer of responsibilities from the national to the local government units (LGUs)
v Disaster and Health Emergency Management
• Disaster
ü It a serious disruption of the functioning of a society, causing widespread human, material or
environmental losses which exceed the ability of the affected society to cope, using only its own
resources.
• Classification of Disaster according to its cause

1. Natural Disaster
2. Human generated/Man-made
• Emergency
ü Requires an immediate response
ü It is the responsibility of all
ü It should be woven into the community and administrative levels
ü It should concentrate on process and people rather than documentation
Main objective: Decrease mortality, morbidity and prevent disability
• Hazards
ü Any phenomenon, which has the potential to cause disruption or damage to humans and their environment
• General Principles
ü First priority: protection of the people who are at risk
ü Second priority: protection of critical resources and systems on which communities depend
ü Disaster management must be an integral function of national development plans and objectives
ü Disaster management relies upon an understanding of hazard risks
ü Capabilities must be developed prior to the impact of a hazard
ü Disaster Management must be based upon interdisciplinary collaboration
• Major Risks to be Considered

1. Natural risks
E.g. flood, earthquake, cyclones
2. Technological risks
ü Chemical, radiological, other events caused by the failure of the socio-technical systems
3. Epidemics
4. Societal risks
ü Caused by social exclusion, extreme poverty and group violence.

NATIONAL VOLUNTARY BLOOD SERVICES PROGRAM

RA 7719 – Blood Services Act 1994
v Objectives
• To promote and encourage voluntary blood donation by the citizenry and to instill public consciousness of the
principle that blood donation is a humanitarian act.
• To provide adequate, safe, affordable and equitable distribution of supply of blood and blood products
• To mobilize all sectors of the community to participate in mechanisms for voluntary and non-profit collection of
blood
v Vision
• Envision a network of modernized national and regional blood centers operating on a fully voluntary, non-
remunerated blood donation system
v Mission
• Ensure adequate, safe and accessible blood supply by:
ü Promoting voluntary blood donation
ü Establishing new blood service facilities
ü Organizing association of blood donors and training medical practitioners on national blood use
v Requirements before donating:

• Weigh more than 45 kg (100 lbs) for 250 ml of donated blood; 50kg (110 lbs) for 450 ml of donated blood
• Be in good health
• Be aged 16-65 years (for ages 16 & 17, parental consent is need)
• Systolic BP =90-160 mm Hg
• Diastolic =60-100 mm Hg
• Hemoglobin at least 12.5g/dL
v Contraindications
• Diabetes
• Cancer
• Hyperthyroidism
• Cardiovascular disease
• Severe psychiatric disorder
• Epilepsy/convulsions
• Severe bronchitis
• AIDS/ Syphilis and other STI (past & present)
• Malaria
• Kidney and Liver disease
• Prolonged bleeding
• Use of prohibited drugs
v Blood extracted for Donation

• Whole blood and red cell concentrates
ü Shelf-life to 5 weeks
• Plasma
ü Can be stored frozen for 12 months
• Considerations after blood donation:
ü Leave the adhesive dressing on your arm for at least 3 hours but not more than twelve (12) hours.
ü Bruising or discoloration may occur and will disappear in a few days
ü Avoid carrying heavy objects with your donating arm
ü Do not smoke for the next 2 hours
ü Avoid alcohol intake for the next 12 hours
ü Eat regular meals and increase fluid intake following your donation

BOTIKA NG BARANGAY
Goal: To promote equity in health by ensuring the availability and accessibility of affordable safe and effective quality
essential drugs to all, with priority for marginalized, underserved, critical and hard to reach areas.
v Objective:
• To rationalize the distribution of common drugs and medicines among intended beneficiaries
• To serve as mechanism for the DOH to establish partnership with Local Government Units (LGUs)
• To optimize involvement of the Barangay Health Workers addressing the health need of the community
v Criteria for Establishing a Botika ng Barangay

• Managed or operated by an established community organization or cooperative which is duly recognized as a
judicial body
• Service or coverage area a barangay that is far flung, depressed, and hard to reach area as defined in the
Magna Carta for public Health Workers implementing Rules and Regulations
• Community-sourced funds at least 1/3 of the initial capital requirements
• Local government unit/other government officials-sourced funds at least 1/3 of the initial capital requirement
• Submission of a barangay socio-economic profile and health profile including a master list of indigents, if
available
• Commitment form a licensed pharmacist to supervise Botika ng Barangay operations
• Identification and selection of at least 2 accredited Barangay Health Workers or Community Volunteer Health
workers trained as botika ng barangay Aides
• Availability of a botika ng barangay space
COMMUNITY ORGANIZING PARTICIPATORY ACTION RESEARCH (COPAR)

DEFINITION
v The strategy used by the health Resource Development Program (HRDP) III in implementing primary health care
delivery in depressed and undeserved communities for them to become self-reliant
v It is collective, participatory, transformative, liberate, sustained & systematic process of building people’s
organizations by mobilizing and enhancing the capabilities and resources of the people for the resolution of their
issues and concerns towards effecting change in their existing oppressive and exploitative conditions (National Rural
CO conference, 1994)
v Importance:
• Tool for community development & people empowerment
• Prepares people/clients to eventually take over the management of a development programs in the future
• Maximizes community participation and involvement
PRINCIPLES
People, especially the most oppressed, exploited and deprived sectors are open to change, have the capacity to
change, and are able to bring about change
Based on the interests of the poorest sectors of society
Should lead to self-reliant community and society
v Process/Methods used in COPAR

• Progressive Cycle of Action Reflection Action
ü Begins with small, local and concrete issues identified by the people and the evaluation and reflection of and
on the action taken by them
• Consciousness Raising
ü Emphasis on learning that emerges from concrete action and which enriches succeeding action
• COPAR is participatory and mass-based
ü Primarily towards and biased in favor of the poor, the powerless and the oppressed
• COPAR is group-oriented not leader-oriented
ü Leaders are identified, emerge and are tested through action
ü Rather than appointed or selected by some external force or entity

COMMUNITY ORGANIZING
v Continuous and sustained process of educating the people let them understand and develop their critical awareness
of the existing conditons
Objectives
• To make the people aware of social realities towards the development of local initiative, optimal use of human,
technical and material resources
• To form structures that uphold the people’s basic interests as oppressed and deprived sections of the community
and as people bound by the interest to serve the people
• To initiate responsible actions intended to address holistically the various community health and social problems
Emphasis
• Members of the community work to solve their own problems
• Direction is internal rather than external
• Development of the capacity to establish a project is more important than the project
• There is consciousness-raising with regard to the situation of health care delivery within the total structure of
society.
COPAR PROCESS
1. Pre – Entry Phase
• Done before going to the community
• Activities
ü Community consultations/dialogues related to site selection
ü Setting of issues/considerations related to site selection
Ø Development of criteria for site selection
Ø Socio-economically depressed and underserved community with majority of the population belonging to
the poor sector
Ø Health services are inaccessible
Ø Community is in poor health status
Ø The area must have relative peace and order
Ø Acceptance of the program by the community
ü Site selection
ü Preliminary Social Investigation (PSI)
Ø Use of secondary data from various government offices, particularly the Provincial Health Office and / or
RHU
Ø Use of secondary data from other community based health programs
Ø Coordination with extension workers form both GO and NGO
Ø Conduct ocular observations, noting the accessibility, geography , terrain, settlement patterns and
available physical resources
ü Networking with local government units (LGUs) NGO and other departments
2. Entry phase
• Integration with community residents
• Deepening Social Investigation
• Information Dissemination
• Core Group (CG) Formation
ü Development of criteria for the selection of CG members
Ø Respected member of the community
Ø Belongs to the poor sector of society
Ø Must be responsible, committed and willing to work for social change and social transformation
Ø Must be willing to learn
Ø Must be able to communicate; can express oneself in a group
ü Defining the roles/functions/tasks of the CG
• Delivery of basic health services
• Coordination/dialogue/consultation with other community organizations
• Self-Awareness and Leadership Training (SALT)
ü This will help each one discover his/her potentials and talents and discover opportunities for growth and
development of the entire community
3. Community Study/Diagnosis phase/Research phase

• Selection of the research team
• Training on data collection methods and techniques
• Planning for the actual data gathering
• Data Gathering
• Community Validation
• Presentation of Community Diagnosis and recommendation
• Prioritization of Community Needs/Problems for action
4. Community Organization & Capacity Building Phase

• Community Meetings
• Election and induction of CHO officers
• Development of management systems and procedures
• Team building Activities /Action-Reflection- Action Session (ARAS)
• Organization of the Working Committees
• Training of CHO officers/ Community Leaders
5. Community Action Phase

• Organization and training of Community Health Workers (CHW)
ü Development of criteria for the selection of CHWs
ü Selection of CHWs
ü Training of CHWs
• Setting up linkages, networks, and referral systems
• Project implementation, Monitoring, and Evaluation (PIME) of health services intervention schemes and
community development projects
• Initial identification and implementation of resource mobilization schemes
6. Sustenance & Strengthening Phase

• Formulation and ratification of constitution and by-laws
• Identification and development of secondary leaders
• Formalizing and institutionalizing of linkages, networks, and referral system
• Setting up and institutionalizing financing scheme for the community health program/activities
• Development and implementation of viable committees, management system and procedures
• Continuing Education of community leaders, CHWs and CHO members and community residents
• Develop medium and long-term community and development plans
10 CRITICAL ACTIVITIES IN COPAR

1. Integration
• Establishing rapport with the people in a continuing effort to imbibe community life and undergoing the same
experience as the people and sharing their hopes, aspirations and hardships towards building mutual trust
and cooperation
2. Social Invertigation
• Process of systematically learning and analyzing the various structures and forces in the community
• Objectives
ü Gather data on the geographic, economic, political and socio-cultural situation of the community
ü Identify the classes and sectors present in the community
ü Determine the correct approach and method of organizing
ü Provide a basis of planning and programming of organizing activities
3. Planning
• Process of formulating specific activities to attain the goals of meeting community needs solving community
problems
4. Ground Working
• Also termed as Agitation
• This entails going around and motivating people on a one-to-one basis to do something about community
issues.
5. Community Meeting
• Ratification of what has been already decided
• The meeting gives a sense of collective power and confidence
6. Role play
• This is means of acting out the meeting or the activity that will take place between the people and the group
targeted by the mobilization
7. Social Mobilization
• This refers to the activities undertaken by the community through the people’s organization to solve problems
confronting the community
8. Evaluation
• The process of discovering by the people the way something has been accomplished, what has been left out
and what remains to be done.
9. Reflection
• Analyzing the finished mass action, its good and weak points identified
10. Organization
• This facilitates wider participation and collective action on community problems
PARTICIPATORY ACTION RESEARCH

ü Active process where the expected beneficiaries of research are the main actors in the entire research process
ü It is combination of education, research and action
ü Purpose is the empowerment of the people
v Characteristics of Traditional and Participatory Action Research

TRADITIONAL PARTICIPATORY
Research has the purpose of identifying and meeting Research seeks social transformation
individual needs within existing social system
Community problems or needs are defined by experts Research problems are defined by the community members
or researchers external to the community group and themselves who are viewed as experts of their own reality
considered neutral or non-biased
Research problem is studied by the researchers who Community group undertakes the investigation on research
control the research process process from data collection to analysis. External researcher
work alongside the community group
Recommendations for the community are based on Community formulates recommendations and an action plan
researcher’s findings and analysis based on research outcome

PHARMACOLOGY
TERMS AND DEFINITION
Pharmacology
v It is the study of drugs, their origin, nature, properties and their effects upon living organism
Pharmacotherapy
v It is the use of drugs to prevent, diagnose, or treat signs, symptoms and disease process.
Pharmacodynamics
v What the drug does to the body
v Involves drug actions on target cells and the resulting alterations in cellular biochemical reactions and functions
Pharmacokinetics
v What the body does to the drug
v Involves drug movement through the body to reach sites of action, metabolism and excretion.
PROCESS OF DRUG TRANSPORT (ADME)

1. Absorption
v Occurs from the time a drug enters the body to the time it enters the bloodstream to be circulated.
Factors Influencing Drug Absorption
Dosage form
Route of administration
Blood flow
GI function
Presence of food or other drugs
2. Distribution
v Transport of drug molecules within the body.
3. Metabolism
v Also known as Biotransformation
v Method by which drugs are inactivated by the body.
4. Excretion
v Refers to the elimination of a drug from the body
v Kidneys, bowel, lungs and skin
v Enterohepatic recirculation
THERAPEUTIC INDEX
Side effects
v Physiologic effects not related to desired drug effects
v Expected and normal
Adverse reactions
v Any undesired responses to drug administration
v More severe than side effects
v Abnormal and reportable
Toxic effects
v Life-threatening effects, emergency
v Result from excessive amounts of drug and
may cause reversible/irreversible damage to body tissues
NURSING RESPONSIBILITIES IN MEDICATION ADMINISTRATION
OBSERVE THE TEN RIGHTS OF MEDICATION

Right route Right to refuse
Right time & frequency Right drug-drug interaction
Right of the patient Right education and information
Right drug Right history and assessment
Right dose Right documentation

Be familiar with the medication
v The reason it is being administered
v Desired effect, side effects and adverse effects
v Typical dose and range of safety, if applicable
v Specific safety regulations before administration
v Check the compatibility of the medication with the other drugs and infusions the patient is receiving.
v Do not administer any medication that you did not prepare.
Assess the patient
v Food or drug allergies
v Past medical history and present condition
v Knowledge deficit and health teaching needed
Evaluate Responses
v Evaluate patient for his or her response to the medication, and document if appropriate
v Report any unfavorable or unexpected response
ALLERGIC RESPONSES
Difficulty of breathing
Rashes /pruritus
Nausea / vomiting
Wheezing
Palpitations
TESTING & CLINICAL TRIALS OF DRUGS

v Testing process begins with animal studies. Next step involves Food & Drug Administration (FDA) to review
the data obtained in animal studies.
PHASE I Determine safe dosage, scheduling, and toxicity.
PHASE II Determine effectiveness with specific diseases.
PHASE III Establish if new drug is more effective than the standard drug.
PHASE IV Drug marketed for general use.
Continuous monitoring and further testing of drug
Nursing Considerations in Drug Administration

v Generally, the client should not take an antacid with medication or with milk because the antacid will affect the
absorption of the drug.
v Enteric-coated and sustained-release tablets should not be opened.
v Capsules should not be opened.
v Never adjust or change medication dose or abruptly stop taking the medication without physician’s order.
v Avoid taking any OTC (over-the-counter drug) or any other herbal reparations unless they are approved.
v Avoid smoking and drinking alcoholic beverages while taking specific drug.
v Never administer medication if the order is difficult to read or the dose is not within therapeutic range.
Hepatotoxic drugs Acetaminophen Ototoxic drugs Aminoglycosides

Erythromycin Aspirin
Iron overdose Chloroquine
Isoniazid Loop diuretics
Rifampicin Drug that can be Macrodantin
Sulfonamides cause staining Iron
Nephrotoxic drugs Acetaminophen Lugol’s solution
Acyclovir Tetracycline
Aminoglycosides Teratogenic Fluoroquinolones
Amphotericin B Aminoglycosides
Ciprofloxacin Tetracycline
Rifampicin Ace inhibitor
Sulfonamides Lithium
Tetracycline Oral hypoglycemic
Contrast medium Agents
Disulfiram reaction Metronidazole
Cephalosporins
Oral hypoglycemic Agents
AUTONOMIC NERVOUS SYSTEM (ANS) AGENTS
ORGAN SYMPA PARASYMPA

Eye Mydriasis Miosis
Bronchioles Bronchodilate Bronchoconstrict
Heart Inc. HR Dec HR
Blood vessel Vasoconstriction Vasodilation
GI tract Dec. Peristalsis Inc. Peristalsis
Urinary Bladder Bladder Relaxation Bladder Contraction
Contracts Sphincter to Prevent Urination Relaxes Sphincter to Permit Urination
Sweat glands Inc. Secretion None
Salivary glands Dec. Secretion Inc. Secretion
Adrenal glands Inc. Secretion of Epinephrine & None
Norepinephrine
SYMPATHETIC NERVOUS SYSTEM

v Also termed as adrenergic thoracolumbar system
v Fight or flight system
v Responsible for preparing the body to respond to stress
v Epinephrine and norepinephrine are the major neurotransmitters
Adrenergic receptor organ cells
v Alpha 1
• Found in the blood vessels, iris and urinary bladder
v Alpha 2
• Found on nerve membranes and act as modulator of NE release
v Beta 1
• Cardiac tissue
v Beta 2
• Bronchi, smooth muscles in the blood vessels, uterine muscles
Drug that mimic the effect of the norepinephrine
v Sympathomimetics
v Adrenergic agonists
Drug that block the effect of norepinephrine
v Sympatholytics
v Adrenergic Antagonist
PARASYMPATHETIC NERVOUS SYSTEM

v Also termed as cholinergic/ craniosacral system
v Acetylcholine is the major neurotransmitter
Drugs that mimic acetylcholine
v Parasympathomimetics
v Cholinergic agonists
drugs that block acetylcholine
v Parasympatholytics
v Cholinergic anatagonists
COMPARISON BETWEEN SYMPATHETIC AND PARASYMPATHETIC RESPONSES
SYMPATETIC PARASYMPA RESPONSE

Sympathomimetic Parasympathomimetic Opposite
Sympatholytic Parasympatholytic Opposite

Sympathomimetic Parasympatholytic Similar
Sympatholytic Parasympathomimetic Similar
Adrenergic Drugs
v Epinephrine
• Used in emergencies
• Treats Allergic reaction, anaphylaxis, bronchospasm & cardiac arrest
• Potent inotropic drug
v Norepinephrine
• Potent vasoconstrictor that increases BP and cardiac output
v Albuterol
• Selective for beta-2 adrenergic receptors
• Response: bronchodilation
• Used to treat bronchospasm, asthma: bronchitis
• Should not be given with MAOI (can cause hypertensive crisis)
v Isoproterenol
• Acts on B1 & B2 receptors
• Response: bronchodilation
v Ephedrine
• Used to treat hypotensive state, bronchospasm
• Relief of hay fever, sinusitis and allergic rhinitis
v Clonidine
• Selective Alpha 2 adrenergic drug
• Used to treat hypertension
v Dopamine
• Drug of choice for shock
v Dobutamine
• Used in treatment of CHF as it increased contractility without changes in rate or increase in O2 demand
Adrenergic Drugs Nursing Responsibilities

v Record baseline VS
v Assess other drugs' that the client is taking to avoid drug-to-drug interaction
v Check urinary output and assess for bladder distention
v Phentolamine mesylate = antidote for NE and dopamine overdose
Adrenergic Blockers
v Inhibit or block stimulation of the sympathetic nervous system
1. Alpha Adrenergic Blockers
v Drugs that block or inhibit a response at the alpha-adrenergic receptor sites
Non-selective Alpha Blockers (Al, A2)

v Phentolamine
Selective Alpha Blockers (A1)

v Doxazosin
v Prazosin
2.Beta-adrenergic Blockers
Non-selective Beta-adrenergic Blockers
v Propranolol
v Nadolol
v Timolol
Caution when giving Non-selective Beta-Adrenergic Blockers:
v COPD
v Bronchial Asthma
v DM

Undesirable effects
v Bradycardia
v Bronchospasm
v Peripheral vascular constriction
v Exhaustion
v Emotional Depression
v Decrease libido
Selective Beta-1 Blockers
v Metoprolol
v Atenolol
v Acebutolol
v Betaxolol
v Esmolol
Cholinergic Agonists
v Drugs that stimulate the parasympathetic nervous system
2 Type of Cholinergic Receptors
v Muscarinic Receptors
• Stimulate smooth muscles & slows heart rate
v Nicotinic Receptors
• Skeletal muscles
Direct -acting Cholinergic Agonist
v Bethanechol (Urecholine)
• Used to treat urinary retention and abdominal distention
v Metoclopramide (Plasil)
• Used to treat GERD
• Increased gastric emptying time
v Pilocarpine
• Constricts the pupil of the eye
• Treatment of glaucoma
SIGNS OF OVERDOSE
• Salivations
• Sweating
• Abdominal cramps
ATROPINE SULFATE = antidote for cholinergic overdose
Indirect - acting Cholinergic Agonists
v Reversible Cholinesterase
• Physostigmine
• Neostigmine
• Pyridostigmine
v Irreversible Cholinesterase
• Potent agents
• Has long-lasting effect
• PRALIDOXIME = antidote for irreversible acetylcholinesterase-inhibiting drugs
Drug Effects of Cholinergic Agents "SLUDGE"
S - alivation
L - acrimation
U - rinary incontinence
D - iarrhea
G - astrointestinal cramps
E – mesis
Anti-Cholinergic Drugs
v Drugs that inhibit the action of acetylcholine by occupying the receptors
Examples
v Atropine
• May be used as an antidote for muscarinic agonist poisoning
v Scopolamine
v Propantheline bromide
v Dicyclomine
v Tropicamide
NEUROLOGIC DRUGS
1. ANTI-CONVULSANTS
v Modify bioelectric activity at subcortical and cortical areas
Examples
• Diazepam (Valium)
• Phenytoin (Dilantin)
• Phenobarbital (Luminal)
Indication: Prevents seizures
Adverse Effects
• Blood dyscrasias
• Nausea and vomiting (N/V)
• Dizziness/Drowsiness
• Phenytoin: ataxia, hirsutism, hypotension
• Give medication with food
• Phenytoin
ü Monitor condition of oral mucosa (S/E: gingival hyperplasia)
ü Don't mix with other IV fluids
ü Monitor blood laboratory results
Health Teaching
• Avoid alcohol
• Notify physician of unusual symptoms
• Carry medical alert information
• Take medication on schedule
• Avoid driving and other potentially hazardous machinery
• Phenytoin: good oral hygiene, frequent dental visits
2. ANTI-PARKINSON AGENTS
Dopaminergics
v Levodopa
• Most effective drug for symptoms of Parkinson's disease
Fact: dopamine cannot cross blood brain barrier
• 1% of administered dopamine dose reaches the brain
• Must be given in large doses
Carbidopa
• Inhibits the enzyme dopa decarboxylase
v Levodopa + Carbidopa
• Levodopa is converted to dopamine by the enzyme dopa decarboxylase.
• This enzyme is present in the peripheral nervous system
• Because of its presence, 99% of the levodopa drug is converted into dopamine before it reaches the brain.
PRECAUTIONS IN ANTI-PARKINSONIAN DRUGS
Anticholinergics Dry mouth
Urinary retention
Constipation Blurred vision Tachycardia Glaucoma
COPD
Levodopa Nausea
Vomiting
Dyskinesia
Orthostatic hypotension
Selegiline Insomnia
Meperidine (drug-to-drug interaction)

3. ACETYLCHOLINESTERASE INHIBITORS
• Prevent breakdown of acetylcholine at nerve endings
• Facilitate transmission of impulses across myoneural junction
• Strengthen muscle contractions including respiratory muscles
Drugs
• Edrophonium chloride (diagnostic purposes)
• Pyridostigmine
• Neostigmine bromide
• Ambenonium
Indication: Treat MYASTHENIA GRAVIS
Adverse Effects:
• N/V
• Diarrhea
• Hypersalivation
• CNS disturbances
• Toxicity: Pulmonary edema, respiratory failure, bronchospasm
Contraindications:
• Intestinal obstruction
• Renal obstruction
• Peritonitis
• Keep Atropine sulfate available for overdosage (cholinergic crisis)
• Monitor V/S during period of dosage adjustment
• Administer medication with some food (S/E: gastric upset)
• Administer medication 30 minutes to 1 hour before meals.
• Health Teaching
ü Wear medic alert jewelry and ID
ü Change position cautiously
4. ANTIDEPRESSANTS
v Increase norepinephrine levels at subcortical neuroeffector sites
Drugs
v Tricyclic Antidepressants (TCA)
• Amitriptyline (Elavil)
• Imipramine (Tofranil)
• Amoxapine (Asendin)
• Nortriptyline (Aventyl)
v Selective Serotonin Reuptake Inhibitors (SSRI)

• Fluoxetine (Prozac)
• Sertraline (Zoloft)
• Fluvoxamine (Luvox)
• Paroxetine (Paxil)
v Monoamine Oxidase Inhibitors (MAOI)

• Tranylcypromine (Parnate)
• Isocarboxazid (Marplan)
• Phenelzine sulfate (Nardil)
Use: Treat depression
Adverse Effects
TCA
• Orthostatic hypotension
• Drowsiness
• Dizziness
• Confusion
• CNS stimulation
SSRI
• May interact with tryptophan
• Insomnia
• Headache
• Sexual dysfunction
• Gastric irritation
MAOI
• Potentiate alcohol, barbiturates, and antihistamines
• Hypertensive crisis with ingestion of foods high in tyramine (beer, wine, chocolate)
• Maintain suicide precautions especially as depression lifts.
• Give SSRI in morning, TCAs at bedtime.
• Health Teachings:
ü Do not take OTC medications without physician's approval
ü Avoid hazardous activities
ü Effect of medication may take up to 2 to 4 weeks
ü SSRIs and MAOls should not be given concurrently or close together
ü MAOI: Avoid food containing tyramine
o Give Phentolamine in case of hypertensive crisis.
5. ANTI-MANIC AGENTS/ MOOD STABILIZERS

v Reduce adrenergic neurotransmitter level in cerebral tissue
Drugs
• Lithium carbonate
• Carbamazepine
• Clonazepam
Use: Control of manic phase of mood disorders; bipolar disorder
Adverse Effects
• Metallic taste
• Hand tremors
• Excess voiding & extreme thirst
• Slurred speech
• Disorientation
• Cogwheel rigidity
• Renal failure
• Respiratory depression
• Monitor blood levels regularly (Normal Lithium: 0.5-1.5 mEq/L).
• Avoid concurrent administration of adrenergic drugs.
• Evaluate client's response to medication.
• Health Teaching:
ü Effect of medication may take several weeks
ü High intake of fluids and normal sodium
ü Toxicity signs: nausea, vomiting, diarrhea, weak muscles, confusion
ü Take medication with meals.
6. ANTI-PSYCHOTICS/NEUROLEPTICS
v Block Dopamine receptors in the CNS and sympathetic nervous system.
Drugs
Typical
• Chlorpromazine (Thorazine)
• Haloperidol (Haldol)
• Thioridazine (Mellaril)
• Fluphenazine (Prolixin)

Atypical (CROQZ)
• Clozapine (Clozaril)
• Risperidone (Risperdal)
• Olanzapine (Zyprexa)
• Quetiapine (Seroquel)
• Ziprasidone (Geodon)
Use: Treatment of psychotic symptoms in schizophrenia, psychosis, Tourette's syndrome
Adverse effects
• Excessive sedation
• Jaundice
• Urinary retention
• Anorexia
• Dry mouth
• Extrapyramidal side effects (EPS)
o Acute dystonia
o Pseudoparkinsonism
o Akathisia
o Tardive dyskinesia
• Assess client's response to therapy
• Monitor for signs of infection, liver toxicity, extrapyramidal symptoms
• Monitor V/S
• Give medication at bedtime
• Health Teaching
ü Avoid alcohol use
ü Avoid driving or other hazardous activities
ü Avoid exposure to direct sunlight
ü Good oral hygiene
ü Report extrapyramidal symptoms or signs of infection
7. HYPNOTICS/SEDATIVES
v Depress CNS
Drugs
• Pentobarbital
• Phenobarbital
• SecobarbitaI
Use: INSOMNIA / SEDATION
ADVERSE REACTIONS
ADVERSE REACTIONS
Hypertension
Pulmonary constriction
Cold and clammy skin
BARBITURATE
Cyanosis of lips
TOXICITY
Insomnia
Hallucination
Delirium
Contraindications
• Hypersensitivity
• Pregnancy

• Monitor client's response to medication
• Health Teaching
ü Take medication exactly as prescribed.
ü Avoid alcohol.
ü Avoid driving and other hazardous activities.
8. ANTI-ANXIETY/ANXIOLYTICS
Drugs
Benzodiazepines
• Alprazolam (Xanax)
• Chlordiazepoxide (Librium)
Azapirone
• Buspirone (Buspar)
Uses:
• Anxiety
• Sleep disorders
ADVERSE REACTIONS
Dizziness
Drowsiness
Lethargy
Orthostatic hypertension
Skin rash
Blood Dyscrasias
Contraindications
• Acute narrow glaucoma
• Liver disease
• Notify health care provider if systolic BP drops 20 mmHg.
• Administer with food or milk.
• Health Teaching
ü Do not take OTC medication without health care provider's approval.
ü Use caution when driving or hazardous.
ü Action potentiated with alcohol or sedatives.
ü Never abruptly stop the medication.
ü Librium = Avoid excessive sunlight
9. GENERAL ANESTHETICS
v Depress the CNS through a progressive sequence
Drugs
v Inhalation Anesthetics
• Cyclopropane
• Enflurane
• Ether
• Nitrous oxide
v IV Barbiturates
• Thiopental (Pentothal)
• Methohexital sodium (Brevital)
v IV & IM Non-barbiturates
• Midazolam (Versed)
• Ketamine (Ketaject)
• Propofol (Diprivan)
ADVERSE REACTIONS
Excitement
Inhalation Anesthetics Restlessness
Nausea
Vomiting
Respiratory distress
Respiratory distress
IV barbiturates Hypotension
Tachycardia
Laryngospasm
Respiratory failure
IV & IM Non-barbiturates Hyper/hypotension Rigidity
Psychiatric disturbance
Contraindications
• CVA
• Increased ICP
• Cardiac decompensation
• Have O2 and emergency treatment available
• Monitor V/S
• Use precautions if agent is flammable
• Safety precautions
10. LOCAL ANESTHETICS

v Decrease nerve membrane permeability to sodium ion influx
Drugs
v Topical
• Benzocaine (Orajel)
• Cocaine
• Lidocaine (Xylocaine)
v Spinal
• Dibucaine (Nupercaine)
• Procaine (Novocaine)
v Nerve block
• Bupivacaine (Marcaine)
• Mepivacaine (Carbocaine)
Use: PAIN CONTROL while the client is conscious
Adverse Effects
• Allergic reactions
• Respiratory arrest
• Arrhythmias / Cardiac arrest
• Convulsion
• Hypotension
• Have oxygen and emergency equipment available
• Monitor V/S during local anesthesia
• SPINAL ANESTHESIA: keep the client flat for 6-12 hours to prevent spinal headache.

MUSCULOSKELETAL DRUGS
1. SKELETAL MUSCLE RELAXANTS
Uses
• Relax muscles
• Treat spasm disorders
Drugs
v Central
• Cyclobenzaprine (Flexeril)
• Orphenadrine (Norflex)
v Peripheral
• Gallamine triethiodide (Flaxedil)
• Succinylcholine (Anectine)
CENTRAL PERIPHERAL
Use Relief of muscle spam and pain Facilitation of endotracheal intubation;
orthopedic manipulation
Action Depress CNS, leading to relaxation of Block nerve impulses at the myoneuraI
voluntary muscles junction
Adverse effects Tachycardia Dizziness Drowsiness Hypotension
Dry mouth Angioedema Respiratory depression
Dysrhythmias
Nursing Monitor client for safety precautions Have resuscitation equipment available
Interventions Teach client to avoid alcohol and hazardous Monitor VS
activities Withhold medication and call care provider if
Administer with meals client shows signs of allergic reaction.
Fluids for dry mouth
Do not discontinue abruptly
2. NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs)

v Interfere with prostaglandin synthesis
Drugs
COX-1 Inhibitors
v Ibuprofen (Motrin)
v Indomethacin (Indocin)
v Salicylates (Aspirin)
COX-2 Inhibitors
v Celecoxib (Celebrex)
v Valdecoxib (Bextra)
Uses
v Rheumatoid arthritis
v Osteoarthritis
v Dysmenorrhea
Adverse Effects
COX-1 Inhibitors:
v Gastric disturbances
v Skin rash
v Blood dyscrasias/bleeding
v CNS disturbances
v Nephrotoxicity
COX-2 Inhibitors:
v CNS disturbances
v Nephrotoxicity
v Myocardial infarction
v Stroke
Contraindications
v Hypersensitivity
v Asthma
v Renal disease
v Liver disease
v Administer one hour before or two hours after meals.
v Monitor VS.
v Monitor response to medication.
3. ANTI-GOUT AGENTS
v Increase excretion of uric acid and decrease uric acid formation
Drugs
• Allopurinol (Zyloprim)
• Colchicine (Novocolchine)
• Probenecid (Benemid)
Use: Prevents GOUT ATTACKS
Adverse Effects
• N/V
• Indigestion
• Liver damage
• Skin rash
• GI disturbances
• Increase OH to prevent renal calculi
• Monitor I & O
• Administer with meals
• Monitor blood work, including serum uric levels, and electrolyte levels
• Health Teaching
ü Lose weight if needed.
ü Avoid high purine foods (organ meats, sardines, shellfish, etc.).
ü Avoid fermented beverages such as beer, ale, wine.
GASTROINTESTINAL DRUGS
1.ANTI-EMETICS
v Prevent expulsion of stomach contents by decreasing stimulation of either the chemoreceptor trigger zone, near
the medulla, or the vomiting center in the medulla
DRUGS
Antihistamines Dramamine
Phenergan
Anticholinergic Scopolamine
Phenothiazines Thorazine
Serotonin receptor antagonist Granisetron Ondansetron
Use: Prevent NAUSEA & VOMITING

Adverse Reactions
• Tachycardia
• Hypotension
• Dry mouth and eyes
• Blurred vision
• Constipation
• Sedation
• Drowsiness
Contraindications
• Narrow-angle Glaucoma
• Liver disease
• Intestinal obstruction
• Depression

• Use non-pharmacologic measures first
ü Dry toast
ü Tea
ü Crackers
ü Monitor VS
• Monitor for signs and symptoms of vomiting is severe.
• Monitor bowel sounds.
• Provide mouth care after vomiting.
• Health Teaching
ü Store drug in tight, light-resistant container.
ü Avoid OTC drugs.
ü Avoid alcohol.
ü Avoid during 1st trimester of pregnancy.
2. ANTACIDS
v Neutralize gastric acid
Drugs
• Aluminum hydroxide (AlOH) gel (Amphogel)
• Magnesium hydroxine (MgOH) (Milk of Magnesia
• AlOH + MgOH (Maalox/Magaldrate)
Uses: Peptic ulcers, reflux esophagitis, hiatal hernia
Adverse Reactions
• Aluminum compounds = constipation, intestinal obstruction
• Magnesium compounds = diarrhea
• Reduced absorption of Ca & Fe Nursing Interventions
• Shake oral suspension well
• Monitor client's response to treatment
• Administer with 8 oz glass of water
• Health Teaching
ü Avoid overuse of antacid
ü Dietary restrictions for ulcers
ü Diet: High in Ca & Fe
ü For clients on low sodium diet
3. ANTI-PEPTIC ULCER DISEASE (PUD)

v Decrease acetylcholine release
v Block release of histamines
v Inhibit secretion of pepsin
v Inhibit proton pump
Drugs
v Proton-pump Inhibitor (PPI)
• Omeprazole (Prilosec)
• Lansoprazole (Prevacid)
v H2-receptor Blockers
• Cimetidine (Tagamet)
• Ranitidine (Zantac)
• Famotidine (Pepcid)
v Cytoprotective agent
• Sucralfate (Carafate)
• Misoprostol (Cytotec)
v Anti-cholinergics
• Chlordiazepoxide (Librax)
• Atropine sulfate
Uses: Management of peptic ulcer disease, GERD; protects gastric mucosa from hydrochloric acid production
Adverse Reactions
• Dry mouth
• Decreased secretions
• Constipation
• Tachycardia
• Urinary retention
• Headache
• Dizziness
• Constipation
• Pruritus
• Impotence
Contraindications
• Anti-cholinergics (narrow-angle glaucoma)
• Renal failure
• Liver disease
• Administer on an empty stomach
• Avoid antacids within 30 minutes of sucralfate
• Avoid antacids within one to two hours of other anti-ulcer drugs
• Administer other drugs one to two hours after sucralfate
• Health Teaching
ü Avoid alcohol, spicy food and caffeinated beverages.
ü Eliminate smoking.
ü Increase fluid intake.
ü Medication can take up to two weeks for full effect.
4. ANTI-DIARRHEAL
v Forms the stool
Use: Treatment of diarrhea
Drugs
v Fluid absorbents (Decrease fluid content)
• Kaolin and Pectin
v Motility Suppressants (Decrease GI motility)
• Diphenoxylate hydrochloride (Lomotil)
• Loperamide hydrochloride (Imodium)
v Enteric bacterium replacements
• Lactobacillus acidophilus (Bacid)
ADVERSE REACTIONS
Fluid absorbents Gastric disturbances CNS toxicity
Enteric bacterium Excessive flatulence abdominal cramps

replacements
Motility Urinary retention
suppressants Tachycardia Sedations
Paralytic ileus
Respiratory depression

Contraindications
• Ulcerative colitis
• Monitor the effect of medication
• Assess for fluid and electrolyte imbalance
• Assess for cause of diarrhea
• Motility suppressants may cause physical dependence, may impair ability to perform hazardous activities
5. LAXATIVES
v Agents which facilitate defecation, and treat constipation
v Increase bulk within the bowel
v Lubricate the intestinal walls
v Increase peristalsis
Drugs
• Mineral oil
• Colace
• Metamucil
• Dulcolax
• Milk of magnesia
Use: To treat CONSTIPATION
Adverse Reactions
• Nausea
• Cramping
• Diarrhea
• Dependence with long-term use
• Intestinal lubricants inhibit absorption of fat-soluble vitamins
• Saline cathartics: dehydration, hypernatremia
Contraindications
• GI obstruction
• Suspected appendicitis
• Abdominal pain
•
• Monitor effects of medication
• Health Teaching
ü Dietary considerations (Inc. fiber and fluid intake)
ü Maintain/increase activity level
ü Caution regarding overuse of laxatives
CARDIO DRUGS
1. CARDIAC GLYCOSIDES
v Make heart beat slower but stronger
v Improve pumping ability of heart
v Increase force of heart's contraction
v Decrease rate of contraction
v Increases cardiac output
Drugs
• Digoxin (Lanoxin)
• Digitoxin (Crystodigin)
ü (+) inotropic (Increased heart contractility)
ü (-) chronotropic (Decreased heart rate)
Uses
• Congestive Heart Failure
• Atrial flutter
• Atrial fibrillation
Contraindications
• Ventricular tachycardia
• Ventricular fibrillation
• Second and third degree heart block
Adverse Effects
• Vision changes: yellow-green halos
• N/V
• Diarrhea
• Anorexia
• Bradycardia
• Xanthopsia
• Muscle weakness
• Dysrhythmia
• Before giving glycosides, check apical pulse and heart rhythm. Report if <60 bpm (adult); <90 bpm (infants)
• Monitor digoxin levels for possible toxicity
(therapeutic range = 0.5 to 2.0 mg/mL)
• Antidote: DIGOXIN IMMUNE FAB (Digibind)
• Monitor intake and output
• Health teaching
ü Take medications as prescribed
ü Teach client how to take and record pulse daily
ü Identify and report signs of toxicity
ü Daily weights: Report two-pound increase
2. ANTI-HYPERTENSIVES
v Dilate peripheral blood vessels
v Prevent hypertension
Drugs
v Angiotensin-converting Enzyme Inhibitors (ACE-I)
• Captopril
• Enalapril
v Angiotensin II Receptor Blockers (ARBs)
• Losartan
• Telmisartan
• Irbesartan
v Calcium Channel Blockers (CCB)
• Verapamil
• Diltiazem
• Nifedipine
• Nicardipine
v Other Drugs
• Hydralazine hydrochloride (Apresoline)
• Reserpine (Serpasil)
• Prazosin hydrochloride (Minipress)
• Methyldopa (Aldomet)
• Clonidine (Catapres)
Use: Treat hypertension
Adverse Reactions
• Dizziness
• bradycardia/Tachycardia
• Deterioration in renal function
• Monitor VS and blood pressure (sitting and standing)
• Monitor for hearing changes
• Monitor renal functioning
• Closely monitor client if hypotensive
• Encourage intake of foods high in Vitamin B
• Health Teaching
ü Low sodium diet
ü Change positions slowly
ü Take medication as instructed
ü Avoid hazardous activities
ü Protect medication from heat and light
3. THROMBOLYTICS
v Binds with plasminogen to dissolve thrombi (clots) in coronary arteries
v Activates conversion of plasminogen to plasmin
v Plasmin is able to break down clots (fibrin)
Drugs
• Streptokinase (Streptase)
• Urokinase (Abbokinase)
Use
• Myocardial Infarction
• Deep vein thrombosis
• Pulmonary emboli
Contraindications
• Active bleeding
• Cerebral embolism/hemorrhage
• Recent intra-arterial diagnostic procedure or surgery
• Recent major surgery
Adverse effects
• Urticaria
• Itching
• Flushing
• Headache
• Monitor for bleeding times
• Monitor coagulation studies
• Monitor for allergic reactions
• Antidote: Aminocaproic acid (Fibrinolysis Inhibitors)
4. ANTI-LIPEMIC
v Lower LDL levels by reducing the synthesis of cholesterol and/or triglycerides
Uses
• Primary hypercholesterolemia
Drugs
HMG-CoA Reductase Inhibitors
• Atorvastatin (Lipitor)
• Simvastatin (Afordel)
Bile Acid Sequestrants
• Colestipol (Colestid)
• Cholestyramine (Questran)
Contraindications
• Pregnancy/Lactation
• Active Liver Disease
Adverse Reactions
• Skin flushing
• Gastric upset
• Reduced absorption of fat-soluble vitamins
• Disruption of liver function
• Muscle tenderness or weakness
• Monitor cholesterol levels
• Monitor liver function test
• Health Teaching
ü Blood work and eye exams will be necessary during treatment
ü Report: blurred vision, severe GI symptoms, or headache, muscle tenderness or weakness
ü Diet: low cholesterol; high-fiber
5. ANTI-ANGINALS
Nitrates
v Dilate arterioles which lowers peripheral vascular resistance (afterload)
Drugs
• Nitroglycerin
• Isosorbide dinitrate (Isordil)
• Isosorbide mononitrate
Types
v Sublingual Medications
• Offer sips of water before giving. Dryness may inhibit absorption
• Instruct to put under the tongue and leave until fully dissolved
v Translingual Medications (tongue spray)
• Instruct the client to spray directly against the oral mucosa.
• Avoid inhaling the spray.
v Transmucosal-Buccal Medications
• Instruct the client to put between the upper lip and gum or in the buccal area between the cheek and
gum.
• Medication will adhere to the mucosa and slowly dissolve
v Transdermal Patch
• Instruct the client to apply the patch over a hairless area, using a new patch and a different site each day.
• Instruct the client to remove the patch after 12-14 hours, allowing 10-12 "patch-free" hours to avoid
tolerance
v Topical Ointments
• Instruct the client to remove the ointment on the skin from the previous dose
• Avoid hairy areas. Cover with plastic wrap. Rotate sites.
•
Use: Treatment and prevention of acute chest pain caused by Myocardial Ischemia
Adverse Effects
• Postural hypotension
• Headache
• Flushing
• Dizziness
Contraindications
• Severe anemia
• Hypotension
• Hypovolemia
• Monitor for orthostatic hypotension
• Monitor for tolerance with long — term use
• Administer every 5 minutes but not more than three tablets
• If pain is not relieved after 15 minutes and

• three tablets, notify physician immediately
• Instruct client:
ü Take pulse before taking medication
ü Take oral preparations without food
ü When to seek medical attention
ü Not to chew or swallow sublingual tablets
ü Make position changes slowly
ü Carry drug so that it is always within reach but avoid exposure to body heat and light
ü Replace drug approximately every six months
ü Avoid alcohol ingestion
Beta-adrenergic blocking agents
v Inhibit sympathetic stimulation of beta-receptors in the heart

v Decrease heart rate and force of myocardial contraction thus decreasing myocardial oxygen consumption
Use
• Reduces frequency and severity of acute anginal attacks, dysrhythmias
Drugs
• Propranolol (Inderal)
• Metoprolol (Lopressor)
• Nadolol
• Timolol
• Acebutolol
• Betaxolol
• Esmolol
• Pindolol
• Penbutolol
Adverse Effects
• Hypotension
• GI disturbances
• Flushing of the skin
Contraindications
• Cardiogenic shock
• Cardiac failure
• Weigh daily. Report weight gain of 5 lbs. or greater
• Monitor ECG if using for dysrhythmia
• Administer on an empty stomach
• Protect injectable solution from light
• Instruct client
ü Take pulse before taking the drug
ü Not to discontinue the drug abrupt
ü Avoid hazardous activities if drowsiness occurs
ü Make position changes slowly
ü Take drug at same time each day
Calcium-Channel Blockers
v Prevent the movement of extracellular calcium into the cell resulting in coronary and peripheral artery dilation
v Decrease cardiac contractility
Uses
• Stable angina
• Dysrhythmias
• Hypertension
Drugs
• Verapamil
• Nifedipine
• Diltiazem
• Nicardipine
• Felodipine
Adverse Effects
• Headache
• Drowsiness
• Dizziness
• GI disturbances
• Flushing of the skin
Contraindication
• Monitor chest pain
• Monitor ECG if used for dysrhythmias
• Administer with food
• Instruct the client:
ü Increase fluids to counteract constipation
ü Take pulse before taking drug
ü Avoid hazardous activities until stabilized on drug
ü Limit caffeine consumption
ü Avoid alcohol
ü Change position slowly
6. MEDICATIONS FOR HYPOTENSION & SHOCK

v Adrenergic agonists
v Mimics the action of the sympathetic nervous system
v Increases the cardiac output, (+) inotrope, (+) chronotrope
o Inotrope: Increases cardiac contractility
o Chronotrope: Increases heart rate
o Dromotrope: Increases AV conduction
Drugs and Uses

• Dopamine & Dobutamine: hypovolemic and cardiogenic shock
• Epinephrine: anaphylactic shock
Adverse Effects
• Dysrhythmias
• Tissue necrosis (extravasation)
• Tremors
• Anxiety
• Dizziness (epinephrine)
Contraindications
• Ventricular fibrillation
• Tachydysrhythmias
• Correct hypokalemia before administering
• Monitor vital signs frequently
• Monitor ECG continuously during administration
• Administer with infusion pump
• Start drug slowly and increase according to health care provider's orders
• Monitor injection site for extravasation
• Protect solution from light
• Do not use discolored solution
• Stop the drug gradually
7. ANTICOAGULANTS
v Disrupt the blood coagulation process,
Thereby suppressing the production of fibrin
Drugs
• Heparin
• Warfarin
Uses
• Pulmonary embolism
• Deep vein thrombosis
• Myocardial infarction
Adverse Effects
• Allergic responses (chills, fever, urticarial)
• Use cautiously if client tends to bleed (hemophilia, peptic ulcer)
• N/V
• Diarrhea
• Abdominal cramps
Contraindications
• Hemophilia
• Leukemia
• Peptic ulcer
• Heparin: Monitor aPTT (activated partial thromboplastin time)
ü Therapeutic levels: aPTT increase by a factor of 1.5 to 2.5 (25 to 38 seconds)
• Parenteral (SQ) Coumadin: Monitor PT (Prothrombin time)
ü INR: 2.0 to 3.0
ü Oral
• Do baseline blood studies before therapy
• Have antidote ready:
ü Heparin: Protamine sulfate
ü Coumadin: Vitamin K
• Monitor client for symptoms of hemorrhage (INC. PR, Dec, BP)
• Avoid salicylates (Aspirin)
• Avoid IM injections
• Teach client
ü Take medication at same time every day
ü Wear medical alert jewel
ü Use of soft toothbrush
ü Report and signs of bleeding, red of black bowel movement, headaches, rashes, red or pink-tinged urine,
sputum
ü Avoid trauma

8. ANTI-DYSRHYTMICS
v Prevent abnormal heart rhythms
DRUGS
Quinidine
Class I (Sodium Channel Procainamide
Blockers) Lidocaine
Flecainide
Acebutolol
Class II (Beta Blockers) Propranolol
Esmolol
Class III (Conduction Bretylium

Delayers) Amiodarone
Verapamil
Class IV (Calcium – channel
Diltiazem
Blockers)
Nifedipine
Use: Treat abnormalities in cardiac rate and rhythm
Adverse Effects
• Hypotension
• N/V
• Diarrhea
• Monitor Cardiac Rhythm
• Monitor blood levels
• Monitor for blood dyscrasias
• Administer oral preparation with meals
• Monitor ECG
• Use infusion-control devices for IV administration
• Health teaching
ü Report changes in heart rate and/or rhythm
ü Report any side effects

RESPIRATORY DRUGS
1. BRONCHODILATORS
v Dilates air passages in the lungs, specific action dependent on type of drug
DRUGS
Albuterol/Salbutamol
Beta-adrenergic Terbutaline
Epinephrine
Aminophylline
Xanthine derivative
Theophylline
Ipratropium Bromide
Uses
• Bronchospasms
• Asthma
Adverse Effects
• Dizziness
• Tremors
• Anxiety
• Palpitations
• GI disturbances
• Headaches
• Tachycardia
• Dysrhythmia
Contraindications
Anticholinergic
• Narrow angle glaucoma
• Severe cardiac disease
Nursing Intervention
• Monitor theophylline levels
(N: 10 to 20 mcg/dL)
• Monitor I & O and VS
• Health Teaching
ü Take medication as
prescribed only
ü Report adverse effects
ü Stop smoking during
therapy
ü Take with meals
ü Avoid OTC drugs
2. MUCOLYTICS / EXPECTORANTS
Mucolytics: act by dissolving chemical bonds within the mucus, causing it to separate and liquefy, thereby reducing
viscosity
Expectorants: stimulate a gastric mucosal production of lung mucous

DRUGS
Acetylcysteine
Mucolytics
(Mucomyst)
Guaifenesin
Expectorants
(Robitussin)
Uses
• Asthma
• Acute / Chronic broncho – pulmonary disease
• Cystic fibrosis
• N-acetylcysteine: Acetaminophen toxicity
Adverse Reactions
• Oropharyngeal Irritation
• Bronchospasm
• Gastric effects
• N/V
Contraindications
• Increased intracranial pressure
• Status asthmaticus
Nursing interventions
• Monitor respiratory status
• Health Teaching
ü Take no fluids directly after oral administration
ü Increase oral fluid intake
ü Encourage coughing and deep breathing, especially before treatment
3. ANTI-TUSSIVES
v Acts on the cough control center in the medulla to suppress the cough reflex
DRUGS
Codeine
Narcotic Hydrocodone bitartrate
Non-Narcotic Dextromethorphan
Uses
• Colds
• Respiratory congestion
• Pneumonia
• Bronchitis
• Cystic Fibrosis
• Emphysema
• Cancer-induced cough
Adverse Effects
• Drowsiness
• Nausea
• Dry mouth
• Dizziness
• Constipation (codeine)
Contraindications
• Hypothyroidism
• Iodine sensitivity
• Monitor blood counts with long term therapy
• Increase fluid intake humidify client’s room
• Avoid driving and other hazardous activity especially if taking narcotic type
• Antitussives add to the effects of alcohol
4. ANTIHISTAMINES
v Blocks histamine at receptor sites
Drugs
• Promethazine HCl (Phenergan)
• Chlorpheniramine maleate
• Diphenhydramine
• Loratadine
• Cetirizine
Uses
• Relieves symptoms of allergies, colds, pruritus
• Prevents problems in blood transfusions and drug reactions
Adverse Reactions
• Drowsiness
• Gastric effects
• Dry Mouth
• Headache
• Thickening of bronchial secretion
Contraindications
• Acute Asthma
• Lower respiratory
• Narrow angle glaucoma
• Discontinue four days before skin testing for allergies
• Avoid interaction with CNS depressants
• Health Teaching
• Avoid driving and hazardous activities
• Take antihistamines with food
• Additive effects with alcohol

• Additive effect with alcohol and other CNS depressants
5. ANTI-INFLAMMATORY DRUGS
v Stabilize mast cells so chemical mediators are not released easily
v Decrease bronchial hyperactivity
v Decrease airway inflammation
DRUGS
Mast Cell Stabilizer Cromolyn Sodium
Beclomethasone
Budesonide
Corticosteroids Mometasone
Fluticasone
Triamcinolone
Leukotriene
Montelukast
Receptor
Zafirlukast
Antagonist
Immunomodulators Omalizumab
Use: Prevent asthma attacks; exercise-induced bronchospasm
Adverse Effects
• Cough
• CNS Disturbances
• Burning, stinging eyes
• Throat irritation
• Headache
Contraindicators
• Status asthmaticus
• Give bronchodilators first before steroids
• Monitor eosinophil count
• Monitor respiratory status
• Store in highly closed light-resistant container
• Health Teaching
ü How to use inhaler
ü Rinse mouth after using steroid inhaler
ü When to call health care provider if medications are not effective
ü Therapeutic effect may take up to four weeks

ENDOCRINE DRUGS
1. ANTI-DIABETIC AGENTS
v Provide insulin to promote transport of glucose
Drugs
v First-generation Sulfonylureas
• Acetohexamide
• Chlorpropamide
• Tolazamide
• Tolbutamide
v Second-generation Sulfonylureas
• Glipizide
• Glyburide
• Glimepiride
v Biguanide
• Metformin
v Alpha Glucosidase inhibitors
• Acarbose
v Thiazolidinediones
• Pioglitazone
• Rosiglitazone
v Meglitinides
• Repaglinide
• Nateglinide
Adverse Effects
• Hypoglycemia
• Irritability
• Confusion
• Convulsions
• Tachycardia
• Tremors
• Moist skin
• Headache
• Nausea
• Bloating
• Diarrhea
Contraindications
• Adrenal insufficiency
• Myocardial infarction
• Thyrotoxicosis
• Monitor client’s response to medication
• Health Teaching
ü Usually life-long therapy
ü Take medication same time each day
ü Monitor pulse rate; report pulse rate over 100
ü Report signs of toxicity (chest pain, palpitations, nervousness)
ü Wear medic alert jewelry/ID
ü Avoid OTC medication unless approved by health care provider

ü Continue medical supervision
3. ANTI-HYPERTHYROID AGENTS
v Blocks synthesis of thyroid hormone
Drugs
• Iodine (Lugol’s Solution)
• Methimazole (Tapazole)
• Propylthiouracil (PTU)
Adverse Effects
• Agranulocytosis
• Skin Disturbance
• Decreased metabolism
• Gastric disturbance
• Iodine: stains teeth, bitter taste
Contraindicators
• Administer iodine preparations through straw
• Monitor effects of medication
• Instruct the client
ü Report side effects
ü Avoid OTC drugs containing iodine
ü Carry medic alert jewelry
4. ANTERIOR PITUITARY: GROWTH HORMONE

v Stimulates the growth of practically all organs and tissues
Drugs
• Somatrem (Protropin)
• Somatropin (Humatrope)
• Sandostatin (Octreotide)
Use: Treat Dwarfism
Adverse Effects
• Hyperglycemia
• Hypothyroidism
• Interaction with glucocorticoids
Contraindicators
• Hypersensitivity to benzyl alcohol
• Closed epiphyses
• Intracranial lesions
• Monitor diabetic client closely
• Instruct client
ü Record height measurements at regular intervals

ü Report to physician if growth is less than expected
5. ANTI-DIURETIC HORMONE (ADH)

v Helps distal renal tubules reabsorb water
Drugs
• Lypressin (Diapad)
• Vasopressin (Pitressin)
Use: Treatment of Diabetes Insipidus
Adverse Effects
• Gastric disturbances
• Hyponatremia
• Water intoxication
• Cardiac disturbances
• Monitor response to therapy: I&O, blood pressure
• Assess for dehydration
GENITOURINARY DRUGS
1. DIURETICS
v Interfere with sodium reabsorption
DRUGS
Hydrochlorothiazide
THIAZIDES
Chlorothiazide
Bumetanide (Bumex)
LOOP
Furosemide (Lasix)
Mannitol
OSMOTIC
Urea
CARBONIC
Acetazolamide
ANHYDRASE
POTASSIUM Spironolactone
SPARING Triamterene
Uses: Hypertension, edema
Adverse Reaction
• GI irritation
• Dehydration
• Electrolyte imbalance: hyponatremia, hypokalemia (except for potassium-sparing)

Contraindicators
• Electrolyte imbalances
• Dehydration
• Monitor weight, intake and output, vital signs
• Give medication in morning
• Monitor client for fluid and electrolyte imbalance
• Health Teaching
ü Change positions slowly
ü Report changes in hearing
ü Diabetic clients: closely monitor glucose levels
2. SULFONAMIDES
Drugs
• Succinylsulfathiazole (Sulfasuxidine)
• Sulfisoxazole (Gantrisin)
• Trimethoprim-Sulfamethoxazole (Bactrim)
Use: Urinary tract Infection
Adverse Effects
• Gastric Irritation
• Rash
• Malaise
• Crystalluria
• Photosensitivity
• Allergic response
Contraindications
• Infants <2 months old
• Pregnancy at term
• Check if the client has history of allergies
• Monitor client’s response to treatment
• Monitor vital signs and blood work
• Health Teaching
ü Increase OFI
ü Take medication as prescribed
ü Avoid OTC medication unless approved by health care provider
ü Avoid direct sunlight
3. IMMUNOSUPPRESSANTS
Drugs
• Cyclosporine (Sandimmune)

Uses
• Prevent organ rejection in transplant patient
• Treat autoimmune disorders
Adverse Effects
• Nephrotoxicity
• Infection
• Hypertension
• Tremor
• Hirsutism
Contraindications
Nursing intervention
• Monitor BUN and creatinine (liver function test)
• Health Teaching
ü Report early signs of infection (fever, sore throat)
ü Medication may be taken with meals
ü Hirsutism is reversible when the treatment stops
4. ANTI-INFECTIVE
v Interferes with several bacterial enzyme system
Drugs
• Nitrofurantoin (Furadantin)
• Methenamine (Hiprex)
Uses
• Pyelonephritis
• Pyelitis
• Cystitis
Adverse Effects
• Anorexia
• N/V
• Methenamine (crystalluria, bladder irritation)
• Nitrofurantoin (exfoliative dermatitis, interstitial nephritis, necrosis)
Contraindications
• Anuria
• Severe renal disease
• Monitors intake and output
• Health teaching
ü Take medication as prescribed
ü Increase OFI
ü Take medication with food or milk
ü Nitrofurantoin

Ø Do not crush pill because it stains teeth: dilute oral suspension and rise mouth after taking
Ø Report muscle weakness, tingling or numbness

Ø Urine may look brown or rust yellow
Ø Avoid alcohol
OTHER DRUGS
Antibiotics
Action
• Destroy or inhibit bacteria
Drugs
v Penicillin
• Ampicillin
• Penicillin G
• Penicillin V
v Cephalosporins
• First Generation
ü Cephalexin
ü Cefadroxil
ü Cefradine
ü Cephazolin
ü Cephalothin
ü Cephapirin
• Second Generation
ü Cefaclor
ü Cefprozil
ü Cefuroxime
ü Cefamandole
ü Cefotetan
ü Cefoxitin
ü Cefmetazole
• Third Generation
ü Cefdinir
ü Cefixime
ü Cefpodoxime
ü Cefotaxime
ü Ceftazidime
ü Ceftriaxone
ü Cefoperazone
• Fourth Generation
ü Cefepime
v Macrolides
• Erythromycin
• Clarithromycin
• Azithromycin
v Tetracycline
• Oxytetracyline
• Doxycycline
• Minocycline
• Aminoglycosides

• Amikacin
• Gentamicin
• Netilmicin
• Streptomycin
• Tobramycin
• Kanamycin
• Neomycin
Use: Treat bacterial infection
Adverse Effects
• Gastric disturbance: N/V, poor appetite, diarrhea
• Allergic reactions
• Loss of water-soluble vitamins and minerals
• Tetracyclines: Hepatotoxicity, phototoxicity, hyperuricemia, tooth enamel hypoplasia, and bone defects in children
under eight years of age
• Fluroquinolones: Photosensitivity
• Aminoglycosides: Ototoxicity, leukopenia, thrombocytopenia, headache, confusion, peripheral neuropathy, optic
neuritis, nephrotoxicity
Contraindications
• Pregnancy
ü Tetracyclines
ü Fluoroquinolones
ü Aminoglycosides
• Fluoroquinolones: children < 18 years of age
• Monitor client for allergies
• Monitor client’s response to treatment
• Teach client
• Take all prescribed medication
• Symptoms of allergic response
• If taking a liquid (suspension), shake it first
• Take medication before meals
• Tetracyclines
ü Not for young children or in last half of pregnancy
ü Possible oral anticoagulant effects
• Fluoroquinolones: Avoid hazardous activities; avoid sunlight
• Aminoglycosides: may potentiate neuromuscular blocking agents, general anesthesia or magnesium effects
ANTIVIRALS
Action
• Interfere with DNA synthesis needed for viral replication
Drugs
• Acyclovir sodium
• Valacyclovir
• Amantadine
• Rimantadine
• Oseltamivir
• Foscarnet
• Vidarabine
• Ribavirin
Use:
• Viral infections
Adverse Effects
• Dizziness
• GI disturbance
• Nephrotoxicity
Contraindication
• Immunosuppression
• Monitor vital signs during antiviral therapy
• Monitor effect of therapy
• Increase fluid intake
• Monitor for signs of superinfection: sore throat, fever, fatigue
ANTIFUNGALS
Action
• Destroy fungal cells or inhibits their reproduction
Drugs
• Amphotericin B
• Nystatin
• Fluconazole
• Ketoconazole
• Miconazole
• Voriconazole
• Posaconazole
• Griseofulvin
Use
• Treat local and systemic fungal infections
Adverse Effects
• Gastric irritability: Nausea & Vomiting
• Headache
• Fever & Chills
• Paresthesia
• Renal Impairment
Contraindications
• Severe bone marrow depression
• Monitor vital signs and I & O during therapy
• Amphotericin B
ü Protect IV solutions from light

ü Monitor blood work
ü Use infusion device for IV administration
• Griseofulvin
ü Instruct the client to avoid sunlight
ANTIPARASITICS
v Interfere with parasite metabolism and reproduction
Drugs
v Anti-helminthic
• Albendazole
• Mebendazole
• Piperazine
v Amebicides
• Chloroquine
• Metronidazole (Flagyl)
v Antimalarials
• Chloroquine
• Quinine sulfate
Use
• Kill parasites, helminths and protozoa
Adverse Effects
• Anti-helminthic
ü GI upset
ü CNS disturbance
ü Skin rashes
ü Headache
• Amebicides
ü GI upset
ü Blood dyscrasias
ü Skin rash
ü CNS disturbances
• Antimalarials
ü GI upset
ü Blood dyscrasias
ü Visual disturbance
• Administer medication with food
• Monitor vital signs, blood work during therapy
• Use safety precautions if CNS disturbances manifested
• Teach client to prevent further infection
• Antimalarials: Frequent visual examinations; urine may turn rust colored

References:
National Council of State Boards of Nursing (NCSBN) Comprehensive Review Class
Smeltzer, Suzanne & Bare Brenda (2010) Brunner and Suddarth’s Textbook of Medical-Surgical Nursing (12th Edition).
Philadelphia: Lippincott Williams & Wilkins.
Huttel, Ray H. Pharmacology Success. F.A Davis Company, 2008.

COMMUNICABLE DISEASE NURSING

TERMINOLOGIES
v Infection
• Implantation and success replication of an organism in the tissue of the host resulting to signs and
symptoms as well as immunologic response.
v Carrier
• An individual who harbors the organism and is capable of transmitting it to a susceptible host without
showing manifestations of the disease.
v Communicable Disease
• It is an illness caused by an infectious agent or its toxic products that are transmitted directly or indirectly
to a well person through an agency, and a vector or an inanimate object.
v Contact
• It is any person or animal who is in close association with an infected person, animal or freshly soiled
materials.
v Contagious Disease
• It is a term given to a disease that is easily transmitted from one person to another through direct or
indirect means.
v Disinfection
• It is the destruction of pathogenic microorganism on inanimate objects by directly applying physical or
chemical means.
v Concurrent
• it is a method of disinfection done immediately after the infected individual discharges infectious
material/secretions.
• Method of disinfection when the patient is still the source of infection.
v Terminal
• It is applied when the patient is no longer the source of infection
• This is done after patient is discharged from the hospital to prepare the room for the next patient.
v Habitat
• It is a place where an organism lives or where an organism is usually found.
v Host
• It is a person, animal or plant on which a parasite depends for its survival.
v Infectious Disease
• It is transmitted not only by ordinary contact but requires direct inoculation of the organism through a
break on the skin or mucous membrane.
v Isolation
• it is the separation from other persons of an individual suffering from a communicable disease during the
period of communicability.
v Quarantine
• It is the limitation of freedom of movement of persons or animals which have been exposed to
communicable disease/s for a period of time equivalent to the longest incubation period of that disease.
v Reservoir
• It is composed of one of more species of animal or plant in which an infectious agent lives and multiplies
for survival and reproduces itself in such a manner that it can be transmitted to man.
EPIDEMIOLOGY
• It is study of occurrences and disturbance of diseases as well as the distribution and determinants of health
states of events in specified population and application of this study to the control of health problems.
• Foundation of preventing disease
Uses
• Study the history of the health population and the rise and fall of disease and changes in their character.
• Diagnose the health of the community
• Study the work of health services with a view of improving them
• Estimate the risk of disease, accident, defects and the chances of avoiding them.
• Complete the clinical picture of chronic disease and describe their history
Epidemiologic Triangle
• Consists of three components – host, environment and agent.
Host
• Any organism that harbors and provides nourishment for another organism
Agent
• Intrinsic property of microorganism to survive and multiply in the environment to produce disease.
Environment
• It is the sum total of all external conditions and influences that affect the development of an organism
which can be:
ü Biological
ü Social
ü Physical
Patterns of Occurrence and Distribution
v Sporadic
• Intermittent occurrence of a few isolated and unrelated cases in a given locality.
• Cases are few and scattered
• E.G. Rabies
v Endemic
• Continuous occurrence throughout a period of time, of the usual number of case in a given locality.
• The disease is therefore always occurring in the locality and the level of occurrence is more or less constant
through a period of time.
• Examples:
§ Schistosomiasis (Leyte & Samar)
§ Filariasis (Sorsogon)
§ Malaria (Palawan)
v Epidemic (Outbreak)
• Unusually large number of cases in a relatively short period of time.
v Pandemic
• The simultaneous occurrence of epidemic of the same disease in several countries.
• E.G. HIV/AIDS and SARS
CHAIN OF INFECTION
1. Causative Agent
v Any microbe capable of producing a disease
v Bacteria, spirochete, virus, ricketssia, chlamydiae, fungi, protozoa and parasites
2. Reservoir of Infection
v Refers to the environment and objects on which an organism survives and multiples
3. Portal of Exit
v It is the path or way in which the organism leaves the reservoir.
v Common portals of exit:
• Respiratory System
• Genitourinary Tract
• Gastrointestinal Tract
• Skin and Mucous Membrane
• Placenta
4. Mode of Transmission
v It is the means by which the infectious agent passes through from the portal of exit of the reservoir to the
susceptible host.
v Easiest link to break the chain of infection
Contact Transmission
• Most common mode of transmission.
Direct Contact
ü Refers to a person to person transfer of organism.
Indirect Contact
ü Occurs when the susceptible person comes in contact with a contaminated object.

Droplet Spread
ü It is the transmission through contact with respiratory secretions when the infected person coughs, sneezes
or talks.
ü Transmission is limited within 3 feet.
Airborne Transmission
• Occurs when fine microbial particles or dust particles containing microbes remain suspended in the air for a
prolonged period.
• Transmission can be more than 3 feet.
Vehicle Transmission
• It is the transmission of infectious disease through articles or substance that harbor the organism until it is
ingested or inoculated into the host.
Vector-borne Transmission
• Occurs when intermediate carriers, such as fleas, flies and mosquitoes transfer the microbes to another living
organism.
5. Portal of Entry
v It is the venue the organism gains entrance into the susceptible host.
v The infective microbes use the same avenues when they exit from the reservoir.
6. Susceptible Host
v When the defenses are good, no infection will take place.
v However, in weakened host, microbes will launch an infectious disease.
IMMUNITY
v Natural
• Active
ü Acquired through recovery from a certain disease
• Passive
ü Acquired through placental transfer
v Artificial
• Active
ü Acquired through the administration of vaccine and toxoid
• Passive
ü Acquired through the administration of antitoxin, antiserum, convalescent serum, and
immunoglobulins
Type of Antigen
v Inactivated (killed organism)
• Not long lasting
• Multiple doses needed
• Booster dose needed
v Attenuated (live, weakened organism)
• Single dose needed
• Long lasting immunity
ISOLATION
v Separation of patients with communicable disease from other so as to prevent or reduce transmission or infectious
agent directly or indirectly.
Categories Recommended in Isolation
v Strict Isolation
• Prevents highly contagious or virulent infections
v Contact Isolation
• Prevents the spread of infection primarily by close or direct contact
v Respiratory Isolation
• Prevents the transmission of infectious diseases over short distance through the air
v TB Isolation
• For TB patients with positive smear or with chest X-ray which strongly suggests active tuberculosis.
v Enteric Isolation
• For infection with direct contact with feces
v Reverse/Neutropenic Isolation
• An immunocompromised client is separated to prevent contracting infection from environment.
v Standard Precaution
• To prevent infections that are transmitted by direct or indirect contact with secretions or drainage (except
sweat) from another person.
• Universal Precaution + Body Substance Isolation (BSI)
• Universal Precaution
§ Intended to prevent parenteral mucous membrane and non-intact skin exposure of health care
workers to blood borne pathogens
v Transmission Based Precaution
• Second Tier of precaution
• Applicable to patient who are highly contagious
• Three types: Contact, Airborne, Droplet
INTEGUMENTARY DISEASE
CHICKEN POX
Other Term: Varicella zoster
Description: Acute infectious disease of sudden onset with slight fever, mild constitutional symptoms and eruptions
which are maculopapular for a few hours, vesicular for 3-4 days and leaves granular scabs.
Etiologic Agent: Human (alpha) herpes virus 3 (Varicella-zoster virus)
Sources of Infection:
v Secretions of respiratory tract of infected persons
v Lesions (little consequence)
v Scabs are not infective
Mode of Transmission
v Direct contact
v Contact with contaminated linen and fomites
v Airborne
Incubation Period
v 2 to 3 weeks
Period of Communicability
v Cases are infectious for up to 2 days before the onset of the rash until 5 days after the first crop of vesicles.
Diagnostic Test
v Isolation of the virus from the vesicular fluid within the first 3 to 4 days of the rash
v Serum antibodies is present in 7 days after onset
Congenital Varicella results in:

v Hypoplastic, deformities and scarring of limb
v Retarded growth
v CNS and ophthalmic manifestation
Nursing Considerations
v Strict Isolation
v Exclusion from school for 1 week after eruption first appears and avoid contact with susceptible
v Concurrent disinfection if throat and nose discharge

v Tell the patient not to scratch the lesions
v Teach the child and the family how to apply topical antipruritic medication correctly
Susceptibility, Resistance & Occurrence

v Universal among those not previously attacked
v Severe in adults
v An attack confers long immunity
v Second attacks are rare
Prevention
v Vaccine
• Varicella – zoster Immune Globulin (VZIG)
ü It should be given within 10 days of exposure
MEASLES
Other Terms: Rubeola / Morbili / 7 – day Measles
Description: it is an acute contagious and exanthematous disease that usually affects children who are susceptible to
Upper Respiratory Tract Infection (URTI)
Etiologic Agent
v Filterable virus of Measles (Paramyxoviridae)
Source of infection
v Secretions of nose and throat of infected persons
v Droplet Spread / Direct Contact with Infected person
v Indirect Contact (articles with secretions)
v Airborne
Incubation Period
v 1-2 weeks
v Starts just before the prodrome and lasts until 4 days after the rash appears.
Clinical Manifestations
Koplik spots – pathognomonic sign
1. Pre-eruptive Stage
• Fever
• Catarrhal Symptoms (cough, conjunctivitis, coryza)
• Photophobia
• Stimson’s line (red line on the lower conjunctiva)
2. Eruptive Stage
• Maculo-papular rash
• High grade fever
• Anorexia and irritability
• Throat is red and extremely sore
3. Convalescence Stage
• Rashes fade away
• Fever subsides
• Desquamation begins
• Symptoms subside and appetite is restored
Diagnostic Procedures

v Nose and Throat Swab
v Urinalysis
v Blood exams (Single raised IgM or rise on IgG)
Treatment Modalities
v Anti-viral drug (Isoprenosine)
v Antibiotics
v Oxygen Inhalation
v IV fluids
Complications
v Bronchopneumonia
v Otitis Media
v Pneumonia
v Nephritis
v Encephalitis
Nursing Management
v Isolation
v Maintain standard and airborne precautions.
v Place the patient on a negative pressure room
v Tepid Sponge Bath (TSB)
v Skin care
v Oral and nasal hygiene
v Eye care (photosensitivity)
v Ear care
v Daily elimination (Mild laxative)
v During febrile stage, limit the diet to fruit juices, milk, and water.
v Give medication as ordered by the physician (Penicillin)
Preventive Measures
v Immunization with:
• Anti-measles at the age of 9 months as a single dose
• MMR vaccine (15 mos.); 2nd dose (11 to 12 years old)
v Measles vaccine should not be given to pregnant women, or to persons with active tuberculosis, leukemia, lymphoma
or depressed immune system.
LEPROSY
Other Terms: Hansen’s Disease / Hansenosis
Description: It is a chronic systematic infection characterized by progressive cutaneous lesions
Three distinct forms

v Lepromatous (Multibacillary) leprosy
• Most serious type
• Not infectious
• Causes damage to the respiratory tract, eyes and testes and well as the nerves and the skin.
• Lepromin test is negative, but the skin lesion contains large amount of Hansen’s bacillus
• Slow involvement of the peripheral nerves, with some degree of anesthesia and loss of sensation and gradual
destruction of the nerves.
v Tuberculoid (Paucibacillary) Leprosy
• Affects the peripheral nerves and sometimes the surrounding skin, especially on the face, eyes and testes as
well as the nerves and the skin.
• Lepromin Test is positive, but the organism is rarely isolated from the lesions
• Macules are elevated with clearing at the center and more clearly defined than the lepromatous form
v Borderline (dimorphous)

• Has the characteristics of both lepromatous and tuberculoid leprosy.
Etiological Agent: Mycobacterium leprae
Incubation Period:
v The incubation period varies from a few months to many years. Lepromatous patients may be infectious for several
years.
v Airborne
v Prolonged skin-to-skin contact
Clinical Manifestation
v Early
• Changes in skin color (reddish/white)
• Loss of sensation on the skin/Anesthesia
• Decrease/loss of sweating and hair growth over the lesion
• Thickened/painful nerves
• Muscle weakness
• Redness of the eye
• Nasal Obstruction
• Ulcers that do not heal
v Late
• Madarosis (Loss of eyebrow and eyelashes)
• Lagopthalmos (inability to close eyelids)
• Clawing of fingers and toes
• Contractures
• Sinking of the nose bridge
• Gynecomastia
Diagnostic Tests
v Slit skin Smear
v Blood Test (Inc. RBC & ESR; Dec, Ca, albumin & Cholesterol level)
v Sulfone Therapy
v Rehabilitation, Recreational and Occupational Therapy
v Multiple Drug Therapy
• Multibacillary (Rifampicin, Clofazimine, Dapsone)
ü Infectious Type
ü Duration of treatment (12 months)
• Paucibacillary (Rifampicin and Dapsone)
ü Tuberculoid & indeterminate
ü Non-infectious types
ü Duration of treatment (6-9 months)
Nursing Management
v Isolation and Medical Asepsis should be carried out
v Diet: Full, nutritious diet
v Give antipyretic, analgesics and sedative as needed.
v Provide emotional support throughout treatment and rehabilitation of affected extremities
v Patients with eye dryness need to use a tear substitute daily and protect their eyes to prevent corneal irritation and
ulceration.
v Tell the patient with an anesthetized leg to avoid injury by not putting to much weight on the leg, testing water
before entering to prevent scalding, and wearing appropriate footwear.
Prevention
v Report all cases and suspect of leprosy
v BCG vaccine
v Health education
SCABIES
Description: It is a highly transmissible skin, infection that is characterized by burrows, pruritus, and excoriations with
secondary bacterial infection.
Etiologic Agent: Sarcoptes scabei var. homonis
Source of Infection
v Human skin
v Skin to skin contact
v Direct contact with fomites
Incubation Period
v The itch mite may burrow under the skin and lay ova within 24 hours of an original contact
v This disease is communicable for the entire period that the host is infected.
v Intense itching that becomes more severe at night
v Burrows (lesions) seen in webs of the fingers, wrists and elbows
v Burrows in immunocompromised, infants, young children and elderly appears in face, neck, scalp and ears
Complications
v Persistent pruritus
v Intense scratching can lead to excoriation, tissue trauma and secondary bacterial infection
Diagnostic Procedure
v Superficial scraping and examination under a low-power microscope of material from a burrow
Treatment
v Aqueous Malathion lotion
v Permethrin derma cream left on the skin for 8-12 hours
v Benzyl Benzoate
v Sulfur in petrolatum
v Ivermectin – Anti-helminthic drug is effective in resistant cases
v Antipruritic emollient or topical steroid for itching
v Have the patient’s fingernails cut short to minimize skin breaks from scratching
v Instruct patient on proper application of the drugs
v Contaminated clothing or beddings should be dry-cleaned or boiled
v Advise patient to report any skin irritation
v Advise family member and other people who had close contact with the patient be checked for possible symptoms
and be treated if necessary
v Practice contact precaution
v Terminal disinfection should be carried out
v Encourage the patient to verbalize his/her feelings
Prevention and Control

v Good personal hygiene
v Avoid contact with infected persons
v All members of the household, including close contact should be treated
GERMAN MEASLES

Other Terms: Rubella / Three-day Measles
Description
v It is a mild viral illness caused by rubella virus
v It causes mild feverish illness associated with rashes and aches in joints.
v It has a teratogenic effect on the fetus.
Etiologic Agent: Rubella virus
v Droplet transmission
v Transplacental transmission in congenital rubella
Incubation Period
v 2 to 3 weeks
v Prodromal Period
• Low grade fever
• Headache
• Malaise
• Mild coryza
• Conjunctivitis
• Post-auricular, sub-occipital and posterior cervical lymphadenopathy which occurs on the 3rd to the 5th day
after onset
v Eruptive Period
• Forchheimer’s spot (pinkish rash on the soft palate)
• Eruption appears after the onset of adenopathy
• Children usually present less or no constitutional symptoms
• The rash may last for one to five days and leaves no pigmentation nor desquamation
• Testicular pain in young adults
• Transients polyarthralgia and polyarthritis may occur in adults and occasionally in children.
v Congenital Rubella
• Classic Congenital Rubella Syndrome
ü Intrauterine growth retardation
ü Infant has low birth weight
ü Thrombocytopenic purpura known as “blueberry muffin” skin
• Intrauterine Infection
ü May result in spontaneous abortion
ü Birth result in spontaneous abortion one or multiple birth anomalies such as:
§ Cleft palate, talipes and eruption of teeth
§ Cardiac defects (patent ductus arteriosus, atrial septal defect)
§ Eye defects (glaucoma, retinopathy, micropthalmia)
§ Neurologic (Microcephaly, mental retardation, psychomotor retardation, vasomotor
instability)
Diagnostic Tests
v Clinical observation
v Cell cultures of the throat, blood, urine and cerebrospinal fluid confirm the presence of the virus
v Convalescent serum that shows a fourfold rise antibody titer supports that the diagnosis
v Acetaminophen for fever and joint pain.
v Isolation
Complications
v Encephalitis
v Neuritis
v Arthritis
v Arthralgias
v Rubella syndrome manifested by:
• Microcephaly
• Mental retardation
• Cataract
• Deaf-mutism
• Heart Disease
Nursing Consideration
v Provide comfort
v Make sure female patients understand how important it is to avoid exposure to this disease when pregnant.
v Report confirmed cases of rubella to local public health officials
v Warn the patient about possible mild fever, slight rash, transient arthralgia, and arthritis.
v If lymphadenopathy persists after the initial 24 hours, suggest a cold compress to promote vasoconstriction and
prevent antigenic cyst formation.
v Patient’s room must be darkened to avoid photophobia
v Patient’s eyes should be irrigated with warm saline to relieve irritation
v Good ventilation is necessary.
Prevention
v Administration of live attenuated vaccine (MMR)
v Pregnant women should avoid exposure to patients infected with rubella virus
v Administration of Immune Serum Globulin one week after exposure to rubella
PEDICULOSIS
Description
v Any human infestation of lice
v May occur anywhere on the body
Types:
v Pediculosis capitis
• Lice feed on the scalp and rarely, on the skin under the eyebrows, eyelashes and beard
v Pediculosis Corporis
• Lice live next to the skin in clothing seams.
v Pediculosis pubis
• Lice are found primarily in pubic hairs but may extend to the eyebrows, eyelashes and axillary or body hair.
v Head-to-head contact
v Fomites
v Sexual activity
Incubation Period
v 3 to 7 days
v Pruritis (most common symptom of infestation)
v Tickling sensation of something moving in the hair may be noticed
v Head lice and their nits are most commonly found behind the ears and on the hairs of the neck and occiput.
v Body lice are found on clothing seams
v Pubic lice will be found attached to the base of the pubic hair and the infestation generally results in severe itching.
Diagnostic Tests
v Wood’s light examination (fluorescence of the adult lice)
v Microscopic examination (presence of nits on the hair shaft)

v Permethrin (Eliminate) / Pyrethin (Rid Mousse)
• Initial treatment of choice
• Topical insecticide
• For Pediculosis capitis & Pediculosis pubis
v Fine-tooth comb dipped in vinegar
v Washing hair with ordinary shampoo
v Oral Anthelminthics (Ivermectin, Levamisole, Albendazole) are effective against head lice infestation
v Prevention of head reinfestation
• Clothes and bed linens must be washed in hot water, ironed or dry cleaned.
• Storing clothes or linens for more than 30 days or placing them in dry heat of 140 F (60 C) kislls lice
Complications
v Excoriation
v Secondary bacterial infections
v If left untreated, pediculosis may result in dry, hyperpigmented, thickly encrusted, scaly skin, with residual scarring
v Contact precautions should be maintained until treatment is complete to prevent spreading the infection
v Have the patient’s fingernails cut short to prevent skin breaks and secondary bacterial infections caused by
scratching.
v Be alert for possible adverse reactions to treatment with an antiparasitic, including sensitivity reactions and in some
cases, central nervous system (CNS) toxicity.
v To prevent self-infestation, avoid direct contact with the patient’s hair, clothing and bedsheets.
v Use gloves, a gown, and a protective head covering when administering delousing treatment.
v After each treatment, inspect the patient for remaining lice and eggs.
v Teach the patient and family how to inspect and identify lice, eggs and related lesions
v Instruct the patient and family about the use of the creams, lotions, powders and shampoos that eliminate lice.
v Instruct the patient in the proper application of lindane, which can be absorbed by the skin and cause CNS
complications.
HERPES ZOSTER
Other Term: Shingles
Description
v It is acute unilateral and segmented inflammation of the dorsal root ganglia caused by reactivation of the herpes
varicella-zoster virus, which also causes chickenpox
v Usually occur in adults
Causative Agent
v Varicella virus
Incubation Period
v Unknown, but it is believed to be 13-17 days
v Communicable a day before the appearance of the first rash until 5-6 days after the last crust
v Airborne
v Droplet
v Direct contact
v Begins with fever and malaise
v Severe deep pain, pruritus, and paresthesia and hyperesthesia, usually on the trunk and occasionally on the arms and
legs
v Small, red, nodular skin lesions (Unilateral) erupt on the painful areas up to 2 weeks after first symptoms

v Vesicles filled with fluid or pus
v Cranial nerve involvement
Complications
v Generalized central nervous system infection
v Acute transverse and ascending myelitis
v Intractable neurologic pain
v Differentiation of herpes zoster from herpes simplex virus through fluorescent light
v Tissue culture technique
v Smear of vesicle fluid
v Microscopy
Management
v Antiviral therapy – Acyclovir
v Analgesics to control pain
v Anti-inflammatory
v Airborne and contact precautions
v If vesicles rupture, apply a cold compress as ordered
v To minimize neuralgic pain, administer analgesics as ordered and evaluate their effects
v Instruct the patients to avoid scratching the lesions
v Keep the patient comfortable and maintain meticulous hygiene
v Encourage sufficient bed rest and give supportive care
Prevention
v Vaccination against varicella
v Avoid exposure to patients with varicella infection
RESPIRATORY DISEASES
DIPHTHERIA
Description: Acute febrile infection of the tonsil, throat, nose, larynx or wound marked by patches of grayish membrane
from which the diphtheria bacillus is readily cultured.
Etiologic Agents: Corynebacterium, diphtheria (Klebs-Loeffier bacillus)
Sources of Infection
v Discharges and secretion from mucus surface of nose and nasopharynx and from skin and other lesions
v Reservoir = Man
v Contact with a patient or carrier or with articles soiled with discharges of infected persons.
v Milk (vehicle)
Incubation Period
v 2 to 5 days
v 2 weeks to more than 4 weeks
v Variable until virulent bacilli has disappeared from secretions and lesions
Types
v Nasal

• With foul – smelling serosanguinous secretions from the nose
v Tonsillar
• Low fatality rate
• Lesions are confined to the tonsils only but tend to spread over the pillars, into the soft palate and uvula.
v Nasopharyngeal
• Cervical lymph nodes are swollen
• Neck tissues are edematous
v Laryngeal
• Most commonly found in children ages 2 to 5 years old
• It is considered as most severe and more fatal type due to anatomical reason
• There is moderate hoarseness; voice is diminished until it is finally absent.
• Most fatal
v Wound / Cutaneous
• Affects to mucous membrane and any break in the skin.
v Bull neck formation (swelling of the soft tissues of the neck)
v Exudates forming the membrane are grayish in appearance (Pseudomembrane)
v Fatigue / malaise
v Slight sore throat
v Breathing difficulty
v Husky voice
v Swelling of the palate
v Low-grade fever
Methods of Prevention and Control

v Active immunization of all infants and children with 3 doses of DPT
v Pasteurization of milk
v Education of parents
v Reporting of case to the Health Officer of proper medical care
Diagnostic Tests
v Swab from the nose and throat
v Schick Test
• Involves giving an injection of 0.1 mL of dilute diphtheria toxin intradermally.
• Area is checked in 3-4 days and the reaction is documented
• Positive Test is indicated by inflammation or induration at the point of injection. This indicates that the client
lacks antibodies to diphtheria.
v Virulence Test
v Moloney Test
• A test to detect a high degree of sensitivity to diphtheria toxoid is given intradermally.
v Penicillin
v Anti-toxin
v Erythromycin
Nursing Care
v Follow prescribed dosage and correct technique in administering anti toxin
v Provide comfort
v Absolute bed rest for at least two weeks
v Soft-food diet; small frequent feedings
v Ice collar applied to the neck
• Visiting bag should be set up outside the room of the patient of should be far from the bedside of the patient
v Watch for signs of shock, which can develop suddenly as a result of systematic vascular collapse, airway obstruction,
or anaphylaxis.
v If neuritis develops, tell the patient it’s usually transient. Be aware that peripheral neuritis may not develop until 2 to
3 months after the onset of illness.
v Explain how to properly dispose of nasopharyngeal secretion and teach proper infection precautions
PERTUSSIS
Other Term: Whooping Cough
Description: Acute infection of the respiratory tract characterized by repeated attacks of spasmodic coughing which
consists of a series of explosive expirations, producing a crowing sound, “the whoop”, and usually followed by vomiting.
Etiologic Agents
v Haemophilus pertussis
v Bordet Gengou bacillus
v Bordetella pertussis
Source of Infection
v Discharges from laryngeal and bronchial mucous membrane of infected persons.
Incubation Period: 7-10 days but may occasionally be up to 3 weeks
v Seven days after exposure to three weeks after typical paroxysms
v Direct spread through respiratory and salivary contacts
v Violent coughing
v Nose bleeding
v Distended neck veins
v Periorbital edema
v Conjunctival hemorrhage
Complications
Most dangerous: bronchopneumonia
v Convulsion
v Umbilical hernia
v Otitis media
v Severe malnutrition and starvation
Diagnostic Tests
v Nasopharyngeal swabs (Positive for B. pertussis)
v Sputum culture
v CBC (leukocytosis)
v Chest Radiography may reveal infiltrates or pulmonary edema with atelectasis
v Supportive Therapy
• Fluid & electrolyte replacement
• Adequate nutrition
• Oxygen therapy
v Antibiotics
• Erythromycin
• Ampicillin
v Post Exposure Treatment: Hyperimmune convalescent serum / gamma-globulin
Nursing Management
v Isolation and medical asepsis
v Suction Equipment should be present at bedside

v Provide warm baths
v Keep the bed dry and free from soiled linens
v I & O should be closely monitored
v General care of nose and throat discharges
v Instruct patients to cover their mouths when they cough or sneeze and to wash their hands immediately afterwards.
Prevention
v Any case of pertussis should be reported
v Patient should be isolated for 4 to 6 weeks
v Previously immunized children should be given reinforcing injection
INFLUENZA
Other Term: La Grippe
Description: It is an acute infectious disease affecting the respiratory system
Etiologic Agents
v Influenza virus A, B, C
Source of Infection: Discharges from the mouth and nose of infected persons
v Droplet
v Direct contact through droplet infection
v Indirect contact (fomites)
Incubation Period
v 1 to 3 days, occasionally up to 5 days
v Infectious period lasts from 1 day before until 3-5 days after onset of symptoms in adults.
v Chilly sensation
v Hyperpyrexia
v Severe aches and pain usually at the back associated with severe sweating
v Vomiting
v Sore throat
v Coryza and cough
Complications
v Hemorrhagic pneumonia
v Encephalitis
v Myocarditis
v Sudden Infant Death Syndrome
v Myoglobinuria
v Blood examinations
• Usually normal but leukopenia has been noted
v Viral Culture (oropharyngeal washing or swabbing during the first few days of illness)
v Viral Serology
• Complement Fixation Test
ü It is an immunological medical test that can be used to detect the presence of either specific antibody
or specific antigen in a patient’s serum

v Chest Radiography may reveal bilateral symmetrical interstitial infiltrates indicative of pneumonia
v Arterial Blood Gas Testing may reveal hypoxemia in severe cases
v Laboratory Tests may reveal leukopenia, lymphopenia, and/or thrombocytopenia.
Management
v Stay at home
v Teach the patient about proper disposal of tissues and good handwashing technique
v Drink plenty of fluids
v Fever Management
• Paracetamol
• Ibuprofen
v Maintain contact and droplet precautions
v Limit strenuous activities
v Watch for signs and symptoms of developing pneumonia such as crackles, another temperature increase , or
coughing accompanied by purulent or bloody sputum
v Instruct patients who are sick with flu-like symptoms to avoid contact with others for at least 24 hours.
Preventive Measures
v Active immunization with influenza vaccine
v Education of the public as to sanitary hazard from spitting, sneezing and coughing
v Avoid crowded places
v Avoid use of common towels, glasses and eating utensils.
ANTHRAX
Other Terms: Wool-sorter’s Disease / Ragpicker’s Disease
Description: An acute bacterial disease usually affecting the skin but which may very rarely involve the oropharynx,
lower respiratory tract, mediastinum or intestinal tract.
Etiologic Agent: Bacillus anthracis
v Cutaneous infection is by contact with:
• Tissues of animals (cattle, sheep, goats, horses, pigs and others) dying of the disease
• Contaminated hair, wool, or products made from them such as drums or brushes
• Soil associated with infected animals or contaminated bone meal used in gardening.
Incubation Period
v Inhalation Anthrax (1 to 7 days) usually within 48 hours
v Cutaneous anthrax (1 to 7 days rarely up to 7 weeks
v Ingestion (1 to 7 days)
v Cutaneous Anthrax
• Most common (over 90% of cases)
• Infection is through the skin
• Over a few days a sore, which begins as a pimple, grows, ulcerates and forms a black scab, around which are
purplish vesicles
• Systemic symptoms may include rigors’ headache and vomiting
• The sore is usually diagnostic: 20% cases are fatal.
v Inhalational Anthrax
• Spores are inhaled with subsequent invasion of mediastinal lymph nodes.
• Abrupt onset of flu-like illness, rigors, dyspnea and cyanosis followed by shock and usually death over the
next 2-6 days.
• Most Fatal

v Intestinal Anthrax
• Occurs following ingestion of meat from infected animals and is manifested as violent gastroenteritis with
fever, vomiting, bloody stools and then septicemia
• Poor prognosis
Diagnostic Tests
v Polymerase Chain Reaction (PCR)
• Definitive test for B. anthracis
v Swabs from cutaneous lesions
v Blood cultures
v Lymph node or spleen aspirates
v CSF shows characteristic bacilli on staining with polychrome methylene blue.
v Chest radiology may show fluid surrounding the lungs or widening of the mediastinum
v Antibiotics
• Penicillin
• Ciprofloxacin (DOC)
• Doxycycline
v Treatment of cutaneous anthrax is oral antibiotic for 7 to 10 days
v Length of treatment for GI anthrax is 60 days, but safety has not been evaluated beyond14 days
Complications
v Cutaneous Anthrax
• Septicemia
v Inhalational Anthrax
• Hemorrhagic meningitis
• Pleural Effusions
• Mediastinitis
• Shock
• Acute Respiratory Distress Syndrome
v GI Anthrax
• Hemorrhage
• Shock
v Obtain culture specimens before starting antibiotic therapy
v Supportive measures are geared toward the type of anthrax exposure
v Teach the patient and family that anyone who has been exposed to anthrax must see a doctor immediately.
v Instruct the patient to take antibiotics as prescribed and until completed.
v Instruct the patient with cutaneous anthrax not to scratch at the lesions.
v Alcohol-based hand sanitizers do not kill anthrax spores; wash hands with soap and water.
Prevention
v Pretreatment of animal product and good occupational health cover are the mainstays of control
v Animals believed to have died of anthrax should be disposed of under supervision.
v Mass vaccination of animals may reduce disease spread
v Non-cellular vaccines for human use are available for individuals at risk from occupational exposure
v Workers handling potentially infectious raw materials should be aware of the risks.

PNEUMONIA
Description: An acute infectious disease of the lungs usually caused by the pneumococcus resulting in the consolidation
of one or more lobes of either one or both lungs.
Etiologic Agents
v Streptococcus pneumonia
v Staphylococcus aureus
v Haemophilus influenzae
v Pneumococcus of Friedlander
Incubation Period
v 2 to 3 days
v Droplet infection
v Rhinitis
v Chest indrawing
v Rusty sputum
v Productive cough
v High fever
v Vomiting
v Convulsions
v Flushed face
v Dilated pupils
v Pain over the affected lung
v Highly colored urine with reduced chlorides and increased urates
Complications
v Emphysema
v Endocarditis
v Pneumococcal meningitis
v Otitis Media
v Jaundice
Diagnostic Test
v Chest X-ray
v Sputum Analysis
v Blood/Serologic Exam
v Dull percussion note on affected side
Management
v Bed Rest
v Adequate salt, fluid, calorie, and vitamin intake
v TSB
v Frequent turning from side to side
v Prevent common colds, influenza and other upper respiratory infections
v Immunization with pneumonia vaccine
v Eliminate contributory factors such as exposure to cod, pollution, and physical conditions of fatigue and alcoholism.
TUBERCULOSIS
Other Terms: Koch’s Disease / Phthisis / Galloping Consumption Disease
v TOP 8 highest cases of TB in the world (Philippines)

Description
v It is a chronic sub –acute or acute respiratory disease commonly affecting the lungs
v Characterized by the formation of tubercles in the tissue which tend to undergo ceseation necrosis and calcification
Etiologic Agents
v Mycobacterium tuberculosis
v M. africanum
v M. bovis
Source of Infection
v Sputum
v Blood from Hemoptysis
v Nasal discharge
v Saliva
v Airborne
v Direct / Indirect contact with infected persons
Incubation Period
v 3 to 8 weeks (occasionally up to 12 weeks)
Period of communicability
v As long as the tubercle bacilli are being discharged in the sputum
v Cough of two weeks or more
v Afternoon rise of temperature
v Chest or back pains
v Hemoptysis
v Significant weight loss
v Fatigue
v Body malaise
v Shortness of breath
v Night sweating
v Sputum positive for AFB
Diagnostic Tests
v Sputum Analysis for AFB
• Confirmatory
v Chest X-ray
v Tuberculin Testing (for TB exposure)

ü Mantoux Test (PPD)
ü Tine Test
ü Heaf Test
v Short – course chemotherapy
• Six-month treatment (Isoniazid, Rifampicin, Pyrazinamide and Ethambutol)
Rifampicin
• Empty stomach
• Body fluid discoloration (red-orange)
• Hepatotoxic (metabolism)
• Nephrotoxic (elimination)

• Permanent discoloration of contact lenses
Isoniazid
• Empty stomach
• Peripheral Neuropathy
• Avoid alcohol
• Hepatotoxic
• Nephrotoxic
• Increase intake of Vitamin B6
Pyrazinamide
• Before meals
• Monitor s/sx of liver impairment
ü Anorexia
ü Fatigue
ü Dark urine
ü Photosensitivity
• Liver Function Studies
• Causes hyperuricemia
Ethambutol
• Not affected by food
• Report visual disturbances
• Hepatotoxic
• Not recommended for children (below 6 years old); can cause optic neuritis
Streptomycin
• After meals
• Report Oliguria – nephrotoxic
• Ototoxic
• Neurotoxic
Direct Observation Treatment Short Course

• Strategy to prevent non-compliance
Nursing Management
v Maintain respiratory isolation
v Administer medicines as ordered
v Educate patient all about PTB
v Stop smoking
v Cough or sneeze into tissue paper and dispose secretion properly
v Provide the patient with a well-balanced, high-calorie diet, preferably in small, frequent meals to conserve energy.
v Allow ret periods
v Caution the patient who is taking an oral contraceptive that the contraceptive may be less effective while she’s taking
rifampin.

v Submit all babies for BCG (Bacille Calmette-Guerin) immunization
v Avoid overcrowding
v Improve nutritional and health status
v Persons who have been exposed (Receive Tuberculin Test)
BIRD FLU
Other Term: Avian Influenza
Description: It is an infectious disease of birds ranging from mild to severe form of illness.
Source of Infection
v Viruses that normally infect only birds and less commonly pigs
Incubation Period
v 3 to 5 days
v Fever
v Body weakness / muscle pain
v Cough
v Sore throat
v May have difficulty of breathing in severe cases
v Sore eyes
Susceptibility, Resistance & Occurrence

v All birds are susceptible to infection but domestic poultry flocks are especially vulnerable to infection that can rapidly
reach epidemic proportion.
Control Measures
v Rapid destruction, proper disposal of carcasses and quarantining and rigorous disinfection of farms
v Restrictions on the movement of live poultry
Nursing Care
v Isolation precaution
v Infected Control
v Early recognition of cases of highly pathogenic Avian Influenza during outbreak among poultry
SEVERE ACUTE RESPIRATORY SYNDROME (SARS)

v Earliest known case (Guangdong Province, China, November, 2002)
v Outbreak and Worldwide Surveillance (March 12, 2003)
v First case in the Philippines (April 11, 2003)
Etiologic Agent
v Human coronavirus
Mode of Transmission:
v Droplet Contact
Incubation Period
v Mean incubation period is 5 days (range 2-10 days) and may reach up to 14 days
v Prodromal Phase
• Fever > 38oC (Initial Sign)
• Chills
• Malaise
• Myalgia
• Headache
v Respiratory Phase
• Dry, non-productive cough with or without respiratory distress
• Hypoxia
• Crackles
• Dullness on percussion
• Decreased breath sounds on physical examination
Preventive Measures and Control

v Screen patents for travel hx, symptoms and/or close contact ith cases
v Isolation of suspected probable case
v Barrier nursing technique for suspected and probable cases

Nursing Care
v Maintain Isolation Measures
v Utilize Personal Protective Equipment (PPE)
v Apply principle of hand washing
GASTROINTESTINAL DISEASES
CHOLERA
Other Term: El Tor
Description: It is an acute bacterial enteric disease characterized by profuse diarrhea, vomiting, massive loss of fluid
and electrolytes that can result to hypovolemic shock, acidosis and death.
Etiologic Agent: Vibrio El Tor
Source of Infection
v Vomitus and feces of infected persons
v Food and water contaminated with vomitus and stools of patients and carriers
Incubation Period
v 6 to 48 hours
v Cases are infectious during the period of diarrhea and up to 7 days after
v Rice-watery stool
v Washer-woman’s hands
v Vomiting
v Diarrhea
v Deep, rapid breathing
v Oliguria
Diagnostic Tests
v Rectal swab
v Darkfield or phase microscopy
v Stool exam
v Blood test
• Elevated BUN & Creatinine Levels
• Increase in serum lactate, protein and phosphate levels
v IV treatment
v Oral Therapy Rehydration
v Coconut water
v Give ORESOL
v Antibiotics
• Tetracycline
• Furazolidone
• Chloramphenicol
• Cotrimoxazole
Nursing Management
v Medical Aseptic protective Care (Hand washing)
v Enteric Isolation
v VS
v I & O monitored accurately

v Personal hygiene
v Proper excreta disposal
v Environmental sanitation
Prevention
v Food and water supply must be protected from fecal contamination
v Water should be boiled and chlorinated
v Milk should be pasteurized
v Sanitary disposal of human excreta is a must
TYPHOID FEVER
Description: It is a systemic infection characterized by continued fever, anorexia, involvement of lymphoid tissue,
especially ulceration of Peyer’s patches.
Etiologic Agents
v Salmonella typhi or Typhoid bacillus
Sources of Infection
v Feces and urine of infected persons
v Fecal-oral Transmission
v Contaminated Urine
v Direct/indirect contact with infected person
v Ingestion of contaminated food, water and milk
Incubation Period
v 1 to 3 weeks; average (2 weeks)
v As long as typhoid bacilli appears in excreta
v Onset
• Headache
• N/V
• Ladder-like fever
• Rose spots on the abdomen
v Typhoid State
• Coma vigil
• Subsultus tendinum
• Carphologia
• Delirium
Complications
v Hemorrhage/Perforation (most dreaded complications)
v Peritonitis
v Bronchitis and Pneumonia
v Typhoid spine
v Septicemia
v Reiter’s syndrome – joint pain, eye irritation
Diagnostic Tests
v Typhidot – confirmatory
v ELISA
v Widal
v Rectal swab
v Bone Marrow Aspiration (identifies S. typhi)

v Chloramphenicol – drug of choice
v Ampicillin
v Co-trimoxazole
v Ciprofloxacin
v Cefixime / Azithromycin
v Ceftriaxone (recommended for complicated cases)
Nursing Management
v Isolation
v Maintain standard precautions unless the patient is incontinent or in diapers or if an outbreak develops in an
institution.
v Give nourishment fluids in small quantities at frequent intervals
v Monitor VS
v Prevent further injury
v WOF: intestinal bleeding / bowel perforation, including sudden pain in the lower right side of the abdomen and
abdominal rigidity.
v Provide good skin and mouth care
v Turn the patient frequently and perform mild passive exercises, as indicated.
v Apply mild heat to the abdomen to relieve cramps.
v Sanitary and proper disposal of excreta
v Proper supervision of food handlers
v Enteric isolation
v Provision of safe drinking water supply
v Detection and supervision of typhoid carriers
BACILLARY DYSENTERY
Other Terms: Shigellosis / Bloody Flux
Description: It is an acute bacterial infection of the intestine characterized by diarrhea, fever, tenesmus and in severe
cases, bloody and mucoid stools.
Etiologic Agents
v Shigella sonnei (most common species in Western Europe)
v Shigella flexneri
v Shigella boydii
v Shigella dysenteriae
Incubation Period
v 12 to 96 hours, but may be up to 1 week
v The patient can transmit the microorganism during the acute infection until the feces are negative of the organism.
v Ingestion of contaminated food
v Drinking contaminated water / milk
v Feco-oral transmission
v Fever
v Tenesmus
v N/V
v Headache
v Colicky or cramping abdominal pain associated with anorexia and body weakness
v Bloody-mucoid stool
v Rapid dehydration

Diagnostic Tests
v Microscopic examination of a fresh stool specimen may reveal mucus, red blood cells, and polymorphonuclear
leukocytes.
v Direct immunofluorescence with specific antisera will demonstrate Shigella.
v Sigmoidoscopy or proctoscopy may reveal typical superficial ulcerations
v Stool culture must rule out other causes of diarrhea, such as enteropathogenic Escherichia coli infection,
malabsorption disease, and amebic or viral diseases.
v Antibiotics
• Ampicillin
• Ceftriaxone
• Trimethoprim-sulfamethoxazole
• Ciprofloxacin
v IV Therapy
v Low Residue Diet
v Contraindicated: Anti-diarrheal drugs (they delay fecal excretion that can lead to prolong fever)

v Sanitary disposal of human feces
v Adequate personal hygiene, particularly handwashing after defecation.
v Sanitary supervision of processing, preparation and serving of food (raw)
v Fly control and protection against fly contamination
v Isolation (Acute Stage)
v Protection and purification of public water supply
v Routine cooking kills shigella
PARAGONIMIASIS
Etiologic Agents:
v Lung Fluke
v Paragonimus westermani
v Paragonimus siamenses
v Ingestion of raw / uncooked crabs/crayfish
v Contamination of Food
v Using meat / juice of infected animals
Reservoir of Hosts
v Cats
v Dogs
v Rats
v Pigs
v Cough of long duration
v Recurrent blood-streaked sputum
v Chest/back pain
v PTB – like signs/symptoms not responding to anti-TB medication
Diagnostic Test
v Sputum Microscopy
v Immunology
v Cerebral Paragonimiasis
Treatment

v Praziquantel (Billtrizide)

v Treatment of infected person
v Anti-mollusk campaigns
v Educated of the population
v Avoid eating infected foods
MUMPS
Other Terms: Infectious Parotitis / Epidemic Parotitis
Description: It is a acute viral disease manifested by swelling of one or both parotid glands, with occasional involvement
of other glandular structures, particularly the testes in male.
Etiologic Agent: Paramyxoviridae
Source of infection: Secretion of the mouth and nose
v Direct contact
v Indirect contact with the articles freshly soiled with secretion from the nasopharynx.
v Cases are infectious for up to a week (normally 2 days) before parotid swelling until 9 days after.
v 48 – hours period immediately preceding onset of swelling is considered the time of highest communicability.
v Sudden headache
v Earache
v Loss of appetite
v Fever
v Swelling of the parotid gland (between the earlobe and angle of the mandible)
Complications
v Orchitis
v Oophoritis
v Mastitis
v Nuchal rigidity
v Deafness
v Meningoencephalitis
v Pancreatitis
v Myocarditis
v Nephritis
Diagnostic Tests
v Serum amylase Determination (most useful test in making early presumptive diagnosis of mumps); elevated amylase
level
v Complement Fixation Test
v Hemo-agglutination Inhibition Test
• Used to determine the immune status
v Neutralization Test
• Determines immunity to mumps
v Viral Culture
v Analgesics for pain
v Antipyretics for fever
v IV Fluid Replacement
v Hot and Cold Application

Nursing Management
v Medical Aseptic Protective Care
• Single-occupancy room
• Oral Care and Personal Hygiene (warm salt-water gargles)
v General Management of the disease

• Bed rest
• Diversional Activities
• Eye care
• Provide extra fluids
v Diet
• No restriction of food
• Soft bland and semi-solid is easily managed
• Acid foods (fruit juices) increases discomfort

v Active Immunization (MMR)
v Reporting of cases to health authorities
v Isolation of patient
BOTULISM
Description
v Rare but severe form of poisoning caused by a gram-positive, anaerobic bacteria.
v It is an illness of descending paralysis and autonomic dysfunction due to a neurotoxin
Causative Agent: Clostridium Botulinum

v Foodborne Botulism
v Wound Botulism
v Infant Botulism
Source of Infection
v Untreated water
v Undercooked and improperly preserved canned foods, especially those with a low acid content
v Home-canned vegetables
v Cured pork and ham
v Smoked or raw fish
v Honey and corn syrup
v Ingestion (or injection) of preformed toxin
v Spores may resist 100 degree Celsius for many hours
v Inhalation of toxin may also cause disease
v Introduction of spores into the wound
Incubation Period: 12 to 72 hours but extremes of 2 hours to 10 days are reported.
Clinical Manifestations:
v Double or blurred vision
v Droopy eyelids
v Dry mouth
v Difficulty swallowing and talking
v Difficulty breathing
v Flaccid paralysis (descending)
v Deep tendon reflexes are decreased or absent
v Initial vomiting or diarrhea followed by constipation
Diagnostic Tests:
v A toxicity screen may identify C. botulinum.

v Stool culture may identify C. botulinum.
v The suspected food may also be cultured to isolate C. botulinum.
v Electromyography will show little response to nerve stimulation in the presence of botulism.
v Diagnostic tests should be conducted as needed to rule out diseases that may be confused with botulism, such as
myasthenia gravis and Guillain-Barre syndrome.
v A mouse-inoculation test will be positive and is the most direct way to confirm a diagnosis of botulism.
Complications
v Aspiration
v Weakness and nervous system problems can be permanent
v Death
v Botulinus antitoxin- IV, IM
v Infants – inducing vomiting or giving an enema
v IV fluid can be administered
v Nasogastric tube
v Endotracheal intubation – respiratory distress
Nursing Consideration
v Obtain a careful history of foods eaten in the past several days.
v Monitor respiratory and cardiac function carefully
v Perform frequent neurologic checks
v Purge the GI tract as ordered
v If giving the botulinus antitoxin, check the patient’s allergies, perform a skin test first.
v Educate the patient and family about the importance of proper hand hygiene
v Teach the patient and family to cook food thoroughly before ingesting.
v Instruct the patient who eats home canned food to boil the food for 10 minutes before eating to ensure that it is safe
to consume.
v Teach patient and families to see their doctors promptly for infected wounds and to avoid injectable street drugs.
Suggested on-call action

v Ensure that the case is admitted to hospital
v Obtain food history as a matter of urgency
v Obtain suspect foods
v Identify others at risk
v Inform appropriate local and national authorities
AMOEBIASIS
Description: Protozoal infection that initially involves the colon but may spread into the liver and lungs by lymphatic
dissemination
Etiologic Agent
v Entamoeba Histolytica
• 2 stages
ü Cyst – considered to be the infective stage and the resistance to environmental conditions and can
survive for few days outside the body
ü Trophozoites / vegetative form – Facultative parasites that invades the tissue
Source of Infection
v Contaminated food and water
v Flies
v Fecal-oral
v Oral-anal

Incubation Period
v Severe infections: 3days
v Average 2-4 weeks
v Communicable for the entire duration of the illness or until cysts are present in the stool
v Acute Amoebic Dysentery
• Slight attack of diarrhea altered with PD of constipation
• Watery foul-smelling stools containing blood streaked mucus
• Gaseous distension of the lower abdomen

• Nausea, flatulence
• Tenderness in the right iliac region
v Chronic Amoebic Dysentery

• Diarrhea for several days, succeeded by constipation
• Anorexia, weight loss, weakness, fatigue
• Watery, bloody mucoid stool
• Flatulence and irregular bowel movement
• Abdomen loses its elasticity
• Severe cases – scattered ulceration is seen through sigmoidoscopy
v Stool exams – cyst (plenty of amoeba on the stool)
v Blood exams – leukocytosis
v Sigmoidoscopy
Management
v Metronidazole (Flagyl) 800mg TID x 5 days
v Tetracycline, Ampicillin, Streptomycin, Chloramphenicol
v Observe isolation and enteric precautions
v Proper collection of stool specimen
• No oil prep for 48 hours
• Large portion of stools containing blood mucus
• Label specimen properly
• Send specimen immediately to the laboratory
v Provide skin care and hygiene
v Provide optimum comfort dysenteric patient should never be allowed to feel cold
v Diet fluid should be forced
• Cereals and strained meat broths without fats
• Bland diet without cellulose or bulk producing foods
• Chicken and fish may be added when convalescence is established
Prevention
v Health education and Fly control
v Sanitary disposal of feces
v Safe drinking water
v Proper food preparation and food handling
v Detection and treatment of carriers
SCHISTOSOMIASIS
Other Terms: Bilharziasis / Snail Fever
Description: Slowly progressive disease caused by blood flukes
Causative Agent
v Schistosoma japonicum – endemic in the Philippines and China
v Schistosoma mansoni – South America, the Caribbean, Africa and countries of the Arab Middle East
v Schistosoma haematobium – Africa and the Middle East
Source of Infection
v Stool and urine of infected persons or animals
v Ingestion of contaminated water
v Penetration through the skin pores
v *Oncomelania hupensis quadrasi is the intermediary host
Incubation Period
v At least 2 months
v 1st stage
• Pruritic rash known as “swimmers itch” occurs 24 hours after penetration of cercariae in the skin
v 2nd Stage
• Bloody mucoid stools (on and off for weeks)
• Katayama Fever – clinical constellation of the following:
ü Fever, headache
ü Cough, chills and sweating
ü Lymphadenopathy and hepatosplenomegaly
v 3rd (Chronic) Stage
• Granulomatous reactions to egg deposition in the intestine, liver, bladder
• Inflammation of the liver
Icteric and jaundice
• Bulging of the Abdomen
• Enlargement of the Spleen
• Sometimes the brain is affected that caused epilepsy
• Eggs are deposited in the bladder wall, leading to hematuria, bladder obstruction
• Hydronephrosis and recurrent urinary tract infection
• Pale and marked muscle wasting
Complications
v Liver cirrhosis and portal hypertension
v Bleeding esophageal varices
v Bladder cancer
v Pulmonary hypertension
v Heart failure
v Ascites
v Renal failure
v Cerebral schistosomiasis
v Fecalysis
v Liver and rectal biopsy
v ELISA
v Circumoval precipitation test (COPT) – confirmatory test
Management
v Drug of choice: PRAZIQUANTEL for 6 months
• 1 tab 2x a day for 1st 3 mos
• 1 tab a day for next 3 mos
• Alternative: Ovamniquine

v TSB
v Skin care
v Provide comfort
v Proper nutrition

v Reduce snail density
• Molluscicides
• Stream Cleaning Vegetation (expose the snails to sunlight)
v Proper waste disposal
v Control of stray animals
v Safe and adequate water supply for bathing, laundering and drinking
v Foot bridges over snail-infested streams
v Health education about mode of transmission and prevention
SEXUALLY TRANSMITTED INFECTIONS

SYPHILIS
Other Terms: Sy, Bad blood, The Pox, Lues Venereal, Morbus Gallicus
Description: it is an acute, chronic infectious disease caused by spirochete and is acquired through sexual contact
Etiologic Agent: Treponema pallidum
Source of Infection
v Discharges from obvious or concealed lesions of the skin or mucous membrane
v Semen
v Blood
v Tears
v Urine
v Mucous discharge from the nose, eyes, genital tract
v Surface lesions
Incubation Period
v Varies, but typically lasts about 3 weeks
v Variable and indefinite
v Sexual Contact
v Indirect contact with the articles freshly soiled with discharges or blood
v Transmission via placenta
v Primary
• Painless chancre (sore) at site of entry of germs, swollen glands
• Chancres disappears after three to six weeks even without treatment
v Secondary
• Rash can be macular, papular, pustular or nodular
• Macules often erupt between rolls of fat on the trunk and on the arms, palm, sole face and scalp
• Alopecia (temporary)

• Nails become brittle and pitted
v Latent
• Patient is asymptomatic for a few months
• Dormancy stage of bacteria
v Late
• Varies from no symptoms to indication of damage to body organs such as brain and heart and liver
Diagnostic Tests
v Dark Field Illumination Test identifies T. pallidum from lesion exudates and provides an immediate diagnosis
v Fluorescent treponemal antibody absorption test
v Venereal Disease Research Laboratory (VDRL) test detects nonspecific antibodies that become reactive within 1 to 2
weeks after the primary syphilis lesion appears or 4 to 5 weeks after the infection begins
v CSF analysis, identifies neurosyphilis when the total protein level is higher than 40 mg/dL
v IM Penicillin G benzathine
v Tetracycline
v Doxycycline
v Stress the importance of completing the treatment even after the symptoms subside
v Practice universal precaution
v In secondary syphilis, keep the lesions dry as much as possible
v Report cases to the Department of Health
v Control prostitution
v Require sex worker to have check up
v Proper sex education
TRICHOMONIASIS
Other Term: Trich
Etiologic Agent: Trichomonas vaginalis
v Direct sexual contact
v Indirect contact (towels, wash clothes, douching equipment)
Incubation Period
v 5 to 21 days
Females: White or greenish – yellow odorous discharge; vaginal itching and soreness, painful urination.
Males: Slight itching of penis, painful urination, clear discharge from penis
Diagnosis:
v Microscopic slide of discharge
v Culture of urethral tissue, urine or semen
v Physical Examination
v The OSOM Trichomonas Rapid Test identifies infection within 10 to 45 minutes, but it is less sensitive and specific
than culture.
Treatment
v Metronidazole (Flagyl) – treatment of choice
v Tinidazole (Tindamax)
Complication
v Cervical cancer

v Follow standard precautions
v Assist with obtaining appropriate specimen for culture or testing
v Tell the patient to avoid ingesting alcohol while taking metronidazole (and for 48 hours after completing the
prescription), as the combination may cause severe nausea and vomiting, abdominal pain, headaches, and flushing.
CHLAMYDIA
Etiologic Agent
v Chlamydia trachomatis
v Vaginal / Rectal intercourse
v Oral-genital contact
Incubation Period
v 7 to 14 days
v Case will remain infectious until treated
v Cervical erosion
v Mucopurulent discharges
v Dyspareunia
v Pain and tenderness of the abdomen
v Chills
v Fever
v Dysuria
v Urinary frequency
v Painful scrotal swelling
v Diarrhea
v Tenesmus
Diagnostic Test
v Culture of the site of infection will reveal C. trachomatis
v Nucleic acid probe will be positive for C. trachomatis
Treatment
v Tetracycline
v Erythromycin
v Azithromycin
Complications
v Sterility
v Prematurity
v Stillbirths
v Infant pneumonia
v Eye Infections (infants)
Nursing Management
v Observe standard precautions
v HIV testing for both partners
v Assess newborn for signs of chlamydial infection
v Urge the patient to inform sexual contacts of his or her infection so they can receive appropriate treatment.
v Stress the importance of completing the course of antibiotics even after symptoms subside.
v Teach the patient to follow meticulous personal hygiene measures
v Instruct the patient to avoid touching any discharge and to wash and dry the hands thoroughly before touching the
eyes to prevent eye contamination.

GONORRHEA
Other Terms: Clap / Flores Blancas / Gleet / Drip
Description: It is a sexually transmitted bacterial disease involving the mucosal lining of the genitor-urinary tract, the
rectum, and pharynx
Etiologic Agent
v Neisseria gonorrhoeae
Incubation Period
v 2 to 5 days
v Direct contact through sexual intercourse
v Direct contact with contaminated secretions of the mother during vaginal delivery
v Females
• 80% are aysmptomatic
• Burning sensation and frequent urination
• Yellowish purulent vaginal discharge
• Redness and swelling of the genitals
v Males
• Dysuria with purulent discharge
• Rectal infection
• Inflammation of the urethra
• Prostatitis
• Pelvic Pain
Complications
v Sterility
v Pelvic Infection
v Epididymitis
v Arthritis
v Endocarditis
v Conjunctivitis
v Meningitis
Diagnostic Tests
v Gram staining
v Culture of cervical & urethral smear
Treatment
v Ceftriaxone (IM)
v Azithromycin or Doxycycline (po)
v Standard precautions
v Sexual abstinence until he/she recovers from the disease
v For gonococcal arthritis (apply moist heat to relieve pain)

v Sex education
v Case finding
v Report cases of gonorrhea

CANDIDIASIS
Other Term: Candidosis / Moniliasis
Description: Superficial fungal infection that usually infects the skin, nails, mucous membrane, vagina, esophagus and
GI tract
Etiologic Agent: Candida albicans
Sources of infection
v Candida are part of the normal flora of the GI tract, mouth vagina and skin, They cause infection when some changes
in the body (such as increased blood glucose or immunocompromised) occurs
v Skin
• Scaly, erythematous, popular rash, sometimes covered with exudates, appearing below the breast, between
the fingers, and the axillae, groin, and umbilicus
v Nails
• Red, swollen, darkened nail bed
• Occasionally, purulent discharge and the separation of a pruritic nail from the nail bed
v Oropharyngeal mucosa (thrush)
• Cream-colored or bluish white curd-like patches of exudates on the tongue, mouth, or pharynx that reveal
bloody engorgement when scraped
v Esophageal mucosa
• Dysphagia
• Retrosternal pain, regurgitation
• Occasionally, scales in the mouth and throat
v Vaginal mucosa
• White or yellow discharge, with pruritus and local excoriation
• White or gray raised patches on vaginal walls, with local inflammation
• Dyspareunia
v Lungs – hemoptysis, cough, fever

v Kidney – fever, flank pain, dysuria, hematuria, pyuria, cloudy urine
v Brain – headache, nuchal rigidity, seizures, focal neurologic deficits
v Endocardium – systolic or diastolic murmur, fever, chest pain, embolic phenomena
v Eye – Endophthalmitis, blurred vision, orbital or periorbital pain, scotoma, exudates
v Blood Culture
v Culture of vaginal scraping
v Echocardiography if here is cardiac involvement
v Fundoscopy for patients with endophthalmitis
Management
v Antifungal: Nystatin, Clotrimazole, Miconazole
ü Mutism
ü Coma
Diagnostic Tests
v Enzyme linked Immuno-Sorbent Assay (ELISA) – presumptive test
v Western Blot – confirmatory test
v Particle agglutination (PA)
v Immunofluorescent Test
v Reverse transcriptase inhibitors (Zidovudine)
v Protease inhibitors (Ritonavir)

Nursing Management
v Avoid accidental wounds from infectious materials used in HIV patients
v Avoid contact of open skin lesions
v Gloves should be worn when handling blood specimens
v Handwashing
v Blood and other specimens should be labelled prominently
v Instruments with lenses should be sterilized after use on AIDS patient
v Needles should not be bent after use, placed it under puncture – resistant
v Patients with active Aids should be isolated
v Care of thermometer – wash with warm soapy water, Soak in 70% alcohol for 10 minutes, dry and store.
VECTOR-BORNE DISEASES
DENGUE FEVER
Other Terms: Breakbone Fever / Hemorrhagic Fever / Dandy Fever / Infectious Thrombocytopenic Purpura
Description: It is an acute febrile disease caused by infection with one of the serotypes of dengue virus.
Etiologic Agents
v Dengue Virus Types 1, 2, 3, & 4
v Chikungunya Virus
v Bite of female infected mosquito (Aedes aegypti)
Incubation Period
v 3 to 15 days
v Unknown
v Presumed to be on the 1st week of illness (when the virus is still present in the blood)
v Human-to0human spread of dengue has not been recorded, but people are infectious to mosquitoes during the
febrile period
Herman’s sign (maculopapular rash with patches of normal skin) – pathognomonic sign
v Febrile / Invasive Stage

• First 4 days
• High fever (39 – 40 C)
• Abnormal pain
• Headache
• Later flushing
v Toxic / Hemorrhagic Stage
• Lowering of temperature
• Severe abdominal pain
• Vomiting
• Melena
• Hematemesis
v Convalescent / Recovery Stage
• Generalized flushing with areas of blanching appetite
• BP stable
Diagnostic Tests
v Tourniquet test (Rumpel – Leede Test)
v Platelet count (decreased)
v Hemoconcentration (increased of at least 20%)
v Occult blood

v Hemoglobin determination
v Dengue NS1 Test (confirmatory)
v Give analgesic (Don’t give Aspirin)
v Rapid replacement of body fluids
v Oxygen Therapy
v Oral Rehydration Solution
v Blood Transfusion (for severe bleeding)
v Sedatives
Nursing Management
v Patient should be kept in mosquito-free environment
v Monitor VS
v Provide periods
v Nose bleeding (apply ice bag on the forehead and at the bridge of the nose)
v Watch out for: signs of shock
v Diet: Low fat, low fiber, non-irritating, non-carbonated
Prevention & Control

v Health education
v Early detection and treatment of cases
v Treat mosquito nets with insecticides
v House spraying
v Avoid too many hanging clothes
v Case finding
MALARIA
Other Term: Ague and Marsh Fever
Description: It is an acute and chronic parasitic disease transmitted by bite of infected mosquitoes and it is confined
mainly to tropical and subtropical areas.
Etiologic Agents
v Plasmodium falciparum (most common)
v Plasmodium vivax
v Plasmodium malariae
v Plasmodium ovale
Incubation Period
v P. falciparum (5 to 7 days)
v P. vivax (6 to 8 days)
v P. ovale (8 to 9 days)
v P. malariae (12 to 16 days)
v Transmitted mechanically through bite of an infected female Anopheles mosquito
v Blood transfusion
v Transplacental transmission
Clinical Manifestation:
v Paxoysms with shaking chills
v Rapid rising fever with severe headache
v Profuse sweating
v Myalgia
v Splenomegaly
v Hepatomegaly
Chemoprophylaxis

v Chloroquine
• This must be taken at weekly intervals, starting from 1-2 weeks before entering endemic areas.
Preventive and Vector Control Measures

v Insecticide – treatment of mosquito nets
v House Spraying
v On-stream seeding
v On-stream clearing
v Wearing of clothes that covers arms and legs in the evening
v Avoiding outdoor night activities (9PM to 3AM)
v Planting of Neem tree
v Zooprophylaxis
FILIRIASIS
Other Term: Elephantiasis
Description
v It is a parasitic disease caused by an African eye worm, microscopic thread-like worm
v Extremely debilitating and stigmatizing disease
Etiologic Agents
v Wuchereria bancrofti
v Brugia malayi
v Brugia timori
v Loa loa
v Mosquito bite (Aedes poecilius)
Incubation Period
v 8 to 16 months
v Asymptomatic Stage
• No clinical signs and symptoms of the disease
v Acute Stage
• Lymphadenitis
• Lymphangitis
• Epididymitis
• Orchitis
v Chronic Stage
• Develop 10 to 15 years from the onset of the first attack
Chronic Signs and Symptoms
• Hydrocele
• Lymphedema
• Elephantiasis
Diagnosis
v Physical examination
v History taking
Laboratory Examinations
v Nocturnal Blood Examination (NBE)
• Blood are taken from the patient’s residence (8pm)
v Immunochromatographic Test (ICT)
• Rapid Assessment Method
• Antigen test can be done at daytime

Treatment
v Diethylcarbamazine citrate (Hetrazan)
Nursing Management
v Health Education
v Environmental Sanitation
v Psychological and emotional support
v Personal hygiene

v Mosquito net
v Mosquito repellent
v Yearly dose of medicine
LEPTOSPIROSIS
Other Terms: Canicola Fever / Hemorrhagic Jaundice / Mud Fever / Swine Herd Disease / Flood Fever / Trench Fever /
Spirochetal Jaundice / Japanese Seven Days Fever
Description: It is a zoonotic infectious bacterial disease carried by animals, both domestic and wild, whose urine
contaminates water or food which is ingested or inoculated through the skin.
Etiologic Agent: Leptospira interrogans
Incubation Period
v 7 to 13 days (range 4 to 19 days)
v Direct contact on the skin through open wounds
v Leptospiremic Phase (4 to 7 days)
• Nausea
• Vomiting
• Fever
• Headache
• Myalgia
• Chest pain
v Immune Phase (4 to 30 days)
• Meningeal irritation
• Oliguria
• Anuria
• Severe cases (shock, coma, congestive, heart failure)
v Convalescence Phase
• Relapse may occur during the 4th to 5th week
Laboratory Tests
v ELISA
v Liver Function Tests
v Leptospira Antigen-antibody test
v Leptospira Antibody Test
Complications
v Meningitis
v Respiratory distress
v Renal interstitial tubular necrosis
v Cardiovascular problems

Treatment
v Doxycycline (Prophylactic)
v Penicillin
v Tetracycline
v Erythromycin
v Administration of Fluid and Electrolyte and Blood
Nursing Management
v Isolate patient
v Darken patient’s room
v Observe meticulous skin care
v Wide Rat Eradication Program
v Encourage Oral fluid intake
Prevention & Control

v Environment Sanitation
v Proper Drainage System and Control of Rodents
v Information - dissemination campaign
CNS DISEASES
RABIES
Other Terms: Hydrophobia / Lyssa
Description: It is a specific, acute, viral infection communicated to man by saliva of an infected animal.
Etiologic Agent
v Rhabdovirus (Bullet Shape Virus)
Incubation Period
v 3 to 8 weeks, but may be as short as 9 days or as long as 7 years, depending on the amount of virus introduced, the
severity of the wound and its proximity to the brain
Susceptibility and Resistance

v All warm-blooded mammals are susceptible
v Prodromal / Invasion Phase
• Fever
• Malaise
• Irritability
• Restlessness
• Apprehensiveness
• Melancholia
• Sensitive to light and sound
v Excitement / Neurological Phase
• Marked excitation and apprehension
• Nuchal rigidity
• Involuntary twitching
• Severe and painful spasm of the muscles of the mouth, pharynx and larynx
• Hydrophobia
• Aerophobia
• Profuse drooling of saliva
v Terminal / Paralytic Phase

• Quiet and unconscious
• Loss of bowel and urinary control
• Cessation of spasms and progressive paralysis
• Tachycardia; respiratory paralysis, heart failure
Diagnostic Tests
v Virus isolation from the patient’s saliva / throat
v Fluorescent rabies antibody (RFA) – most definitive diagnosis
v Presence of negri bodies in the dog’s brain
v Wash with soap and water
v Application of antiseptics such as povidone iodine may be done
v Patients should not be bathed and there should not be any running water in the room
v Concurrent and terminal disinfection should be carried

v Vaccination of all dogs (immunized 3 months of age and every year thereafter)
v Confinement of any dog that has bitten a person for 10 to 14 days
v Provide public education
TETANUS
Other Term: Lock Jaw
Description: It is an acute illness caused by toxin of the tetanus bacillus. This infection is usually systemic; less
commonly, it is localized.
Etiologic Agent: Clostridium tetani
Source of Infection:
v Soil
v Feces
v Transmission occurs when spores are introduced in the body through
• Dirty wound
• Injecting drug use and occasionally during abdominal surgery
Incubation Period
v 3 to 21 days depending on the site of the wound and the extent of contamination
v Localized
• Spasm
• Increased muscle tone in the wound
v Generalized
• Marked muscles hypertonicity
• Hyperactive deep tendon reflexes
• Tachycardia
• Profuse sweating
• Low-grade fever
• Painful, involuntary muscle contractions:
ü Neck and facial muscles
Ø Lockjaw (trismus)
Ø Painful spasms of masticatory muscles
Ø Difficulty opening the mouth

Ø Risus sardonicus
ü Somatic Muscles
Ø Arched-back rigidity and board-like abdominal rigidity

ü Intermittent tonic seizures lasting several minutes, which may result in cyanosis and sudden death by
asphyxiation
Diagnostic Tests
v Clinical features
v Blood cultures and tetanus antibody tests are often negative, only a third patients have a positive wound culture
v Cerebrospinal fluid pressure may rise above normal
v Drainage of ski abscesses
v Administration of antibodies
• Metronidazole (first-line agent)
• Pen G
v Administration of tetanus immunoglobulin (TIG)
v Sedatives
v Patients with severe, generalized or rapidly progressing muscle spasm should be intubated sedated and paralyzed if
necessary
v Manage autonomic instability
• Labetalol
Complications
v Atelectasis
v Pneumonia
v Pulmonary emboli
v Acute gastric ulcers
v Seizures
v Flexion contractures
v Cardiac Arrhythmias
Nursing Management
v Maintain an adequate airway and ventilation to prevent pneumonia and atelectasis
v Suction often and watch for signs of respiratory distress
v Maintain an IV line for medications and emergency care, if necessary
v Monitor for arrhythmias
v Record intake and output accurately and check vital signs often
v Keep the patient’s room quiet and dimply & Warn visitors not to upset or overly stimulate the patient
v Give muscle relaxants
v Perform passive-range-of-motion
v Provide adequate nutrition to meet the patient’s increased metabolic needs.
v Stress the importance of maintaining active immunization with a booster dose of tetanus toxoid every 10 years
v Teach the patient or family about proper wound care.
POLIOMYELITIS
Other Terms: Polio / Infantile Paralysis
Description: It is an acute communication disease caused by the poliovirus
Etiologic Agent: Poliovirus Types 1, 2 and 3
v Direct contact with infected oropharynges secretions or feces
Incubation Period
v 7 to 14 days
v Fever
v Headache

v Vomiting
v Lethargy
v Irritability
v Pains in the neck, back, arms, legs and abdomen
v Muscle tenderness, weakness an spasms in the extensors of the neck, back, hamstring and other muscles during
range-of-motion exercises
v Loss of superficial and deep reflexes
v Positive Kernig’s and Brudzinski’s signs
v Hypersensitivity to touch
v Urinary retention
v Tripod (arms extended behind for support when sitting up)
v Hoyne sign (head falls back when surprise and shoulders are elevated)
v Inability to raise the legs a full 90 degrees from a supine position.
v Diplopia
v Dysphasia
v Difficulty chewing
v Inability to swallow or expel saliva
Diagnostic Tests
v Viral culture = Stool sample
v Convalescent serum antibody titers four times greater than acute titers support the diagnosis
v CSF pressure and protein levels may be slightly increased, and the white blood cell count elevated initially, thereafter
mononuclear cells constitute most of the diminished number of cells.
v Electromyographic findings in early poliomyelitis show a reduction in the recruitment pattern and a diminished
interference pattern due to acute motor axon fiber involvement.
v Fibrillations develops in 2 to 4 weeks, and fasciculations also may be observed
v Analgesics (No Morphine)
v Moist heat application
v Bed rest is necessary only until extreme discomfort subsides
v Physical therapy
v Braces
v Corrective shoes
Complications
v Respiratory failure
v Pulmonary edema
v Pulmonary embolism
v Urinary Tract Infection
v Urolithiasis
v Atelectasis
v Pneumonia
v Cor Pulmonale
v Paralytic shock
v Observe the patient for paralysis and other neurologic damage
v Maintain patent airway
v Check blood pressure frequently
v Provide an adequate, well-balanced diet
v Good skin care and frequent repositioning

v Inform ambulatory patients about the needs for careful handwashing.
v Instruct the patient or caregivers about measures need to manage symptoms and prevent complications.
Prevention
v Administration of Oral Polio Vaccine

v Boosters are required at 10-years intervals for travel to endemic areas.

OBSTETRIC NURSING
HUMAN SEXUALITY
Sexuality
v Encompasses the complex emotions, feelings, preferences, attitude and behaviors that are related to sexual self
and eroticism.
v Behavior of being a male or female
Gender
v Sense of femininity or masculinity
Sex
v Biologic male or female status
FEMALE
EXTERNAL GENITALIA
v Vulva
• Collective term for external female genitalia
v Mons pubis
• Also termed as Mons Veneris
• Pad of adipose tissue that lies over symphysis pubis covered by skin and at puberty covered by hair.
v Labia Majora
• Large lips
• Two folds of adipose tissue covered by loose connective tissue and epithelium.
• Serves as protection for the external genitalia and the distal urethra and vagina.
v Labia Minora
• Two hairless folds of connective tissue covered with mucous membrane and the external surface with skin.
v Clitoris
• Pea-shaped composed of erectile tissues and sensitive nerve endings
• Site of sexual arousal and eroticism in females
v Fourchette
• Formed by the posterior joining of the labia minora and majora
• Common site for episiotomy
v Vestibule
• Almond-shaped structure containing urinary meatus, Skene's gland, hymen, vaginal orifice and Bartholin's
gland
v Urinary Meatus
• Urethral opening for urination
v Skene's Gland
• Also called Paraurethral Gland
• Secretes small amount of mucous which functions as lubrication during sexual intercourse or coitus
v Bartholin's Gland
• Also termed as Paravaginal Gland
• Secretes alkaline substance responsible for neutralizing the acidity of the vagina to keep the sperm alive.
v Vaginal Orifice
• External opening of the vagina
v Hymen
• Membranous tissue that covers vaginal orifice
v Perineum
• Muscular structure in between vagina and anus
INTERNAL GENITALIA
v Passageway of menstruation and fetus
v 6-7 cm (anterior wall); 8-9 cm (posterior wall)
v Has dilatable canal
v Rugae
• Thick folds of membranous stratified epithelium which permits stretching without tearing.

v Uterus
• Hollow, muscular, pear-shaped organ for containment and nourishment of the fetus
• Function for menstruation pregnancy and labor
• Size (non-pregnant: 2.5 cm thick, 5 cm wide ,5-7 cm long
• Shape (non-pregnant): pear shape
• Shape (pregnant): ovoid
• Weight
ü Non pregnant: 60 g
ü Pregnant: 1000g
UTERINE ANATOMY
Fundus • Upper cylindrical layer
• Portion that can be palpated at the abdomen to determine the
amount of uterine growth occurring during pregnancy
Isthmus • Short segment between the body and the cervix
• Portion of the uterus that is most commonly cut when a fetus is born
by a Cesarean section
Corpus • Portion of the structure that expands to contain the growing fetus
(Body)
Cervix • Lower uterine segment
• Lowest portion of the uterus
• Approximately half of it lies above the vagina and half extends to the
vagina
UTERINE LAYERS
Endometrium • Innermost layer
• Composed of 2 layers (basal layer and glandular layer)
Myometrium • Muscle layer of the uterus
• Constricts the tubal junctions and preventing regurgitation of menstrual
blood into the tubes
• Contracts during the labor and delivery processes
Perimetrium • Outmost layer or the uterus
• Serves the purpose of adding strength and support to the structure
v Decidua – Latin word for “falling off”

3 Types of Decidua
Decidua basalis Endometrium that lies directly under the embryo
Decidua Portion of the endometrium that stretches or encapsulates the
capsularis surface of the trophoblast
Decidua vera Remaining portion of the uterine lining
v Ovaries
• 4cm long by 2cm in diameter and approximately 1.5cm thick or almond shape, grayish-white, female sex
gonads producing progesterone and estrogen.
• Function
ü Produce, mature and discharge ova (egg cells)
ü Produce estrogen and progesterone and initiate and regulate menstrual cycle.
v Fallopian Tube
• 10 cm long
• Conveys ova from the ovaries to the uterus and provides a place for fertilization of the ovum by the
sperm
SEGMENTS
Infundibulum • Approximately 2 cm long and is funnel shaped
• Covered by fimbria that help to guide the ovum into the fallopian tube
Ampulla • Longest portion on the tube
• Common site for fertilization; common site for ectopic pregnancy

Isthmus • Portion of the tube that is cut or sealed in a tubal ligation or tubal
sterile procedure
Interstitial • Most dangerous site for ectopic pregnancy
MALE
v Penis
• Male organ for copulation and urination
• Layers
ü 2 corpus cavernosa - lateral column of erectile tissue
ü 1 corpus spongiosum -located on the underside of the penis
v Scrotum
• Pouch hanging below the penis
• Contains the testes
• Temperature regulator of the testes
v Testes
• Two ovoid glands, 2-3 cm wide, that lie in the scrotum.
INTERNAL GENITALIA
v Epididymis
• Responsible for conducting sperm from the testis to the vas deferens
• Site of maturation of the sperm
v Vas Deferens
• Carries sperm from the epididymis through the inguinal canal into the abdominal cavity
• Sperm matures as it passes the vas deferens.
v Seminal Vesicle
• Secretes viscous portion of the semen.
• Contains:
ü Fructose
ü Protein
ü Prostaglandin
v Ejaculatory Duct
• Conduit of semen and joins the seminal vesicles to the urethra.
v Prostate Gland
• Produces alkaline substance for the protection of the sperm
• Reduces the acidity of the vagina
v Cowper’s gland
• Also termed as bulbourethral gland.
• Secretes lubricant into the urethra to facilitate transport of sperm during ejaculation
v Urethra
• Vessels of transport of urine and semen.
MENSTRATION
AVERAGE CYCLE: 28 days (23-35days)
Duration of menstrual flow
• 4-6days (normal)
• 1-9 days (abnormal)
Normal blood loss: 30-80 cc, ¼ cup
Interplay of 4 major organs:
• Hypothalamus
• Anterior pituitary gland
• Ovaries
• Uterus

v Hypothalamus
• Produces GnRH or gonadotropin-releasing hormone to stimulate the anterior pituitary gland for the
release of hormones
v Anterior pituitary gland
• Also termed as adenohypophysis
• Secretes Gonadotropins (Hormones that stimulate the Gonads or Ovaries)
• Stimulates the ovaries to secrete estrogen and progesterone
v Gonadotropins
v Follicle-stimulating Hormone (FSH)
ü Hormone that is active early in the cycle and is responsible for maturation of the primordial follicle.
v Luteinizing Hormone (LH)
• Hormone most active at the midpoint of the cycle and is responsible for ovulation.
v Ovary
• Release of the ovum (egg cell)
v Uterus
• Stimulation from the hormones
• Develops stratum functionalis in preparation for pregnancy – sheds of as menstruation if ovum not
fertilized
MENSTRUAL CYCLE
v Proliferative Phase
• Other terms: follicular phase/ estrogenic phase / post-menstrual phase
• 6 to 14 days
• First phase of menstrual cycle
• Always variable in length
• Immediately after the menstrual flow, the endometrium is very thin, approximately once cell layer in
depth
• Endometrium begins to proliferate as the ovary begins to produce estrogen
• Levels of estrogen will increase in this phase
v Graafian follicle
• Most mature of all follicles
• With cavity and ovum ready to be extruded
• With clear fluid rich in estrogen
• Only 1 follicle matures per menstrual cycle
Primordial follicle
• Immature follicle
ESTROGEN: secretion effect in Uterus
• Thickens the uterine lining approximately eight-fold
ü From one millimeter to eight millimeters
• Peak of uterine lining coincides with ovulation
• Peaking of estrogen will signal luteinizing hormone surge (increase in blood levels of luteinizing hormone)
LH Surge
• Coincides with ovulation
• Extrusion of ovum from the Graafian follicle signals OVULATION
v Luteal Phase
• Other terms: Secretory Phase / Progestational Phase / Premenstrual Phase
• Second phase of menstrual cycle
• Remains constant: always 14 days in length
• Production of corpus luteum occurs
• Secretion of luteinizing hormone (LH) peaks in this phase
• Cavity is left inside the follicle
• Stimulates change in fluid in Graafian follicle (yellowish, milky white fluid high in progesterone)
PROGESTERONE EFFECT
• Maintains and organizes uterine lining
• If estrogen is present, the uterine lining would continue to thicken
• Under the influence of luteinizing hormone, the progesterone in the corpus luteum causes the glands of the
uterine endometrium to become corkscrew or twisted in appearance.
• Depo Pro-Vera — this drug contains progesterone and used for dysfunctional uterine bleeding.
v Ischemic Phase
• If fertilization does not occur, the corpus luteum in the ovary begins to regress after 8 to 10 days.
• Production of progesterone and estrogen in this phase also decreases
• The decrease in these hormones makes the endometrium to degenerate
• Capillaries rupture with minute hemorrhages and the endometrium sloughs off
v Menstrual Phase
• Low levels of Estrogen & Progesterone
• Passage of menstrual flow
TERMINOLOGIES
v Zygote
• Product of fertilization
• < 2 weeks aog
v Embryo
• Intrauterine growth period from the time following implantation until organogenesis is complete
• 2 to < 8 weeks aog
v Fetus
• 8 weeks to birth
v Viability
• Fetus can be delivered and capable of living outside the utero
• Period of viability: 24 weeks and above (Pillitteri, 2010)
v Gravida
• number of pregnancies that reach the age of viability regardless of the outcome of the pregnancy.
TPAL
T- term (38- 42 weeks)
P- preterm (<37 weeks)
A- abortion (any terminated pregnancy)
L- living children
v Implantation
• Contact between the growing structure and the uterine endometrium.
• Occurs approximately 8 to 10 days after fertilization.
v Nulliparous
• Had been pregnant before but has never given birth to a viable, or a live, infant
v Nulligravid
• Had never been pregnant
PREGNANCY
1. Presumptive Signs
v Least indicative of pregnancy
v Largely subjective as they are experienced by the woman but cannot be documented by the examiner
Examples:
v Breast changes
• Feeling of tenderness, fullness, or tingling, enlargement and darkening of areola
v Nausea and Vomiting
• Increase in human chorionic gonadotropin (HCG) levels
Interventions:
• Provide dry, unsalted Crackers
• Ice Chips
• Small, Frequent Feedings
• Less fatty foods in diet
• Encourage ambulation
v Amenorrhea
• Absence of menstruation because of hormonal changes
v Changes in Urination
• Urinary Frequency — 1st and 3rd Trimester
• Frequency of urination occurs in early pregnancy due to the pressure of the growing uterus on the
anterior bladder.
v Fatigue
• General feeling of tiredness due to increased metabolic requirement’s
v Quickening
• Fetal movement felt by the woman.
• Approximately 18 to 20 weeks.
v Skin changes
• Melasma /chloasma- mask of pregnancy
• Linea nigra – darkening of skin from symphysis pubis to umbilicus
• Striae gravidarum- silvery in color, due to distention of the collagen of the abdomen as uterus enlarges.
2. Probable Signs
v Can be documented by the examiner
v Still not confirmatory
Examples:
v Laboratory tests
• Test of blood serum/urine reveal the presence of hormone
v Positive Pregnancy Test
• Indicator: hCG levels
• This can be detected 10-14 days after the missed period.
• Peak level of hCG = 10 weeks Age of Gestation or 2 months
v Abdominal enlargement
• Symmetrical and globular
LANDMARKS
12 WEEKS Symphysis pubis
16 weeks Halfway between umbilicus and symphysis pubis
20 weeks Level of umbilicus
Increase of one centimeter in fundic height = additional 4 weeks in ages of gestation

+ 1 cm above the umbilicus 24 weeks
+ 2 cm above the umbilicus 28 weeks
+3 cm above the umbilicus 32 weeks
+ 4 cm above the umbilicus 36 weeks (level of the xiphoid process)
One centimeter below the xiphoid process 40 weeks
v Chadwick's Sign
• Bluish-purple discoloration of the vagina due to increase in vascularity of the vagina
v Goodell's Sign
• Softening of the cervix to ready cervix for dilation and effacement
v Hegar's Sign
• Softening of the lower uterine segment
v Ballottement
• When lower uterine segment is tapped on a bimanual examination, the fetus can be felt to rise against
abdominal wall.
• At 16th -20th week
v Braxton-Hicks Contraction
• Periodic uterine tightening occurs.
• Starts 28 weeks and above
3. Positive Signs
• Fetal Heart Tone
• Fetal movement felt by examiner
• Fetus seen through Ultrasound or X-ray

MATERNAL PHYSIOLOGY
Prenatal Clinic
1. Take Client's History
2. Physical Examination
• Taking woman's blood pressure
ü Let the mother rest for approximately 15 minutes
ü Blood pressure reading varies with position
ü Sitting: BP is slightly higher (highest reading of the three positions)
ü Supine: Intermediate reading
ü Left Lateral: Lowest reading among the three positions
• Abdominal Assessment
ü Place the woman in supine position with both legs flexed.
ü Inspection: Look for presence of striae; linea nigra
ü Take the client's fundic height
o Place at tip of symphysis pubis up to level of fundus and note the measurement.
o Use centimeter scale of tape measurement
Perform Leopold’s Maneuver
Purpose:
• To determine fetal presentation and position
Let patient void before Doing so promotes comfort and allows for more productive palpation
performing Leopold’s because fetal contour will not be obscured by a distended bladder
Maneuver
Position the woman supine Flexing the knees relaxes the abdominal muscles. Using a pillow or towel
with knees slightly flexed. tilts the uterus off the vena cava , thus preventing supine hypotension
Place a small pillow or rolled syndrome
towel under one side
Wash your hands using Hand washing prevents the spread of possible infection. Using warm
WARM water water aids in client comfort and prevents tightening of abdominal muscles
In the first three maneuvers, nurse faces the head part of the bed. However, during the last maneuver
the nurse will be facing the foot part of the bed.
v Leopold's Maneuver 1
• Determines whether fetal presentation is cephalic or breech.
• Palpates uterine fundus
Important Concepts:
• Palpate the superior surface of the fundus and determine the consistency, shape and mobility.
ü Head: more firm than breech; round and had moves independently of the body.
ü Breech: less-well defined; moves only in conjunction with the body.
• LM 1 determines the fetal presentation.
ü Fetal presentation refers to the body part that will first contact the cervix or be born first.
ü Types of Presentation: Cephalic, breech, shoulder
v Leopold’s Maneuver 2
• Locates the fetal back
• Fetal back is characterized by smooth, hard, resistant surface.
• However, if the assessment findings reveal several angular nodulations, the areas palpated may be part of the
knees and elbows of the fetus
Important concept:
• Fetal back= where fetal heart tone is most audible
• Determines the part of the fetus at the inlet and its mobility.
• Determines if the presenting part is engaged or not engaged.
• If head is not engaged: the presenting part moves upward or either sideward
• If head is engaged: head is firmly settled into the pelvis
• Determines fetal attitude and degree of fetal extensions into the pelvis.
• It should be done only if the fetus is in a cephalic presentation.
• Information about the infant’s anteroposterior position may also be gained from this final maneuver

Fetal attitude
• This is the degree of flexion of the baby in utero
TYPES OF ATTITUDE
Occiput/Vertex • The head is sharply flexed, making the parietal bones, or the space
(Full flexion) between the fontanels presenting part
• Present the suboccipito-bregmatic (smallest) diameter
Sinciput (military) • Fetus is not as well flexed
• Presents occipitofrontal diameter to inlet
Brow • From this position, extreme edema and distortion of the face may occur
(Partial extension)
Face • Widest diameter (occipitomental) is the presenting part.
(Poor flexion) • As a rule, a fetus cannot enter the pelvis in this presentation
PRENATAL ASSESSMENT/ ANTENATAL VISITS

In the ideal setting:
At (0 - 28) Age of Gestation
• Ask client to come back every 4 weeks
At (28 - 36) Age of Gestation
• Ask client to come back every 2 weeks
At (36) weeks onwards
• Ask client to come back every week
PHYSIOLOGICAL CHANGES DURING PREGNANCY

1. Cardiovascular System
• The heart is displaced upward, to the left, and forward.
• As the uterus enlarges, pressure of blood vessels increases and slows the circulation. It leads to edema and
varicosities of the legs, vulva and rectum
• The pressure of the enlarged uterus on the cava causes supine hypotensive syndrome during the second
trimester (when the woman lies supine).
• Position of Choice: Left lateral/Sim's position (so as not to impede the vena cava)
• Cardiac output increases significantly by 25% to 50%
• Heart rate increases 10 beats per minute.
2. Hematologic system
• Presence of hemodilution in response to increase in plasma volume during pregnancy
• Physiologic anemia occurs during pregnancy.
Management:
• Advise mother about the increase in iron requirements
• Take iron supplements
• Increase intake of iron-rich foods
3. Respiratory system
• Shortness of breath – due to uterine enlargement
• Total oxygen consumption increased by as much as 20%
• Total volume is increased up to 40 %
• Clients tends to hyperventilate resulting to respiratory alkalosis.
Manifestations of respiratory alkalosis:
• Tingling sensation on the lower ends of extremities
• Light-headedness
Nursing managements
• Breathe through a paper bag or through cupped hands.
4. Gastrointestinal Tract
v Pica
o Medical disorder characterized by an appetite for substances largely non-nutritive
o Inedible (metal, clay, coal, sand, dirt, soil, chalk, pens, and pencils)
o The underlying cause may be attributed to hyper salivation
o if not checked, this causes vomiting
v Epulis
• Swelling of the gums causing gingival bleeding
• Attributed to the increased estrogen levels.
Management
• Use soft-bristled toothbrush
• Avoid using strong mouthwash.
v Ptyalism
• May be due to increase levels of estrogen
• Management: provide hard candies
v Heartburn
• Because of the rapid increase in the size of uterus, it tends to push the stomach and intestines toward the
back and sides of the abdomen
• The pressure applied on the stomach may slow the peristalsis and emptying of the stomach, leading to
heartburn
Nursing management
• Do not assume supine position after eating
• Gradual ambulation
• Small frequent feeding
5. Renal system
Changes result in the following:
• Effects of high estrogen and progesterone levels
• Compression of the bladder and ureters by the growing uterus resulting to increase urinary frequency
• There is relaxation of renal pelvis and the ureter leading to urine stagnation. Because of this, patient is
prone to urinary tract infection (UTI)
6. Endocrine system
• Woman is at greatest Risk for Hyperthyroidism
• Patient may die when in labor with hyperthyroidism
• Thyroid Storm leads to arrhythmia, which could lead to death
• Carefully monitor the client about the presence of signs and symptoms that may signal hyperthyroidism
7. Musculoskeletal System
v Placenta can produce the hormone, relaxin
• Relaxes pelvic joints
• Therefore, the pelvic is more movable
v Diastasis Recti
• Separation of rectus abdominis muscle
• Only fascia remains in between
• This is a normal physiological response of the body
• Rectus abdominis muscle goes back after pregnancy
v Physiologic Lordosis
• Also known as the Pride of Pregnancy
• Increased outward curvature
• Presence of back pain
Nursing Management
• Do Pelvic Rocking
• Place direct pressure on lumbar area
• Prevent supine position (increases pressure on the spine)
• No analgesic
FREQUENT USED DRUGS THAT SHOULD NOT BE TAKEN DURING PREGNANCY

NSAIDS (Indomethacin)
v Not advisable
v Causes premature closure of the Ductus Arteriosus
v No supply to the lower half of the body of the fetus
v This drug also causes decrease urine output resulting in oligohydramnios.
v In the neonate born after prenatal indomethacin exposure, reported complications have included:
• Necrotizing enterocolitis
• Intracranial hemorrhage
• Cystic brain lesion
• Renal dysfunction
ASPIRIN
v May cause:
• Hemorrhage
• Premature closure of the ductus arteriosus
• Prolonged gestation and labor
• Intrauterine growth restriction
• Congenital salicylate intoxication
Important concept
• Use low-dose aspirin.
• Stop taking about four weeks prior to EDD.
Diagnostic Exams
1. Amniocentesis
v Withdrawal of amniotic fluid through the abdominal wall for analysis
v Best done at 14-16 weeks age of gestation or during 2nd trimester
Important considerations:
• Void before the procedure
ü Reduces bladder size and prevents accidental puncturing during the procedure
• Let the patient stay and observe foe 30 minutes after the procedure
ü Be certain that labor contraction are not beginning and fetal heart rate remains with in normal limits
v Normal amount amniotic fluid
o 800-1200 ml
v Oligohydramnios - less than 500mL
v Hydramnios/polyhydramnios - more than 1200mL
Information obtained
v Color: clear to slightly yellowish
Important consideration:
• Strong yellow color: suggest blood incompatibility
• Green: meconium staining
v Fetal lung maturity
• Analyzed for lung surfactant phosphatidyl glycerol and desaturated phosphatidylcholine
• Lecithin: sphingomyelin (L:S) ratio
o Lecithin: lung surfactant
o Normal ratio is 2L:1S
• If there is anticipated premature delivery, amniocentesis is done to know if delivery is viable.
v Bilirubin determination
• Presence of bilirubin may be analyzed if a blood incompatibility is suspected
• If bilirubin is going to be analyzed the specimen must be free of blood or a false-positive reading will
occur.
v Inborn errors of metabolism
• Amniocentesis call detect presence of cystinosis and maple syrup urine disease (MSUD)
*Maple syrup urine disease - an inherited disorder; unable to process amino acids properly
*Cystinosis - Cystine storage disease; accumulation of cystine within cells
2. Ultrasound
v Measures the response of sound waves against solid objects
Purposes
• To diagnose pregnancy.
• To establish sex of the fetus.
• To predict maturity of the fetus.
• To confirm the presence, size, and location of the placenta and amniotic fluid.
Types:
v Transabdominal Ultrasound
• Ask the client to drink plenty of water 1 hour before procedure.
• Full bladder will push uterus to pelvic cavity for better visualization at abdomen.
v Transvaginal Ultrasound
• Ask client to void.
Ultrasound in the First Trimester
v Information obtained:
ü Confirmation of Pregnancy
(+) cardiac movement
(+) yolk sac
(+) Fetal Heart Tone
ü Identification of Intrauterine Device (IUD) in Place
ü Identification of H-MOLE
Ø Snow-storm appearance
Ø There are specks of white in a dark background; these are vesicles filled with fluid
Ultrasound in the Second and Third Trimester
• Information obtained:
ü Location of Placenta
ü Growth of the fetus
ü Amount of Amniotic Fluid
ü Fetal Position and Fetal Presentation
ü Sex / Gender of the Baby
Ø Determinable at sixteen (16) weeks of gestation
Ø Ideal time is twenty-eight (28) weeks
v Congenital / Chromosomal Problems
Ø Determined by three-dimensional (3D) ultrasound
3. Biophysical score
v Combines five parameters which are as follows:
• Fetal reactivity
• Fetal breathing movement
• Fetal tone
• Amniotic fluid volume
• Fetal heart activity
v May be done as often as daily during a high-risk pregnancy
v Fetal score of 8-10= fetus is doing well
v Fetal score of 6 = considered to be suspicious
v Fetal score of 4 = this shows a fetus in jeopardy
Instruments used:
v Sonogram
• Criteria for score of 2
Fetal breathing At least one episode of 30 second of sustained fetal breathing movements
within 30 mins of observation
Fetal movement At least three separate episodes of fetal limb or trunk movement within a 30
mins observation
Fetal tone The fetus must extend and then flex the extremities or spine at least once in 30
min
Amniotic fluid A pocket of amniotic fluid measuring more than 1 cm in vertical diameter must
be present
v Non-stress Test
Criteria for a score of 2
• Fetal heart reactivity: two or more fetal heart rate accelerations of least 15 beats/min above baseline and of
15 seconds in duration with fetal movement over a 20-minute time period.
4. Non-Stress Test
v Measures the response of fetal heart rate in relation to fetal movements
v Uses Cardiotocograph (CTG) Tracing

v Non-invasive
Results:
Reactive (Normal): Two or more accelerations of fetal heart rate of 15 beats/min lasting 15 seconds or more
following fetal movements in a 20-minute period (15 bpm for 15 seconds).
Non-reactive: No accelerations occur with the fetal movement.
Safety consideration: Woman should not lie supine to prevent supine hypotension syndrome.
5. Contraction Stress Test (CST)
v Measures response of fetal heart rate to uterine contractions
v Stimulation of contractions through: (1) Nipple stimulation or (2) Oxytocin Challenge
v Best done when the mother is at thirty-eight (38) weeks Age of Gestation
v Done when NST is NON-REACTIVE.
Results:
Negative (Normal): No late decelerations with contractions
Positive (Abnormal): Late decelerations
Safety consideration: Observe woman for 30 minutes to see that contractions are quiet and preterm labor does
not begin.
v Nipple Stimulation
• Explain procedure and Position the client comfortably
• Rub nipples
• Give pack / warm soaks for 10 minutes prior to stimulation to increase circulation / vascularity
• Start 4 cycles per stimulation
• Start with the first cycle. If after these and there are NO CONTRACTIONS, stop and rest for 2 to 4
minutes
• Do the procedure up to 4 cycles
• If no contractions after the Fourth cycle
ü Stop stimulation
ü Proceed with Oxytocin Challenge Test
v Oxytocin Challenge Test
• Give diluted form of oxytocin at a titrating dose
• Start 10-12 drops per minute to a maximum of 40 drops per minute
• Wait for 2 Consecutive Uterine contractions
• Stop Oxytocin Challenge Test if 2 uterine contractions are obtained
• Now compare Uterine Contractions with Fetal Heart Tone
Important Concepts
• Note for timing of deceleration in relationship to contraction
ü Deceleration is seen after contraction
ü U-shaped deceleration
v Interventions for Late deceleration (Positive CST result)
• Place client in the left lateral position.
• Stop oxytocin immediately: no contractions wanted.
• Give oxygen to the mother: rate is 8-10 liters per minute.
• Hydrate with plain water.
• If deceleration is > 10 minutes, Cesarean section may be necessary.
6. Chorionic villi sampling
v It is a diagnostic technique that involves the retrieval and analysis of chorionic villi from the growing placenta for
chromosomes or DNA analysis
v Done at 8 to 10 weeks
Post procedure: Instruct to report chills or fever suggestive of infection or threated miscarriage.
7. Alpha-fetoprotein (AFP)
v Alpha-fetoprotein is a glycoprotein produced by the fetal liver that reaches a peak in maternal serum
between the 13th and 32nd week of pregnancy,
Results:
• Elevated: Neural tube defect
• Decreased: Fetal Chromosomal Disorder (e.g. Down syndrome)

PSYCHOLOGICAL TASKS OF THE MOTHER
First Trimester
v Mother should accept that she is pregnant (though ambivalence may be present)
v Concern of the mother towards herself is greater than her concern towards the baby
Second Trimester
• Acceptance of the baby is the main task
• Concern towards the self is equal to concern for the baby
Third Trimester
• Acceptance of parenthood
• Concern for the self is less than concern for the baby
LABOR
Theories of Parturition
1. Fetal sign
• The baby feels that it is already capable of living outside the utero
2. Oxytocin theory of parturition
• Receptors for oxytocin in the uterus increase as term approaches.
3. Progesterone Withdrawal Theory
• Level of progesterone assayed in preterm and term pregnancy
• Preterm: Progesterone level is still high
• Approaching Term: Level of progesterone decreases causing contraction of uterus
4. Prostaglandin Theory
• Prostaglandin stimulates uterine contraction
FACTORS AFFECTING LABOR

1. Pelvic Dimension
Android Pelvis Male pelvis.
The pubic arch in this pelvis type forms an acute angle, making the lower
dimensions of the pelvis extremely narrow.
"Ape-like" pelvis.
Anthropoid Pelvis The transverse diameter is narrow, and the anteroposterior diameter of the inlet is
larger than normal.
Gynecoid Pelvis "Normal" female pelvis.
The inlet is well-rounded forward and backward
Ideal for childbirth.
"Flattened" pelvis.
Platypelloid Pelvis The inlet is an oval, smoothly curved, but the anteroposterior diameter is shallow.
2. Fetal Dimensions
v Fetal Size
• Correlation of size of baby to pelvic size
Cephalopelvic Disproportion (CPD)

• Head of the baby is INCONGRUENT with the maternal pelvis.
• Size of the fetal head is greater than the maternal pelvis.
Important Concepts:
• Despite the presence of CPD, there is a trial of Labor and not an absolute Cesarean Section
• Number of Cesarean Section in hospitals should not be more than 20% of all deliveries
v Fetal Attitude
• This describes the degree of flexion a fetus assumes during labor or the relationship of the fetal parts to each
other
• If in complete extension, labor may not progress since this does not allow an adequate fetal movement
v Fetal Lie
• The relationship between the long axis of the fetal body and the long axis of a woman's body.
• Types of fetal lie: Longitudinal, transverse, oblique
• If in a transverse lie, dilatation will not progress

v Fetal Presentation
• Denotes the body part that will first contact the cervix.
• This is determined by a combination of fetal lie and the degree of fetal flexion/fetal attitude
v Fetal Position
• It is the relationship of the presenting part to specific quadrant or a woman pelvis
• Examples: Right occipitoposterior (ROP), Left sacroanterior (LSA)
v Fetal Station
• Relationship of the presenting part to the level of ischial spines
Level of ischial spine Station
3cm above ischial spine -3 (floating)
2cm above ischial spine -2
1cm above ischial spine -1
At the ischial spine 0 (engaged)
1cm below ischial spine -1
2cm below ischial spine -2
3cm below ischial spine -3 (crowning)
• Linea terminalis- divides the false from true pelvis
ü Above linea terminalis = false pelvis
o Support uterus during the late months of pregnancy
o Aids in directing the fetus into the pelvis for birth
ü Below the linea terminalis = true pelvis
3. Fetal diameters
v Suboccipitobregmatic diameter
• Narrowest/Smallest diameter
• Approximately 9.5 cm wide
• Measurement is from the inferior aspect of the center of the anterior fontanelle
v Occipitofrontal diameter
• Measurement is from the occipital prominence to the bridge of the nose.
• Approximately 11 cm wide
v Occipitomental diameter
• Widest/Largest anteroposterior diameter
• Approximately 13.5 cm wide
• Measurement is from the posterior fontanelle to the chain
4. Fetal Head
v Anterior fontanelle
• Diamond shape
• Closes at 12-18 months of age
v Posterior fontanelle
• Triangle shape
• Closes at 2-3 months of age
PRELIMINARY SIGNS OF LABOR

v Lightening
• Primigravida= 2 weeks prior to labor
• Multigravida= at time of labor
v Braxton-Hicks contractions
• Starting at 28 weeks AOG (or last week/ days before labor begins), Braxton Hicks contractions are strong
v Increase in level of activity
• Increase in activity is related to an increase in epinephrine release initiated by a decrease in progesterone
produced by the placenta
v Slight loss of weight
• As progesterone level falls, body fluid is more easily excreted from the body
• This increase in urine production can lead to a weight loss between 1 and 3 pounds
v Ripening of the cervix
• Internal sign seen only on pelvic examination
• Goodell’s sign = cervix feels softer than normal to palpation (“butter-soft”)
Sign of True Labor
True Labor False Labor

Start at lumbar or back Confined to hypogastric area
Regular interval Irregular interval
Progressive cervical dilation and effacement No cervical dilation and effacement
Intensity is increasing No change on intensity
Ambulation intensifies uterine contraction in true labor Ambulation stop the contraction
Sedation has no effect Sedation stop false labor
v Uterine contraction
• The surest sign that labor has begun is productive uterine contractions.
v Bloody show
• As the cervix soften and ripens, the mucus plug that filled the cervical canal during pregnancy
(operculum) is expelled
v Rupture of membranes
• a sudden gush or a scanty, slow seeping of clear fluid from the vagina
v Cervical dilation
STAGES OF LABOR
FIRST STAGE
v Starts from true contraction to full cervical dilatation (10cm)
PHASES (LAT)
LATENT PHASES • Begins at the onset of uterine contractions.
• Contraction quality: Mild
• Duration: 20 to 40 seconds, every 5 to 10 minutes
• Cervical effacement occurs
• Cervical dilation: 0 to 3 cm.
• Nullipara: 6 hours
• Multipara: 4.5 hours
ACTIVE PHASE • Contraction quality: Moderate, stronger
• Cervical dilation: 4 to 7 cm
TRANSITION PHASE • Contraction quality: Strongest
• Cervical dilation: 8 to 10 cm
NITRAZINE TEST
v Used to determine whether fluid is amniotic or not
v Nitrazine paper is in contact with the vaginal secretions.
v Results:
o Blue (alkaline): Amniotic fluid
o Red (acidic): Urine
Important Concepts:
• If membrane has ruptured for greater than 24 hours and still no birthing occurred, infection will most likely occur
and immediate Cesarean Section is needed.
SECOND STAGE
v Starts from full cervical dilatation (10 cm) up to delivery of the fetus
v Primigravida: 1-4 hours
v Mutigravida: 20-45 minutes
Important Concepts:
• Do not encourage pushing if cervix is not fully dilated and if there is no presence of contraction.
• Main purpose of pushing: to shorten the Second Stage of Labor
• Ask client to pant-breathe if there is an urge to push
Mechanisms of Labor (ED FIRE ERE)
- Engagement
- Descent
- Flexion
- Internal Rotation
- Extension
- External Rotation (Restitution)
- Expulsion
Essential Intrapartum and Newborn Care (EINC)
Properly timed cord clamping (when pulsation stops or after 2 minutes)
Immediate drying of baby (prevent hypothermia)
Non-separation of mother and baby
Early breastfeeding (within 60 minutes postpartum)
THIRD STAGE
v Starts from the delivery of the baby to the delivery of placenta
v Lasts for five (5) to ten (10) minutes
v Maximum waiting time is thirty (30) minutes
v Beyond 30 minutes is already abnormal
Signs of Placental Expulsion
• Calkin's Sign (Uterus becomes firm and globular)
• Lengthening of the Cord
• Sudden Gush of Blood
• Rising of the Uterus into the abdomen
ü Up to the level of the umbilicus 1cm after the delivery of the placenta
Two Types of Placental Expulsion
v Schultze Presentation
• Shiny and glistening from the fetal membranes
• Placenta separates first at its center and last at its edges
• Less chances of bleeding
v Duncan Presentation
• Raw, red, and irregular
• Placenta separates first at its edges
• Associated with more bleeding and hemorrhage
Nursing Responsibilities:
• Assess the appearance and completeness of the cotyledons (16-20). If not complete, reclean the uterus
to prevent bleeding.
• Measure the placental diameter.
• Weigh the placenta.
• Measure the umbilical cord.
• Expect presence of blood vessels.
ü 2 arteries and 1 vein (AVA)
Drugs for Third Stage of Labor

• Ergotrates
ü Includes Methergine I.V. or I. M.
ü Best given immediately after delivery of placenta
ü Massive contraction of the uterus traps placenta inside, therefore, do not give before placental expulsion
• Oxytocin
ü Give prior to expulsion of placenta to add to contraction
ü Given at minimal amounts
ü Normally at a rate of eleven to twelve drops per minute (11-12 gtts/min)
ü After the delivery of placenta, give oxytocin at greater amounts
Important Concept
• In the Third stage of Labor, priority is minimizing risk for hemorrhage.

FOURTH STAGE
v First 1-4 hours after delivery of the placenta
v Priority: Achieve homeostasis and minimize bleeding risks.
v All water retained previously will be reabsorbed into the circulation leading to:
• Increased in Cardiac Output
• Increase in Oxygen Consumption
• Thus, most detrimental or difficult stage of labor in gravidocardiac patients.
Postpartum Assessment (BUBBLE-HE)
Breast
Uterus
Bladder
Bowels
Lochia
Homan’s sign: pain upon dorsiflexion (possible deep vein thrombosis)
Episiotomy
HEMORRHAGIC DISORDERS IN PREGNANCY
FIRST TRIMESTER
1. Abortion/Miscarriage
v Any interruption of a pregnancy before a fetus is viable.
v Viable Fetus - fetus of more than 24 weeks of gestation or one that weighs at least 500 g.
Two types of Abortion
v Spontaneous Abortion
• Most common cause of spontaneous abortion is chromosomal in nature.
• Embryo is defective.
TYPES OF SPONTANEOUS ABORTION

Threatened Abortion Presence of vaginal bleeding; no cervical dilation and effacement
Inevitable/imminent abortion Presence of vaginal bleeding; cervical effacement and dilation
Complete abortion All products of conception have passed in the vagina
Incomplete abortion Some products of conception have passed the vagina
Habitual abortion Occurrence of three or more pregnancies that end in miscarriage of the fetus
v Induced abortion
• Also termed as ‘elective termination of pregnancy”
• A procedure performed to end a pregnancy before fetal viability
Types of Induced abortion

• Therapeutic abortion
• Illegal
2. Ectopic Pregnancy
v Implantation occurs outside the uterine cavity
v Most common site: Ampulla of Fallopian tube
v Most common predisposing factor: Pelvic Inflammatory Disease (PID)
v Other factors include:
• Previous Surgery
• Presence of Intrauterine Device
• History of previous ectopic pregnancies
Triad Manifestations
• Amenorrhea
• Vaginal bleeding or Spotting
• Unilateral lower abdominal pain/tenderness
• Severe, sharp knife-like a pain; Unilateral pain
• Abdominal rigidity
ü Bleeding inside
ü Hemoperitoneum
ü Peritonitis
• Positive (+) for Cullen's Sign
ü Ecchymosis around due to hemoperitoneum
• Decreased Blood Pressure
• Excruciating pain when the moved (wriggling tenderness)
Diagnosis for Ectopic Pregnancy
• Culdocentesis
ü Refers to the extraction of fluid from the recto-uterine pouch posterior to the vagina through a needle.
Medical Management
v Methotrexate
o A sclerosing agent: Shrink and absorb products of conception.
o Chemotherapeutic agent attacks and destroys fast-growing cells.
o Given I.M. to the mother if ectopic pregnancy is less than 3 cm
Surgical Management
v Salpingotomy
o Limited to unruptured (<3 cm)
o Left to heal
v Salpingectomy
o For a ruptured ectopic pregnancy
SECOND TRIMESTER
3. Hydatidiform Mole
v Also termed as H-Mole/ Gestational Trophoblastic Disease / Molar Pregnancy villi
v Abnormal proliferation and then degeneration of the trophoblastic villi
v Vesicle-like structure is formed instead of placenta
Cause
• Unknown
Predisposing Factors
• Low socio-economic status
• Low protein intake
• Age
ü Less than 18
ü Greater than 35
Manifestations of H-Mole
• Excessive vomiting (because of high levels of HCG)
• Bleeding: pinkish vaginal discharge
• FHT: absent
• Rapid abdominal enlargement
• pregnancy induced hypertension
• Occurs earlier because Human Chorionic Gonadotropin is very high in H-Mole
Management
v Dilation and curettage
• To expel H-Mole components
• Sinuses open
ü Early dissemination of tissues or metastasis to lungs, brain
v Monitor HCG Titer
• Normal: 100,000 U to 400,000 U
• H-Mole: 1,000,000 U to 2,000,000 U
• Close follow up is mandatory
• Monitor level of beta–HCG level every 2 weeks until normal
• When normal continue monitoring levels of beta –HCG every 2-4 weeks for duration of 1 year
• No pregnancy for 1 year
4. Premature Cervical Dilation
v Previously termed as incompetent cervix
v Refers to a cervix that dilates prematurely and therefore cannot hold a fetus until term
v Most common cause of habitual abortion
v Habitual abortion: 3 or more consecutive abortions
v First symptoms may either be a “show “ (pink-stained vaginal discharge) or increased pelvic pressure
• Developmental Factors
ü Defective collagen formation in the cervix
• Repeated Trauma to the cervix
• Repeated Dilatation and Curettage
Management
• McDonald's Procedure
ü Purse string suture applied to cervical opening
ü Purpose is to make the cervix tense
ü Done if fetus is less than 12 weeks old
ü Mother is allowed to deliver by normal spontaneous delivery if pregnancy persists
ü Nylon sutures are placed horizontally and vertically across the cervix and pulled tight to reduce the cervical
canal to a few millimeters in diameter.
ü Sutures are removed 37 to 38 weeks of pregnancy.
• Shirodkar / Barter Procedure
ü Sterile tape is threaded in a purse-string manner under the submucous layer of the cervix and sutured in
place. to achieve a closed cervix
ü Cervix is closed but menstrual blood is allowed to come out
ü Sutures are placed by a transabdominal route.
ü Delivery is via Cesarean Section
• Bed rest
• Position of choice: Modified Trendelenberg
o Lumbar area elevated; feet lowered
• Coitus is temporarily restricted
• Tocolytic therapy (stops uterine contractions): Ritodrin (Yutopar) & Terbutaline (Brethine)
THIRD TRIMESTER
5. Placenta Previa
v Placenta is implanted abnormally in the uterus.
v Most common cause of painless bleeding in the third trimester of pregnancy
Predisposing factors
• Multiparity
• Tumor or mass in the uterus
ü Previous Cesarean Section
ü Scar is avoided by the placenta
• Developmental Anomaly in the Uterus
(Bicornuate Uterus)
TYPES
Low Lying • Implantation in the lower rather than in the upper position of the
uterus
Marginal • The placenta extends to the edge of the cervix but does not cover it
Partial • Implantation that occludes a portion of the cervical os
Total • Also called Placenta Previa Totalis
• Implantation that totally obstructs the cervical os
Clinical Assessment
• Bleeding that occurs is usually abrupt, painless & bright red
• Uterine consistency; soft
Nursing Management
• Place the woman on bed rest
• Position: Side lying
• Assess the following:
ü Duration of pregnancy
ü Time the bleeding began
ü Woman’s estimation of the amount of blood (number of cups/tablespoons)
ü Color of blood
• Never attempt a pelvic or rectal examination with painless bleeding late in pregnancy
• Continue to assess blood pressure every 5 to 15 minutes
• IV therapy
• Monitor urine output every hour
• Attach external monitoring equipment to record fetal heart sounds and uterine contractions
• Have oxygen equipment available in case of fetal distress
• Typically, a woman remains in the hospital on bed rest for close observation for 48 hours
• If the bleeding stops, she can be sent home with a referral for bed rest and home care
6. Abruptio Placenta
v Early separation of the placenta prior to delivery of the fetus
v Abnormal separation occurs on the second stage of labor
Cause
• Unknown
• Cocaine
• Cigarette smoking
• High parity
• Advanced Maternal Age
• Short umbilical cord
• Chronic hypertensive disease
• Pregnancy-induced hypertension
Clinical Assessment
• Sharp, stabbing pain in uterine fundus
• Heavy bleeding but may not be readily apparent
• Rigidity of the uterus
• Fetal heart tone may not be heard
Separation in Abruptio Placentae may be:
v Peripheral Separation
• Better and safer
• Blood goes out of the introitus
• Tachycardia
• Hypotensive
• Increases degree of separation
• Increases degree of fluctuation of vital signs
v Central Separation
• More dangerous
• Couvelaire Uterus – Blood does not seep off through the introitus but enters myometrium, leaving the uterus
bluish or copper-colored
• Results to difficulty of contraction of the Myometrium
• Uterine Atony – uterus remains soft and boggy

• Because of the presence of uterine atony, Hysterectomy will be done
Management
• Fluid replacement
• Provide oxygenation to limit fetal anoxia
• Monitor fetal heart sounds externally
• Record maternal vital signs every 5 to 15 minutes for baseline data
• Position: Lateral; Avoid supine position to prevent pressure on the vena cava
• Do not perform any abdominal, vaginal or pelvic examination
• If there is presence of fetal distress, outright delivery may be necessary
PRETERM RUPTURE OF MEMBRANES (PROM)

v Rupture of fetal membranes with loss of amniotic fluid during pregnancy before 37 weeks
Cause
• Unknown
• Chorioamnionitis (Infection of the membranes)
Complications
v Infection
• Gold standard is 24 hours
• If more than twenty-four hours, there will be sepsis
v Cord Prolapse
• Extension of the cord out of the uterine cavity into vagina
• This condition could interfere with fetal circulation
Management
• Bed rest
• Corticosteroid such as Betamethasone to hasten fetal lung maturity
• Do not reinsert the cord
• Moisten gauze with NSS and cover the cord
• Provide Oxygenation
• Get fetal heart tone
• Outright delivery may be necessary if there is presence of maternal infection, fetal distress and labor
PREMATURE LABOR
v Labor that occurs before the end of week 37 of gestation
v Responsible for almost two-thirds of all infant deaths in the neonatal period
v Preventable
Causes
• Unknown
• Dehydration
• Urinary Tract Infection
• Periodontal Disease
• Chorioamnionitis
Risk factors
• African-American women
• Adolescents
• Women who receive inadequate prenatal care
• Women who are exposed to stressful work
Management
• Bed rest (to relieve the pressure of the fetus on the cervix)
• Intravenous therapy (to keep the woman well hydrated because hydration may stop contractions)
• Tocolytic agents are given to halt labor
• Coitus restriction

POST TERM PREGNANCY
v Pregnancy that exceeds 42 weeks long
v Also termed as Postmature/Postdate
v Post term pregnancy occurs in 3% to 12% of all pregnancies
Related Causes
• High dose of salicylates
ü Salicylate interferes with the synthesis of the prostaglandins, which may be responsible for the initiation of
labor
• Myometrial Quiescence
ü Uterus that does not respond to normal labor stimulation
Complications
• Meconium aspiration
• Fetal Macrosomia
Management
• Prostaglandin gel or Misoprostol may be applied to the cervix to initiate ripening
• Oxytocin administration to begin labor
• Monitor fetal heart rate closely during labor
PRECIPITATE LABOR
v Occur when uterine contractions are so strong that a woman gives birth with only a few, rapidly occurring
contractions
v Labor that lasts for less than 3 hours
Precipitate dilatation
v Cervical dilatation that occurs at a rate of 5cm or more per hour in a primipara or 10cm or more per hour in a
multipara
Dangers of Precipitate Labor
• Non-institutionalized delivery
ü Exposes baby to sepsis
• Exposes mother to laceration
ü Head of baby thumps to pelvis resulting to hemorrhage
• Intracerebral hemorrhage of the head of baby as the baby’s head bumps the mother’s bony prominences
BREECH DELIVERY
v Either the buttocks or the feet are the first body parts that will contact the cervix
v Occur in approximately 3% of births and are affected by the fetal attitude
Types:
1. Complete
• Baby assumes a position similar to sitting
• The fetus has thighs tightly flexed on the abdomen; both the buttocks and the tightly flexed feet present to
the cervix
2. Frank
• Attitude is moderate because the hips are flexed but the knees are extended to rest on the chest. The
buttocks alone present to the cervix
3. Footling
• Neither the thighs nor lower legs are flexed
• Simple Footling
• Double Footling
Problems Associated with Breech Delivery
• Cord Prolapse
• Head Entrapment
• Shoulder dystocia
Key Concept
• In Breech delivery, it is normal to see Meconium Staining
MULTIPLE PREGNANCIES
v Multiple Gestation: a complication of pregnancy because a woman’s body must adjust to the effects of more than
one fetus
v Occurs in 2% to 3% of all births
2 Types
• Monozygotic
• Dizygotic
• Identical twins
• 1 ovum and 1 sperm
Monozygotic • One placenta, one chorion, two amnions and two umbilical cords
• Always of the same sex
• Fraternal twins
• 2 ova and 2 sperms
• 2 placentas, 2 umbilical cords,
• 2 amnions, 2 chorions
Dizygotic • May be of the same or different sex
Clinical
Assessment
• Uterus begins to increase in size at a rate faster than usual
• Alpha-fetoprotein levels are elevated
• At the time of quickening, woman may report flurries of action at different portions of her abdomen rather than
at one consistent spot.
• Ultrasound can reveal multiple gestation sacs early in pregnancy
Complications
• PIH
• Hydramnios
• Placenta previa
• Preterm labor
• Anemia
• Postpartum bleeding
• Low-birth weight babies
• Higher risk of congenital anomalies
PREGNANCY INDUCED HYPERTENSION (P.I.H.)

v It is a condition in which vasospasm occurs during pregnancy in both small and large arteries
v Unknown cause
Classic Signs of PIH
• Hypertension after 20th week AOG
• Proteinuria: (>250 mg/dl)
• Edema
• Vision changes
General Classifications
• Gestational Hypertension
• Mild Pre-eclampsia
• Severe Pre-eclampsia
• Eclampsia
1. Gestational Hypertension
• Elevated blood pressure (140/90 mm Hg)
• No proteinuria
• No edema
• Blood pressure returns to normal after birth
2. Mild Pre-eclampsia
• Proteinuria (1+ or 2+)
• BP (140/90 mm Hg)
• Diastolic blood pressure is extremely important to document because this pressure best indicates the degree of
peripheral arterial spasm
• Systolic BP greater than 30 mm Hg above pre-pregnancy values
• Diastolic BP greater than 15 mm Hg above pre-pregnancy values
• Weight gain over 2 lbs. per week in 2nd trimester
• Weight gain of 1 lb. per week in 3rd trimester
Management:
• Bed rest to conserve oxygen
ü Due to constriction of vessels
• Normal salt intake (2-3 grams/day)
o Do not restrict/limit salt intake as it will activate the RAA system, which will further increase blood
pressure.
• Closer follow-up: weekly check-up
3. Severe Pre-Eclampsia
• 160/110 mm Hg
• Marked proteinuria (3+ or 4+)
• Protein of more than 5 g in a 24-hour sample
• Extensive edema
• Elevated serum creatinine more than 1.2 mg/dL
• Epigastric pain
• Hepatic dysfunction
Management
• Prevention of seizures
• Give Magnesium Sulfate
ü Can cause a marked decrease in BP
ü Check deep tendon reflex
ü Check respiratory rate as this causes respiratory depression
ü Check urine output
Antidote: Calcium gluconate
4. Eclampsia
• Most severe classification of PIH
• Grand-mal seizure or coma occurs
• Accompanied by signs and symptoms of pre-eclampsia
Management
• Give additional medications aside from Mg 𝑆𝑂!
ü Diuretics: Furosemide
ü Digitalis (Digoxin)- to promote contractility of heart; check apical pulse
Ø Administer K+ as this drug causes a decrease in the serum levels of K+
ü Barbiturates: these are fast acting sedatives; arrests seizure
ü Hydralazine: to treat hypertension
Other Nursing Responsibilities
• Provide dim light room
• Limit visitors
• Put side rails up
• Suction machine at bedside
• Don’t put anything in mouth if there is seizure
• Open collar
• Turn patient to side to promote drainage of saliva
• Promote safety

HELLP SYNDROME
v Hemolysis, Elevated Liver enzymes, Low Platelet (HELLP)
v Occurs in 4% to 12% of patients with PIH
v Maternal mortality rate of 24%
v Infant mortality rate of 35%
Cause:
• Unknown
• Presence of antiphospholipid antibodies
Manifestations
• Proteinuria
• Edema
• Increased blood pressure
• Nausea
• Epigastric pain
• General malaise
• Right upper quadrant tenderness because of liver inflammation
Laboratory studies
• Transfusion of fresh-frozen plasma or platelets
• Correct hypoglycemia through Intravenous glucose infusion
• Epidural anesthesia may not be possible because of low platelet count and high possibility of bleeding at the
epidural site
GESTATIONAL DIABETES MELLITUS

v A condition of abnormal glucose metabolism that arises during pregnancy
Cause: unknown; Human Placental Lactogen (HPL)
Risk factors:
• Obesity
• Age over 25 years
• Race
• History of large babies (10 lbs. or more)
• History of unexplained fetal or perinatal loss
• History of congenital anomalies in previous pregnancies
• Family history of diabetes
Diagnosis
50-g Oral Glucose Tolerance Test (OGTT)
• Done at week 24 to 28 of pregnancy
• Venous blood sample will be taken for glucose determination 60 minutes later
• If the serum glucose level at 1 hour is more than 140 mg/dl, woman is scheduled for a 100-g 3 hour fasting
glucose tolerance test
• If two (2) of the four blood samples collected for this test are abnormal or the fasting value is above 95 mg/dl,
this confirms the diagnosis
Management
• DIET: Maintain daily calorie intake of 1,800 to 2,400 kcal/day
• Refrain from eating simple sugars and saturated fats. Instead, consume complex carbohydrates
• Exercise: Appropriate for Age of Gestation
Pharmacologic Therapy
• Insulin Therapy
• Oral Hypoglycemic agents are teratogenic

HEART DISEASE (GRAVIDOCARDIA)
Four Functional Classifications of Heart Disease
Class I
• Uncompromised
• Ordinary Physical activity causes no discomfort
Class II
• Slightly compromised
• Ordinary physical activity causes excessive fatigue, palpitation, and dyspnea or angina pain
Class III
• Markedly compromised
• During less than ordinary activity, woman experience, excessive fatigue, palpitations, dyspnea, or angina pain
Class IV
• Severely compromised
• Woman is unable to carry out any physical activity without experiencing discomfort
Important Concepts
• If you belong to Class I and Class II
ü you can go through normal pregnancy
• If you belong to Class III and Class IV
ü you cannot go through normal pregnancy
ü not a good candidate for pregnancy
VARIABILITY
v FHR Variability is one of the most reliable indicators of fetal well-being
v Periodic changes or fluctuations in FHR occur in response to contractions and fetal movement
Four Responses
1. Accelerations
• Non-periodic accelerations are temporary normal increases in FHR caused by:
ü Fetal movement
ü Change in maternal position
ü Administration of an analgesic
2. Early Deceleration
• Begins and ends simultaneously with uterine contractions
• Due to fetal head compression
• Early decelerations normally occur late in labor
• If they occur early in labor, before the head has fully descended, the waveform change could be the result of
cephalopelvic disproportion
3. Late Deceleration
• Delayed until 30 to 40 seconds after the onset of a contraction and continue beyond the end of contraction
• Has a late recovery
• Uteroplacental Insufficiency is present
Management
• Stop or slow the oxytocin administration
• Change the woman’s position from supine to lateral (to relieve pressure on the vena cava)
• Administer Intravenous fluids
• Provide oxygen as prescribed
• If late decelerations persist or becomes abnormal (either absent or deceased), prepare for possible prompt
birth of the infant
4. Variable Deceleration
• Has unpredictable occurrence
• May be due to fetal cord compression
Management
• Change the woman’s position from supine to lateral or trendelenburg to relieve pressure on the cord
• Amnioinfusion
PUERPERIUM
v This refers to the 6-week period after childbirth
Main priority: Achieve involution
**Involution is the return of reproductive organs to pre-pregnancy state (Normal: 1cm/fingerbreadth per day)
• Progressive: Production of milk for lactation, restoration of the normal menstrual cycle, and beginning of a
parenting role
Rubin’s Phases of Puerperium
1. Taking-in Phase
• First phase
• Time when the woman reviews her pregnancy and the labor and birth
• Woman is largely passive, prefers to be taken care of or dependent for care for self and the newborn
• Rejecting rooming-in is Normal
2. Taking-hold Phase
• Woman begins to initiate action
• Mother is now independent of self-care and newborn care
• She prefers to get her own washcloth and to make her own decisions
• Time of evidence of Postpartum psychosis
ü Brief Psychotic episode lasts for 3 months
3. Letting-Go Phase
• Woman finally redefines her new role
• She gives up the fantasized image of her child and accepts the real one
• She gives up her old role of being childless
LOCHIA
v Rubra
• Day 1 to day 3
• Bright red in color with only small particles of decidua and mucus
v Serosa
• Day 3 to day 10
• Pinkish or brownish in color
• Composed of blood, mucus, and invading leukocytes
v Alba
• Day 10 until 3rd week up to 6th week postpartum
• White in color
Important Concept
• After six weeks, there should be no more Lochia
Characteristics of Normal Lochia
• Normal Odor: Musty but not foul smelling
ü Foul smell indicates infection
• Color
ü Should not be yellowish/cloudy
ü Yellowish color indicates infection
• Order of Appearance
ü Should never be reversed
ü Reversal in appearance indicates retained placental fragments
ü Women who underwent Cesarean delivery will also experience lochia
LACTATION AMENORRHEA
3 Requirements:
v Exclusively breastfeeding/lactating
v No menstruation: some suppression of ovulation
v Within 6 months postpartum
Important Concepts
• If the mother is not breastfeeding, expect menstruation to return after 6 to 10 weeks
• If the mother is breastfeeding, it would take 6 months before menstruation returns
• After 3 to 4 weeks, coitus is allowable
POST-PARTUM PROBLEMS
1. Maternal Hemorrhage
v Early post-partum hemorrhage
• Occurs within the first 24 hours after delivery
• Most common cause: Uterine atony
• Laceration is the second most common cause
• Inherent clotting disorders occur:
ü Thrombocytopenia
ü Leucopenia
• Late post-partum hemorrhage: occurs after first twenty-four hours of delivery
• Common causes:
ü Primary cause (Retained Placental Fragment/s)
ü Secondary Cause (Hematoma)
2. Infection
• Endogenous infection
• Normal flora causes infection and may travel up to the uterus
Perineal Infection
• On site of episiotomy: Antibiotic therapy
Surgical Management
• Remove suture
• Drain pus
• Position in semi-fowler’s position
ENDOMETRITIS
v Infection of the lining of the uterus
v Maternal fever >38℃
v Foul smelling vaginal discharge
v Uterine or abdominal tenderness
Management for Endometritis
• Antibiotics
• Position: Semi-fowler’s position
Important Concept
• Endometritis is a prelude to thrombophlebitis
THROMBOPHLEBITIS
• Most common sites are the vessels of the lower extremities
• (+) for Homan’s Sign
ü Upon lying supine with legs extended. Ask the patient to dorsiflex the foot
ü Stretching of the blood vessels causes pain on calf muscles (gastrocnemius muscle)
Management:
ü Antibiotics
ü Anticoagulant: Heparin

PEDIATRIC NURSING
DEFINITION OF TERMS
1. Growth: physical change and quantitative increase in size of the whole body or any of its parts. The best index
of growth is weight.
• Growth takes place in the first 20 years of life
• Most rapid in infancy
• Growth spurt during adolescent
2. Development: changes that mark an increase in function, complexity and progression of skill.
• Development is qualitative
• Continues after 20 years, even after growth stops
• Growth and development are independent and interrelated processes
3. Maturation involves intrinsic processes of development that are genetically and organically programmed.
CONCEPTS:
ASYNCHRONOUS GROWTH
v Whole body does not grow at once
v Different regions and systems develop at different rates and times
THE PACE OF GROWTH & DEVELOPMENT IS UNEVEN
v Growth is greater/very rapid in two periods: infancy period and adolescence
ALL BODY SYSTEMS DO NOT DEVELOP AT THE SAME RATE
v Neurologic tissues grow during the first year of life while genital tissue grows until puberty
DEVELOPMENT PROCEEDS FROM GROSS TO REFINED SKILLS
v This principle parallels the preceding one. Once children are able to control distal body parts such as fingers, they
are able to perform fine motor skills.
(A 3-yr old colors best with a large crayon; a 12-yr old can write with a fine pen).
PRINCIPLES OF GROWTH AND DEVELOPMENT

1. Growth and development are continuous processes from conception until death
• At all times a child is growing new cells and learning new skills
2. Growth and development proceed in an orderly sequence
• Growth in height occurs in only one sequence from smaller to larger
• Development proceeds from gross to refined skills
3. There is an optimum time for initiation of experiences or learning
• Children cannot learn tasks until their nervous system is mature enough to allow that particular learning
4. All body systems do not develop at the same rate
• Certain body tissues mature more rapidly than others. For example, neurologic tissue experiences its peak
growth during the first year of life, whereas genital tissue grows little until puberty
5. Development is cephalocaudal
• Development proceeds from their head to tail
• Newborns can lift only their head off the bed when they lie in a prone position. By age 2 mo, infants can lift
both the head and chest off the bed
6. Development proceeds from proximal to distal body parts
• Development starts from the midline of the body and progresses towards the extremities
Basic Division of Childhood
Stage Age period
Neonate First 28 days of life
Infant 1 month – 1 year
Toddler 1-3 years
Preschooler 4-6 years
School-age-child 7-12 years
Adolescent 13-18 years

FREUD’S STAGES OF CHILDHOOD
Psychosexual Stage
Infants Oral stage Explores the world using mouth
Toddler Anal stage Control of urination and defecation
Preschool Phallic Stage Sexual Identity through awareness of genital area
School-age Latent Stage Personality development appears to be non-active or dormant
Adolescent Genital stage Sexual maturity and relationships with the opposite sex
ERIKSON’S STAGES OF CHILDHOOD

Developmental Task
Infant Sense of trust versus mistrust To love and be loved
Toddler Sense of autonomy versus shame To be independent and make decisions for self
Preschool Initiative versus guilt To start doing things (basic problem solving) and that doing
things is desirable
School-age Sense of industry versus inferiority To do things well
Adolescent Sense of identity versus role Learn who they are, what kind of person they will be by
confusion adjusting to a body image
Maternal Bonding
• A special mutual relationship between mother and infant
• Best initiated immediately after birth
• Can be achieved within the first 30 mins
Language Development
Age Vocabulary
3 yrs 900 words
4 yrs 1500 words
5 yrs 2100 words
STAGES OF GROWTH AND DEVELOPMENT
INFANT
FEAR: Stranger and Anxiety
Play: Solitary
Toys: Mobile, rattle, musical toys, crib (Sensory toys)
v Rapid growth and development
v Birth until 1 year
Freud’s Psychoanalytic Theory
Freud termed the infant period the “oral phase”
because infants are so interested in oral stimulation or
pleasure during this time
Psychosexual: Oral
• Meet the oral needs of the infant: Provide safe and washable toys such as a pacifier
• Feed on demand: Feed according to the child’s biologic need for food
• When oral feeding is contraindicated but sucking is not, give a pacifier to suck
PIAGET’S: COGNITIVE DEVELOPMENT

1-4 months Primary circular reaction (body is center of attention)
4-8 months Secondary circular reaction (from body to environment)
8-12 months Coordination of secondary reaction
12-18 months Tertiary circular reaction (trial and error)
Kohlberg’s Theory of Moral Development

The infancy period is a pre-religious stage. Infants learn that when they do certain actions, parents give affection
and approval; for other actions, parents scold and label the behavior “bad.”

TODDLER
FEAR: Separation Anxiety
PLAY: Parallel
TOYS: Push and Pull toys
v Age 1 to 3 yrs
v Characterized by alternating rapid and slow rate of growth & development
v Pot-belly
v Bow-legged
v Ask questions constantly, up to 400 a day
v A consistent bedtime ritual helps prepare the toddler for sleep
v Security objects at bedtime may assist in sleep
v Children generally have all 20 of their deciduous teeth by 3 years of age
Signs of Readiness For Toilet Training

• Child is able to stay dry for 2 hours
• Child is waking up dry from a nap
• Child is able to sit, squat, and walk
• Child is able to remove clothing
• Child recognizes urge to defecate or urinate
• Child expresses willingness to please parent
• Child is able to sit on toilet for 5 to 10 minutes without fussing or getting off
Negativism – Toddlers often say “no” when asked to do something or may not obey requests from people other than
their parents because they do not view their authority as being at the same level as their parents’ authority
Nursing intervention:
• Offer choices to them
• Avoid using close-ended questions, use open-ended questions instead
Freud’s Psychoanalytic Theory
Freud described the toddler period as an “anal phase” because during this time, children’s interests focus on the anal
region as they begin toilet training
Piaget Cognitive Development
Preoperational thought 2-7 yrs
Thought becomes more symbolic; can arrive at answers mentally instead of through physical attempt. Comprehends
simple abstractions but thinking is basically concrete and literal. Child is egocentric (unable to see the viewpoint of
another)
Kohlberg: Moral Development
Pre-conventional (2-3 yrs old) Stage 1
Morals are thought to be motivated by punishment and rewards
PRESCHOOL PERIOD
FEAR: Mutilation and Castration
PLAY: Associative & imitation/make-believe
TOYS: A simple puzzle, dolls, coloring book
v Age 3-5 yrs
v The preschooler grows 2 ½ to 3 inches per year
v By 5 years old, the child tends to focus on social aspects of eating, table conversations, manners, and willingness
to try new foods
v Oedipus and Electra complex
• An Oedipus complex refers to the strong emotional attachment a preschool boy demonstrates toward his
mother
• Electra complex is the attachment of a preschool girl to her father
v Centering
• Children tend to look at an object and see only one of its characteristics
• They see that a banana is yellow but do not notice it is also long
v Magical Thinking
• They perceive animals and even inanimate objects as being capable of thought and feeling
v Egocentrism
• Perceiving that one’s thoughts and needs are better or more important than those of others

Pre-conventional (4-7 years old) Stage 2
Individualism Carries out actions to Satisfy own needs rather than society’s
SCHOOL-AGE PERIOD
FEAR: Displacement from school
PLAY: Indoor competitive
TOYS: Computer games and table games
v Age 6-12 yrs
v Characterized by having a slow period of growth and development patterns
Freud’s Psychosexual Stage
Freud saw the school-age period as a “latent phase,” a time in which children’s libido appears to be diverted into
concrete thinking
Piaget’s: Cognitive Development
Concrete operational 7-12 yr
Concrete operations include systematic reasoning. Classifications involve sorting objects according to attributes such as
color. Child is aware of reversibility, an opposite operation or continuation of reasoning back to a Starting point (follows
a route through a maze and then reverses steps)
Level II: conventional (7-10 yrs old)
Orientation to interpersonal relations of mutuality. Child follows rules because of a need to be a “good” person in own
eyes and eyes of others
Reasoning during school age tends to be inductive, proceeding from specific to general: school-age children tend to
reason that a toy they are holding is broken, the toy is made of plastic, so all plastic toys break easily
ADOLESCENCE
FEAR: Displacement from peers
PLAY: Outdoor competitive (Athletic & sports)
TOYS: Basketball etc.
v Age 13-18 yrs
v Accelerated growth and maturation
v Influenced by hormonal changes characterized by growth spurt which begins early in girls, about 1-2 years ahead
than boys
v Sebaceous and sweat glands become active and fully functional
Freud’s Psychosexual Stage
Freud termed the adolescent period the “genital phase.” Freudian theory considers the main events of this period to be
the establishment of new sexual aims and the finding of new love objects
Piaget’s: Cognitive Development
Formal operational 12 yr
Can solve hypothetical problems with scientific reasoning; understands
Thought causality and can deal with the past, present and future. Adult or mature
Thought. Good activity for this period: “talk time” to sort through attitudes
Post-conventional (Older than 12 yrs. old)
Social contract. Utilitarian law-making perspectives. Follows standards of society for the good of all people
Universal ethical principle orientations. Follows internalized standards of conduct
Adolescents can be responsible for self-care because they view this as a standard of adult behavior
Many adults do not reach this level of moral development

ASSESSMENT APGAR SCREENING TEST
v Done twice at 1 and 5 minutes
CRITERIA 0 1 2
Appearance Blue Acrocyanosis Pink
Pulse Absent <100 >100
Grimace No response Grimace Vigorous cry
Activity Limp/flaccid minimal Full flexion
Respiration Absent Weak cry Vigorous cry
Interpretation
1-3 Poor-needs immediate resuscitation (CPR)
4-7 Fair-needs further observation & stimulation, needs suctioning (rubber)
8-10 Good-Healthy
ESTIMATION OF AGE OF GESTATION CRITERIA

PHYSICAL CHARACTERISTICS
PRE-MATURE TERM FULL-TERM
Skin Very thin, gelatinous, visible Smooth, thick, less visible Leathery, cracked, wrinkled
blood vessels blood vessels
Lanugo Abundant Thinning Bald
Plantar Creases Anterior transverse 2/3 with creases Entire sole w/ creases
Breast Stripped areola Raised areola Full areola
Ear Flat and folded Thin and soft Thick and firm
Genital (m) Undescended Testis Intermediate Fully descended
Genital (f) Prominent labia and clitoris Labia minora & clitoris partially Completely covered minora &
covered by labia majora clitoris
PROFILE OF A NEWBORN
NORMAL BIRTHWEIGHT: 2.5-4.0 kg
v Doubles at 6 mos
v Triples at 12 mos
v Quadruplets at 2 ½ yrs
*Second-born children
Usually weigh more than first-born. Birth weight continues to increase with each succeeding child in a family
*During the first few days after birth, a newborn loses 5% to 10% of birth weight (6 to 10 oz). This weight loss occurs
because a newborn is no longer under the influence of salt and Fluid-retaining maternal hormones
Low birth Weight (LBW): <2,500 grams
Large for gestational age (LGA): >4,000
BIRTH LENGTH:
46-54 cm
HEAD CIRCUMFERENCE:
33-35 cm
(Largest circumference in an infant)
CHEST CIRCUMFERENCE:
31-33 cm
NEUROLOGIC ASSESSMENT
Reflexes:
Extrusion
v Food placed on infant’s tongue is thrust forward and out of mouth
Tonic Neck
v As head is turned to one side, arm & leg on that side extends and opposite extremities in flexion
v Response usually disappears within 3 to 4 months
Palmar Grasp
v Elicited by placing finger in NB’s palm
v Palmar response lessens within 3 to 4 months

Moro
v Place the newborn on a flat surface and strike the surface or make a loud abrupt noise to startle the newborn
v The newborn symmetrically abducts and extends the arms
v A persistent response lasting more than 6 months may indicate the occurrence of brain damage during pregnancy
Sucking and Rooting
v Touch the newborn’s lip, cheek, or corner of the mouth with a nipple
v Newborn turns head toward the nipple, opens the mouth, takes hold of the nipple, and sucks
v Rooting reflex usually disappears after 3 to 4 months but may persist for up to 1 year
Stepping or Walking
v Hold the newborn in a vertical position, allowing one foot to touch a table surface
v The newborn simulates walking, alternately flexing and extending the feet
v The reflex is usually present for 3 to 4 months
Babinski Sign: Plantar Reflex
v Beginning at the heel of the foot, gently stroke upward along the lateral aspect of the sole, and then move the
finger along the ball of the foot
v The newborn’s toes hyperextend while the big toe dorsiflexes
v The reflex disappears after the newborn is 1 years old
v Absence of this reflex indicates the need for a neurological examination
VITAL SIGNS
v Temperature: Axillary, 97.9° to 98℉
v Apical rate: 120 to 160 beats/min
v Respirations: 30 to 60 (average 40) breaths/min
v Blood pressure: 73/55 mm Hg
*Newborns can conserve heat by constricting blood vessels and moving blood away from the skin. Brown fat, a special
tissue found in mature newborns, apparently helps to conserve or produce body heat by increasing metabolism
PHYSICAL ASSESMENT
HEAD
Anterior fontanel -Soft, flat, diamond shaped,3-4cm wide by 2-3 long
-Closes between 12-18mos
Posterior fontanel -Triangular shaped, 05-1cm wide
-Closes 2-3mos
Caput succedaneum -Swelling of scalp caused by prolonged labor crosses over suture line
-Gradually disappears at about third day of life
Cephalhematoma -Collection of blood caused by increase pressure of birth
-Caused by rupture of Periosteal capillary
-Absorbed within 3-6 weeks
Craniotabes -Localized swelling of the cranial bones caused by pressure of the fetal skull against the
mother’s pelvic bone in uterus
-Condition corrects itself without treatment
EYES
v Infant eyes assume their permanent color between 3 and 12 months of age
v Lacrimal ducts do not fully mature until about 3 months of age
v Strabismus is normal until 6 mos
v Subconjunctival hemorrhage – a red spot on sclera on inner aspect of eye due to pressure at birth (absorbed in
2-3 wks)
EARS
v The pinna normally align from inner to outer canthus of the eye
v The low set ears indicate Chromosomal disease such as
• Trisomy 21(Down Syndrome)
• Kidney anomaly
v Test newborn hearing by ringing a bell held 6 inches from each ear

NOSE
v Nasal Flaring is the enlargement of the opening of the nostrils during breathing
v NASAL FLARING indicates respiratory distress
v Test for CHOANAL ATRESIA (blockage at the rear of the nose) by closing the newborn’s mouth and compressing
one nares at a time with your fingers. Note any discomfort or distress while breathing this way
NECK
v Short chubby with creases skin folds Rigidity of neck may indicate: CONGENITAL TORTICOLLIS/MANINGITIS
v The trachea may be prominent on the front of the neck, and the thymus gland may be enlarged because of the
rapid growth of glandular tissue
v The thymus gland will triple in size by 3 years of age; it remains at the size until the child is about 10 years old,
and then shrinks
CHEST
v It is approximately 2 inches smaller than head circumference
v Retractions or drawing in of the chest during inspiration should not be observed. It could indicate respiratory
distress
ABDOMEN
v The abdomen of the child should look slightly protuberant, a scaphoid or sunken appearance could indicate
missing abdominal contents
v Bowel sounds should be present 1 hour after birth
v Umbilical cord
• Stump should appear as a white, gelatinous structure with blue and red streaks of the umbilical vein and
arteries
• (2 arteries and 1 vein)
• Single artery could signify congenital heart or kidney anomaly
• Umbilical cord should break free by day 6 to 10
• If umbilical hernia is present, taping or putting buttons or coins on the cord do not help defects to close
ANOGENITAL AREA
v Inspect the anus of a newborn to be certain it is present, patent, and not covered by a membrane (imperforate
anus)
v If a newborn does not do so in the first 24 hours, suspect imperforate anus or meconium ileus
MALE GENITALIA
v Both testes should be present in the scrotum
v If one or both testicles are not present (cryptorchidism) caused by agenesis (absence of an organ)
v Ectopic testes (the testes cannot enter the scrotum because the opening to the scrotal sac is closed), or
undescended testes
v Newborns with agenesis of the testes are usually referred for investigation of kidney anomalies, because the
testes arise from the same germ tissue as the kidneys
v Elicit a cremasteric reflex. This is a test for the integrity of spinal nerves T8-T10. The response may be absent in
newborns who are younger than 10 days
v Urethral opening should be on the tip of the glans, not on the dorsal surface (epispadias) or on the ventral
surface (hypospadias)
FEMALE GENITALIA
v The vulva in female newborns may be swollen because of the effect of maternal hormones
v Pseudomenstruation: Female newborns have a mucus vaginal secretion, which is sometimes blood-tinged, which
is normal
BACK
v Inspect the base of a newborn’s spine carefully to be sure there is no pinpoint opening, dimpling, or sinus tract in
the skin which would suggest a dermal sinus or spinal bifida occulta

EXTREMITY
v Unusually short arms may signify achondroplastic dwarfism- Achondroplasia is a form of short-limbed dwarfism
v Inspect the palm for a simian crease which could signify down syndrome
v Assess for webbing (syndactyly),
v Extra toes or fingers (polydactyly)
v Both hips can be flexed and abducted to such an extent (180 degrees) that the knees touch or nearly touch the
surface of the bed if the hip joint seems to lock short of this distance (160 to 170 degrees), hip subluxation (a
shallow and poorly formed acetabulum) is suggested
Congenital Anomaly Appraisal

PROCEDURE ABNORMALITIES CONSIDERED
Inquire for Hydramnios or Presence of hydramnios suggests congenital gastrointestinal obstruction.
Oligohydramnios Oligohydramnios suggests genitourinary obstruction or extreme prematurity
Appearance of abdomen Distended abdomen suggests ascites, possible bowel obstruction, or tumor
Empty abdomen suggests diaphragmatic hernia
Passage of nasogastric tube (no. 8 Failure to pass nasogastric tube through nares on either side establishes
feeding catheter) through, nares choanal atresia. Failure to pass it into the stomach confirms presence of
into stomach esophageal atresia
Counting of umbilical arteries The presence of one artery suggests possible congenital urinary or cardiac
anomalies chromosomal trisomy (if other portions of examination are
consistent)
Breast Feeding Facts
v Almost all drugs pass into breastmilk. A breastfeeding mother must be certain not to take any medication
without contacting her primary care provider to be certain it is compatible with breastfeeding
v If a baby will be formula fed, be certain the parents understand the potential danger of warming bottles in a
microwave oven (the inner core of milk may grow very hot)
v Caution parents not to prop bottles, because it increases the risk for aspiration and otitis media. It also
deprives infants of the pleasure of being held for feedings
v To avoid baby bottle syndrome (cavities of the lower teeth), infants should not be put to bed with a bottle
PEDIATRIC DISORDERS
SPINA BIFIDA
v Congenital defect of the spinal/neutral tube in which there is an incomplete closure of the spinal column due to
one or two missing vertebral arches
v Usually occurs during 4th week of embryonic life, but the exact cause is unknown
Classifications
1. Spina Bifida Occulta – seen as a small dimple at the lower back; usually asymptomatic and creates health
problems; often, no treatment is needed
2. Meningocele – sac like cyst that contains meninges and spinal fluid that protrudes through the defect
3. Myelomeningocele – with herniated sac of meninges, spinal fluid and a portion of the spinal cord and its
nerves, which protrude through the defect in the spine
• It is the most severe form
Etiology
• Deficiency in folic acid of the mother during pregnancy
• Hereditary and environmental factors
Assessment
• Visible sac-like structure or dimpling of the skin at any point on the spinal column
• Associated defects/problems found in myelomeningocele
ü Hydrocephalus
ü Bowel/bladder dysfunction
ü Paralysis of lower extremities
ü Associated meningitis

Management: Surgery
• Currently, it is done as soon after birth as possible (usually within 24 to 48 hours) so infection through the
exposed meninges does not occur
NURSING INTERVENTION
Women are advised to undergo amniocentesis.
• Women who have had one child with a spinal cord disorder are advised to have a maternal serum assay or
amniocentesis for AFP levels to determine if such a disorder is present in a second pregnancy (levels will be
abnormally increased if there is an open spinal lesion)
• Evaluate sac and lesions
• Perform neurological assessment
• Monitor ICP
• Measure head circumference, assess anterior fontanels for fullness protect the sac, cover with a sterile, moist
non-adherent dressing
• Place in a prone position to minimize tension on the sac and the risk of trauma
• Use aseptic technique to prevent infection
• Assess the sac for redness, clear or purulent drainage, abrasion, irritation and signs of infection
• Administer antibiotics as prescribed
• Administer anti-cholinergics to improve urinary continence and laxatives to achieve bowel continence
PREVENTION
• Pregnant women are advised to ingest 600 micrograms of folic acid daily to help prevent these disorders during
the first trimester
HYDROCEPHALUS
• Excess of CSF in the ventricles of the subarachnoid space
TYPES OF HYDROCEPHALUS
1. COMMUNICATING
• Occurs as a result of impaired absorption within the sub-arachnoid space
2. NON-COMMUNICATING/OBSTRUCTIVE
• Obstruction of cerebrospinal flow within the ventricular system occurs
RISK FACTORS
• Infant meningitis / encephalitis – leave adhesion behind
• Hemorrhage of Tumor – blocks passage of fluid
• Arnold-Chiari disorder – elongation of the lower brainstem & displacement of the 4th ventricle into upper
cervical canal
• Surgery for meningocele – portion of subarachnoid space is removed causing less surface area for absorption
of CSF
CAUSES OF EXCESS CSF

• Overproduction of fluid by choroids plexus in 1st or 2nd ventricle
• Obstruction of the of fluid in narrow aqueduct of sylvius (most common)
• Interference with the absorption of CSF from subarachnoid space
SIGNS AND SYMPTOMS

• Anterior fontanel bulging
• (Macewen’s sign) Bones of the head are widely separated that produces a cracked pot sound upon percussion
• (Bossing sign) Brow bulges
TREATMENT: SURGICAL SHUNTING

Ventriculoperitoneal (V-P) shunt
• Connects the lateral ventricle of the brain to the peritoneal cavity
• Most commonly used shunt in children
Atrioventricular (A-V) shunt
• Connects the lateral ventricle to the right atrium of the heart
Ventriculoureteral (V-U) shunt

• Connects the lateral ventricle of the brain to the ureter; requires unilateral nephrectomy which, may cause
recurrent fluid and electrolyte imbalance
Nursing Care
1. Assess daily head circumference
2. Protect the child’s head
3. Maintain nutrition and hydration
PREOPERATIVE INTERVENTIONS
1. Monitor intake and output; give small frequent feedings as tolerated until a preoperative NPO status is prescribed
2. Reposition head frequently and use an egg crate mattress under the head to prevent pressure sores
3. Prepare the child and family for diagnostic procedures and surgery
POSTOPERATIVE INTERVENTIONS
1. Monitor vital signs and neurological signs
2. Position the child on the unoperated side to prevent pressure on the shunt valve
3. Keep the child flat as prescribed to avoid rapid reduction of intracranial fluid
4. Observe for increased ICP; if increased ICP occurs, elevate the head of the bed to 15 to 30 degrees to enhance
gravity flow through the shunt
5. Monitor for signs of infection and assess dressings for drainage
6. Measure head circumference
7. Monitor intake and output
8. Provide comfort measures; administer medications as prescribed, which may include diuretics, antibiotics, or
anticonvulsants
BACTERIAL MENINGITIS AND ENCEPHALITIS

• An acute bacterial infection of the central nervous system that may be acquired as the primary disease or as a
result of a local infection (e.g., otitis media, sinusitis), systematic infections, trauma and neurosurgery
CAUSES
• Bacterial meningitis (Haemophilus influenza type B, Streptococcus pneumonia, or Neisseria meningitidis) occurs in
epidemic form and can be transmitted by droplets from nasopharyngeal secretions
• Viral meningitis is associated with viruses such as mumps, paramyxovirus, herpesvirus, and enterovirus
Meningitis: inflammation of membranes surrounding the brain and spinal cord
Encephalitis: Inflammation of the brain itself
SIGNS AND SYMPTOMS

• Opisthotonus position
• Stiff neck and nuchal rigidity
• (+) Kernig’s sign
ü Inability to extend the leg when the thigh is flexed anteriority at the hip
• (+) Brudzinski sign
ü Neck flexion causes adduction and flexion movements of the lower extremities
DIAGNOSTIC TEST
• Lumbar Puncture:
ü Clouding of CSF, Increased Protein and Decreased Glucose
• Smear and culture of CSF and blood demonstrate the presence organism
TREATMENT
• Antibiotic Therapy/ I.V: Penicillin G (Drug of Choice)
NURSING CARE
1. Isolate infant: first nursing implementation on admission
2. Ensure patent airway and promote safety during seizures
3. Monitor and control temperature
4. Perform neurological assessment and monitor for seizures; assess for the complication of inappropriate
antidiuretic hormone (ADH) secretion, causing fluid retention (cerebral edema) and dilutional hyponatremia

5. Assess for changes in level of consciousness and irritability
6. Monitor intake and output
7. Assess nutritional status
8. Determine close contacts of the child with meningitis because the contacts will need prophylactic treatment
CEREBRAL PALSY
v A neuromuscular disorder characterized by lack of control of the voluntary muscles, abnormal muscle tone and
incoordination
ETIOLOGY
• Anoxia to the brain: the most significant factor to causation
• Infection
THREE TYPES OF CEREBRAL PALSY

• Spastic (most common): The cortex is affected resulting in the child having a scissor-like gait where one foot
crosses in front of the other foot
• Athetoid: The basal ganglia are affected resulting in uncoordinated involuntary motion
• Ataxic: The cerebellum is affected resulting in poor balance and difficulty with muscle coordination
SIGNS AND SYMPTOMS

• Infant may manifest early signs of cerebral palsy
ü Abnormal posturing
ü Difficulty feeding
ü Tremors/Seizures
ü Persistence of primitive reflexes
• Signs of delayed motor development
TREATMENT
• Exercises: passive and active
• Medications: muscle relaxants, anti-convulsants and tranquilizers
• Braces, ambulation devices: Crutches, walkers
NURSING CARE
• Promote adequate nutritional intake
• Promote maximum mobility and development of self-help skills
• Ensure safety when ambulating
DOWN SYNDROME (TRISOMY 21)

v A chromosomal aberration characterized by Trisomy 21 or the tripling of chromosome number 21
v Presence of an extra copy of chromosome 21 resulting in a total number of 47 rather than 46
ETIOLOGY
• It is found to be more common among children of mothers with increased or advanced age
ASSESSMENT
• Facial characteristics: wide gap between the eyes, flat nose, large tongue
• Head characteristic flattened posterior and anterior surfaces of the skull, obviously flat occiput
• Extremities: simian crease: abnormal single horizontal line on the palm of the hands; plantar furrow: vertical line
on the sole; first and second toes widely spaced
• Brushfield’s spots – white specks in the iris of the eye
• Low-set ears
• Potbelly – High waist circumference
ASSOCIATED PROBLEMS AND FINDINGS

• Intelligence varies from severely retarded to below normal (IQ less than 20 to IQ between 50-70)
• Congenital anomalies, VSD, Hirschsprung’s disease and leukemia
• Growth is reduced, with rapid weight gain
• Sexual development maybe delayed, incomplete or both

NURSING INTERVENTIONS
• Goal for the child is to reach his optimum development potential and be able to cope as effectively as possible to
this mental handicap
• Treatment is based on the child’s developmental age rather than chronological age
• Emphasize the importance of providing the child consistent care to favor the development of trust (foundation of
personality) and feeling of security
SIGNS AND SYMPTOMS

• Tachycardia; tachypnea
• Profuse scalp sweating
• Fatigue; irritability
• Respiratory distress
• Feeding problem
• Poor weight gain/failure to thrive
• Frequent respiratory injections; cough
ACYANOTIC HEART DEFECTS

v Acyanotic heart disorders: heart or circulatory anomalies that involve either a stricture to the flow of blood or
a shunt that moves blood from the arterial to the venous system (oxygenated to unoxygenated blood, or left-to-
right shunts)
• VSD: ventricular septal defect
• ASD: atrial septal defect
• PDA: patent ductus arteriosus
• PS: Pulmonary stenosis
• COA: coarctation of aorta
SIGNS AND SYMPTOMS

• Audible murmurs-most common sign
ü Loud systolic murmur – VSD
ü Machinery like murmur – PDA
• Easy fatigability shown as brow sweating (during feeding or crying episodes)
• Hepatomegaly – due to backup of blood
COMPLICATIONS
• Congestive Heart Failure most common complication
• Respiratory distress manifested by: moist cough, diaphoresis, severe dyspnea
VENTRICULAR SEPTAL DEFECT

v Almost always left to right shunt
v Abnormal opening between the left and right ventricles
v Most common CHD: 30%
v Overloading of RV and pulmonary circulation
v Pulmonary hypertension and respiratory failure may occur
v Reverse shunt (right to left) may develop: Eisenmenger syndrome (pulmonary hypertension)
ATRIAL SEPTAL DEFECT

v Abnormal opening between the atria that causes an increased flow of oxygenated blood into the right side of the
heart
v Failure of the atrial septum to close
THREE MAJOR TYPES

• ASD 1 – Ostium primum (opening at the lower end of the septum)
• ASD 2 – Ostium Secundum (opening near the center of the septum)
• ASD 3 – Sinus Venosus Defects (opening near the junction of the SVC and the right atrium)

MANIFESTATIONS
• Asymptomatic if small defect
• Systolic ejection murmurs
• Growth retardation (slow weight gain)
• Heart failure symptoms usually occur in ostium primum defects
• Right ventricular hypertrophy
• Frequent respiratory infections; dyspnea
• Easy fatigability
• Provide family teaching about treatment options
• Small defect spontaneously close
• Non-surgical treatment: the defect may be closed by using devices during a cardiac catheterization
• Defects are usually repaired in girls due to possibility of pulmonary hypertension during pregnancy
• Surgical treatment: open repair with cardiopulmonary bypass before school age
PATENT DUCTUS ARTERIOSUS

v Results when the fetal ductus arteriosus fails to close completely after birth
Blood from the Aorta
Patent Ductus Arteriosus
Back to the Pulmonary Artery and Lungs
Increased Left Ventricular workload
Increased Pulmonary Vascular congestion
ASSESSMENT
• Asymptomatic – if defect is small
• Loud machine like murmur
• Frequent respiratory infection
• CHF with poor feeding, fatigue,
Splenomegaly, poor weight gain, Tachypnea and irritability
• Widening pulse pressure
TREATMENT
• Ibuprofen or Indomethacin, prostaglandin inhibitors, may be administered to close a patent ductus in
premature infants and some newborns
• Some PDA’s close spontaneously
• Premature infants-prostaglandin Synthetase inhibitors (stimulates closure of ductus)
• Management: the defect may be closed during cardiac catheterization or the defect may require surgical
management
COARCTATION OF AORTA
v Restricted lumen of the aorta proximal to, at, or distal to the ductus arteriosus
v Localized narrowing of the aorta
ASSESSMENT
• Elevated upper-body blood pressure produces headache and vertigo
• Bounding radial pulse and absent femoral pulse (pathognomonic sign)
• Epistaxis, headache, fainting, lower leg cramps

• Systolic murmur
TREATMENT
• Children with this disorder require therapy with digoxin and diuretics it aims to reduce the severity of the
congestive heart failure from hypertension
• Interventional angiography (a balloon catheter) or surgery
• With surgery, the narrowed portion of the aorta is removed and the new ends of the aorta are anastomosed
PULMONARY STENOSIS
v Pulmonary stenosis is narrowing at the entrance to the pulmonary artery
v Resistance to blood flow causes right ventricular hypertrophy and decreased pulmonary blood flow; the right
ventricle may be hypoplastic
v Pulmonary atresia is the extreme form of pulmonary stenosis in that there is total fusion of the commissures
and no blood flows to the lungs
ASSESSMENT
• A characteristic murmur is present
• The infant or child may be asymptomatic
• Newborns with severe narrowing will be cyanotic
• If pulmonary stenosis is severe, CHF occurs
• Signs and symptoms of decreased cardiac output may occur
TREATMENT
• Nonsurgical treatment is done during cardiac catheterization to dilate the narrowed valve
SURGICAL TREATMENT
• In infants, transventricular (closed) valvotomy procedure
• In children, pulmonary valvotomy with cardiopulmonary bypass
TWO BROAD CLASSIFICATIONS
1. CYANOTIC HEART DEFECTS

• Tetralogy of Fallot
• Truncus Arteriosus
• Tricuspid Atresia
• Transposition of Great vessel
SIGN AND SYMPTOMS
• Central cyanosis
• Recurrent respiratory infection
• Easy fatigability
• Retarded physical growth
• Clubbing of fingers
• Squatting in older children
• Increase hematocrit
COMPLICATIONS
• Brain infarctions and blood clots
• Left sided heart failure
TETRALOGY OF FALLOT
A combination of 4 defining features:
v Pulmonary stenosis
v RV hypertrophy
v Overriding aorta
v VSD
ASSESSMENT
Infant – cyanotic at birth or may have mild cyanosis over the first year of life
• TET SPELLS – irritability, pallor, blackouts or convulsions
• Cyanosis at rest
• Squatting
• Slow weight gain
• Exertional dyspnea, fatigue, slowness due to hypoxia

• Maintain respiration/Oxygenation
• Proper positioning
ü Cyanotic child, lateral position, knee-chest, squatting for preschool or older children
• Promote Rest
• Keep warm
• Prevent infection
• Administer drugs, as ordered: digitalis and diuretics
TRICUSPID ATRESIA
v Tricuspid atresia is an extremely serious disorder because the tricuspid valve is completely closed, allowing no
blood to flow from the right atrium to the right ventricle
v As long as the foramen ovale and ductus arteriosus remain open, the child can obtain adequate oxygenation
ASSESSMENT
• Cyanosis, tachycardia and dyspnea
• Older children – chronic hypoxemia and clubbing
TREATMENT
• Surgery consists of the construction of a vena cava-to-pulmonary artery shunt, which deflects more blood to the
lungs, or a Fontan procedure (sometimes termed a Glenn Shunt Baffle), which restructure the right side of
the heart
• An IV infusion of PGE1 is begun to ensure that the ductus remains open
RESPIRATORY DISORDERS
CHOANAL ATRESIA
v A congenital disorder in which the back of the nasal passage (choana) is blocked; may be unilateral or bilateral
ASSESSMENT
Danger sign:
• Cyanosis during feeding (because of the obstruction of the nasal passages by the tongue, which may further
restrict the airway), which may improve when the baby cries (as the mouth is open in cry and is used for
breathing
TREATMENT
• Temporary alleviation of dyspnea: insertion of an oral airway into the mouth
• Surgical correction of the defect by perforating the atresia followed by insertion of a stent or repetition of
dilation to keep the newly formed airway patent
NURSING CARE
• Early screening
• Maintain patency of oral airway
• Monitor respiration
• Provide pre- and post-op care as indicated
TONSILLITIS/ADENOIDITIS
• Inflammation of lymphoid tissue which circles the pharynx and form part of the waldeyer’s ring
ETIOLOGY
• Common cause: streptococci (beta-hemolytic streptococcus A)
• Environmental pollutants and immunizations decrease the protective role of the waldeyer’s ring
• The child’s increasing age results in increased socialization (church, school, community) and leads to recurrent
upper respiratory infection
SIGNS AND SYMPTOMS
• Inflammation and hypertrophy of the tonsils and adenoids leads to obstruction of breathing and swallowing
• Soreness of throat
• Altered sense of smell, taste and hearing
DIAGNOSTIC TESTS/PROCEDURE
• Physical examination

• CBC: leukocytosis
• Elevated ESR
RISK FOR:
• Acute glomerulonephritis occurs 5 to 21 days after a streptococcal infection
• Rheumatic fever presents 2 to 6 weeks following an untreated or partially treated group. A beta-hemolytic
streptococcal infection of the upper respiratory tract
• The most serious complication is rheumatic heart disease, which affects the cardiac valves, particularly the
mitral valve
TREATMENT
• Antibiotic treatment to control acute infection Surgical removal/excision two to three weeks after acute infection
to prevent bacterial spread to other body parts
Criteria:
ü Recurrent tonsillitis with documented streptococcal infection (4 times/year) and marked swallowing difficulties
and speech distortion
• Contraindication to tonsillectomy and adenoidectomy
ü Age: under 5 to 6 years unless condition is life threatening
ü Bleeding disorders
ü Acute respiratory infection in the child or immediate family
INTERVENTIONS POST-OPERATIVELY
• Position the child prone or side-lying to facilitate drainage
• Have suction equipment available, but do not suction unless there is an airway obstruction
• Monitor for signs of hemorrhage (frequent swallowing may indicate hemorrhage); if hemorrhage occurs, turn the
child to the side and notify the physician
• Discourage coughing or clearing the throat
• Provide clear, cool, non-citrus and noncarbonated fluids
• Avoid milk products initially because they will coat the throat
• Avoid red liquids, which simulate the appearance of blood if the child vomits
• Do not give the child any straws, forks, or sharp objects that can be put into the mouth
• Administer acetaminophen (Tylenol) for sore throat as prescribed
• Instruct the parents to notify the physician if bleeding, persistent earache, or fever occurs
• Instruct the parents to keep the child away from crowds until healing has occurred
EPIGLOTTITIS (BACTERIAL CROUP)

v Epiglottitis is inflammation of the epiglottis (the flap of tissue that covers the opening to the larynx to keep out
food and fluid during swallowing)
v Life threatening inflammation of the epiglottis by H. influenza
v Considered an emergency situation
ASSESSMENT
• Child suddenly develops severe inspiratory stridor and hoarseness
• Difficulty swallowing that they drool saliva
• Fever and leukocytosis (20,000 to 30,000 mm3)
• Tripod positioning: while supporting the body with the hands, the child thrusts the chin forward and opens the
mouth in an attempt to widen the airway
INTERVENTIONS
• Children need moist air to reduce the epiglottal inflammation
• An antibiotic, such as a third-generation cephalosporin such as cefotaxime
• ET intubation or tracheostomy is performed to maintain a patent airway. Swelling decreases after 24 hours-
extubated the third day
• Do not leave the child unattended
• Gagging procedure causes complete obstruction of the glottis and shuts off the ability of the child to inhale.
Never attempt to visualize the epiglottis directly with a tongue blade or obtain a throat culture
BRONCHIAL ASTHMA
v A chronic pulmonary disorder characterized by reversible obstructive condition of bronchi/bronchioles in response
to certain biochemical, immunological and psychological factors
ETIOLOGY
• Intrinsic or extrinsic triggering factors (allergen) that cause bronchospasm

SIGNS AND SYMPTOMS

• Audible wheezy breathing more common during expiration
• Rapid labored respiration
• Respiratory symptoms include a hacking, irritable, nonproductive cough caused by bronchial edema
• Accumulated secretions stimulate the cough; the cough becomes rattling and there is production of frothy, clear,
gelatinous sputum
STATUS ASTHMATICUS
v Child displays respiratory distress despite vigorous treatment measures
v Status asthmaticus is a medical emergency that can result in respiratory failure and death if left untreated
TREATMENT
• Mild attack: albuterol p.o. or per inhalation (nebulizer) every four to six hours
• Moderate attack: albuterol PRN p.o. or per inhalation (nebulizer), plus Cromolyn sodium by inhaler or nebulizer
for prevention
• Severe attack: inhaled corticosteroid and inhaled albuterol PRN
NURSING CARE
• Position the child upright, assist with mechanical ventilation as indicated
• Monitor VS, breath sounds and chest retractions
• Monitor ABG’s and oxygen saturation as ordered
• Administered IV fluids, oxygen, emergency drugs as ordered
• Nebulizer, metered-dose inhaler (MDI) or peak expiratory flow meters may be used to administer medications; if
the child has difficulty using the MDI, medication can be administered by nebulization
• Chest physiotherapy includes clapping, vibration, postural drainage, suctioning, and breathing exercises
ü Chest physiotherapy is not recommended during an acute exacerbation
GASTROINTESTINAL DISORDER
CLEFT LIP/CLEFT PALATE
v A congenital anomaly that occurs as a result of failure of soft tissue or bony structure to fuse during embryonic
development
CAUSES
• Genetic; hereditary
• Environment – exposure to radiation
• Rubella virus, chromosome abnormalities, teratogenic factors
ASSESSMENT
• Cleft lip – can range from a slight notch on to a complete separation from the floor of the nose
• Cleft Palate – nasal distortion, midline or bilateral cleft, variable extension from the uvula and soft and hard
palate
ü Assess the ability to suck, swallow, handle normal secretions and breathe without distress
ü Assess fluid and calorie intake daily
ü And monitor weight
ü Modify feeding techniques
ü Enlarge nipple
ü Stimulate the sucking reflex
ü Rest to allow infant to finish swallowing what has been placed in the mouth
ü Hold the child in upright position and
ü Direct the formula to the side and back of the mouth
ü Position on the side after the feeding
ü Keep suction equipment and bulb syringe at bedside
ü Encourage breastfeeding if appropriate
INTERVENTION POST OPERATIVELY CLEFT LIP
REPAIR (CHEILOPLASTY)
Ø Closure of cleft lip defect precedes that of the cleft palate and is usually performed during the first weeks of
life
ü A lip protector device may be taped securely to the cheeks to prevent trauma to the suture line

ü Position the child on the side opposite to the repair or on the back, avoid prone position to prevent rubbing
of the surgical site on the mattress
ü After feeding, cleanse the suture line with plain normal saline solution
ü Prevent the child from crying if possible
ü Do not let the Logan Bar get wet
CLEFT PALATE (PALATOPLASTY)
• Cleft palate repair is performed sometime between 12 and 18 months of age to allow for the palatal changes
that take place with normal growth; a cleft palate is closed before the child develops faulty speech habits
ü Child is allowed to lie on the abdomen (prone)
ü Feeding are resumed by bottle, breast or cup
ü Oral packing maybe secured to the palate
ü Do not allow the child to brush teeth
ü Avoid hard foods
ü Soft elbow or jacket restraints maybe used to keep the child from touching the repair site
ü Avoid contact with sharp objects near the repair site
ü Avoid oral suction or placing objects in the mouth
ü Provide analgesics for pain
PYLORIC STENOSIS
v Hypertrophy of the circular muscles of the pylorus causes narrowing of the pyloric canal between the stomach
and the duodenum
v Stenosis develops in the first few weeks of life
ASSESSMENTS
• With this condition, at 4 to 6 weeks of age, infants begin to vomit almost immediately after each feeding
• Peristaltic waves are visible from left to right across the epigastrium during or immediately following a feeding
• Vomiting grows increasingly forceful until it is projectile
• Pyloric stenosis. Fluid is unable to pass easily through the stenosed and hypertrophied pyloric valve
• Vomiting – projectile, non – bilious Hunger and irritability
• Olive shaped mass in the epigastrium just right of the umbilicus
• Dehydration and malnutrition
• Electrolyte imbalance
TREATMENT
• Prepare the child for pyloromyotomy
ü An incision through the muscle fibers of the pylorus that may be performed by laparoscopy
• Monitor vital signs; intake and output and weight
• Monitor for signs of dehydration and electrolyte imbalance
• Oral feedings are withheld to prevent further Electrolyte depletion
• An infant who is receiving only IV fluid generally needs a pacifier to meet nonnutritive sucking needs
LACTOSE INTOLERANCE
v Inability to tolerate lactose as a result of an absence or deficiency of lactase, an enzyme found in the secretions
of the small intestine that is required for the digestion of lactose
ASSESSMENT
• Symptoms occur after the ingestion of milk products
• Abdominal distention
• Crampy, abdominal pain; colic
• Diarrhea and excessive flatus
• Eliminate the offending dairy product
• Provide information to the parents about enzyme tablets that predigest the lactose in milk or supplement the
body’s own lactase
• Substitute soy-based formulas for cow’s milk formula or human milk
• Provide calcium and vitamin D supplements to prevent deficiency
• Limit milk consumption to one glass at a time
• Instruct the child and family that the child should drink milk with other foods rather than by itself

• Encourage consumption of hard cheese, cottage cheese, or yogurt, which contains the inactive lactase enzyme
• Encourage consumption of small amounts of dairy foods daily to help colonic bacteria adapt to ingested lactose
• Instruct the parents about the foods that contain lactose, including hidden sources
CELIAC DISEASE
v Celiac disease also is known as gluten enteropathy or celiac sprue
v Intolerance to gluten, protein component of
B-arley
R-ye
O-ats
W-heat
v Celiac disease results in the accumulation of the amino acid glutamine, which is toxic to intestinal mucosal cells
v Intestinal villi atrophy occurs, which affects absorption of ingested nutrients
v There is usually an interval of 3 to 6 months between the introduction of gluten in the diet and the onset of
symptoms
ASSESSMENT
• Acute or insidious diarrhea
• Steatorrhea
• Anorexia
• Abdominal pain and distention
• Muscle wasting, particularly in the buttocks and extremities
• Vomiting
CELIAC CRISIS
• Precipitated by infection, fasting, ingestion of gluten
• Can lead to electrolyte imbalance, rapid dehydration, severe acidosis
• Causes profuse watery diarrhea and vomiting
• Maintain a gluten-free diet, substituting corn, rice, and millet as grain sources
• Instruct parents and child about lifelong elimination of gluten sources such as wheat, rye, oats, and barley
• Administer mineral and vitamin supplements including iron, folic acid, and fat-soluble supplements A, D, E and K
FOODS ALLOWED
• Beef
• Pork
• Fish, eggs, milk, and dairy products
• Vegetables fruits, rice, corn, gluten-free wheat flour, puffed rice, cornflakes
FOOD PROHIBITED
• Commercially prepared ice cream
• Malted milk
• Prepared puddings
• Grains, wheat, rye, oats, or barley, such
ü Breads, rolls, cookies, cakes, crackers, cereal, spaghetti, macaroni noodles and beer
DUODENAL ATRESIA
v Congenital absence or complete closure of a portion of the lumen of the duodenum
ASSESSMENT
• Early bilious vomiting
• No abdominal distention
• Continued vomiting even when infant has not been fed for several hours
• Absent bowel movements after first few meconium stools usually confirmed by radiography
• An x-ray of the abdomen shows two large air filled spaces, the so-called “double bubble” sign
HIRSCHSPRUNG’S DISEASE
v The disease occurs as the result of an absence of ganglion cells in the rectum and other areas of the affected
intestine
• Congenital anomaly also known as congenital aganglionosis or aganglionic megacolon
• Involves an enlargement of the colon caused by bowel obstruction

ASSESSMENT
• “Ribbon like stools”
• Shows symptoms in the first 6 weeks of life
• No bowel movement in the first 48 hours of life
• Gradual bloating of the abdomen
• Gradual onset of bile stained vomitus
• Fecal odor of breath
• Loss of appetite, delayed growth;
• Anemia
• Passing small, watery stool
DIAGNOSIS
• Abdominal x-ray
• Barium enema
• Biopsy of the rectum or large intestine
MEDICAL TREATMENT: SURGERY
• Bowel resection
• Abdominoperineal pull through by about one year
ü Maintain low-fiber, high-calorie, high-protein diet; parenteral nutrition may be necessary in extreme situations
ü Administer stool softeners as prescribed
ü Administer daily rectal irrigations with normal saline to promote adequate elimination and prevent obstruction
as prescribed
NURSING INTERVENTION (POST-OP)
• Measure abdominal girth daily and PRN
• Assess the surgical site for redness, swelling, and drainage
• Assess the stoma if present for bleeding or skin breakdown (stoma should be red and moist)
• Maintain NPO status until bowel sounds return or flatus is passed, usually within 48 to 72 hours
• Maintain the nasogastric tube to allow intermittent suction until peristalsis returns
• Maintain IV fluids until the child tolerates appropriate oral intake, advancing the diet from clear liquids to regular
as tolerated and as prescribed
• Provide the parents with instructions regarding colostomy care and skin care
ABDOMINAL WALL DEFECTS OMPHALOCELE

v Herniation of the abdominal contents through the umbilical ring with intact peritoneal sac
v Protrusion is covered by translucent sac that contain bowel or other abdominal organs
v Immediately after birth cover sac with sterile gauze soaked in normal saline to prevent drying of
abdominal contents
UMBILICAL HERNIAS
v Caused by a small defect in the Abdominal muscles which allows a portion of the peritoneum to protrude,
and push the umbilicus outward
v More obvious when the infant cries
v Increased pressure results in more visible bulging
v In most cases, by age 3 the umbilical hernia shrinks and closes without treatment
INDICATIONS FOR UMBILICAL HERNIA REPAIR:
• Incarcerated (strangulated) umbilical hernia
• Defects not spontaneously closed by 4-5y/o
• Children under 2 with very large Defects
• Unacceptable to parents for Cosmetic reasons
GASTROSCHISIS
v Herniation is lateral to the umbilical ring
v No membranes cover the exposed bowel
v Exposed bowel is covered loosely in saline soaked pads and the abdomen is wrapped in a plastic drape
• Surgery is performed several hours after birth – no membrane is covering the sac
• Position the child supine
• Keep the sac from drying

IMPERFORATED ANUS
ASSESSMENT
• Failure to pass meconium stool
• Absence or stenosis of the anal rectal canal
• A “wink” reflex (touching the skin near the rectum should make it contract) will not be present
• Inability to insert a rubber catheter into the rectum
• No stool will be passed, and abdominal distention will become evident
THERAPEUTIC MANAGEMENT
• Degree of difficulty in repairing an imperforate anus depends on the extent of the problem
• Repair involves simple anastomosis of the separated bowel segments
• All repairs are complicated if a fistula to the bladder or vagina is present
TALIPES
v Popularly called clubfoot
v More often in boys than in girls
v It probably is inherited as a polygenic pattern. It usually occurs as a unilateral problem
A true talipes disorder can be one of four separate types:
1. Plantarflexion
ü (an equinus or “horsefoot” position, with the Forefoot lower than the heel)
2. Dorsiflexion
ü (the heel is held Lower than the forefoot or the anterior foot is flexed toward the anterior leg)
3. Varus deviation (the foot turns in)
4. Valgus deviation (the foot turns out)
• Use of DENIS BROWNE-TYPE SPLINTS to maintain the correction obtained by manipulation and stretching
the most frequently used surgical approach is posteromedial release
• Correction is achieved best if it is begun in the newborn period. A cast is applied while the foot is placed in an
overcorrected position
• Infants grow so rapidly in the neonatal period that casts for talipes deformities must be changed almost every 1
or 2 weeks
• After approximately 6 weeks (the time varies depending on the extent of the problem), the final cast is removed.
After this, parents may need to perform passive foot exercises such as putting the infant’s foot and ankle through
a full range of motion several times a day for several months
DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH)/ CONGENITAL HIP DYSPLASIA

(A) A normal femur head and acetabulum
(B) A dislocated hip
With this disorder, the acetabulum of the pelvis is flattened or shallow. This prevents the head of the femur from
remaining in the acetabulum and rotating adequately improper formation and function of the hip socket
CAUSES
• Physiologic (having to do with the child’s basic make up as well as the child’s response to the maternal
hormones)
• Mechanical (positional influences in utero); breech presentation
• Pelvic relaxation around the time of birth Aggravate the instability of the newborn hip joint allow softening
and stretching of the baby’s hip ligaments
ASSESSMENT
• Barlow test is the most important maneuver in examining the newborn hip. The examiner attempt to push the
ball of the hip rearward out of the socket. A feeling of the femur head slipping out of the socket
posterolaterally is a positive Barlow’s sign indicative of hip instability
• Associated with developmental hip dysplasia one knee will appear to be lower than the other (a galeazzi sign)
• Correction of subluxated and dislocated hips involves positioning the hip into a flexed, abducted (externally
rotated) position to press the femur head against the acetabulum and cause it to deepen its contour by the
pressure or casts may be used. The small number of children who do not achieve correction by these
methods will have surgery and a pin inserted to stabilize the hip
• Ortolani test is a maneuver to reduce a recently dislocated hip

Positive = examiner feels a “clunk” as it pops back into place
• Ortolani maneuver
An initial downward pressure further dislocates the hip, which then relocates as the thigh is adducted. A palpable
“clunk” is noted
• Multiple Diapers or Splints. Often splint correction (to hold the legs in a frog-leg, or abducted, externally
rotated position) is begun during the newborn’s initial hospital stay by placing two or three diapers on the infant
GENITO-URINARY TRACT DISORDERS
EPISPADIAS/HYPOSPADIAS
v A congenital condition in which the urethral opening is located behind the glans penis or on the dorsal segment
(epispadias) or on ventral or undersurface of the penis (hypospadias) a ventral curvature of the penis
(chordee) is often associated, causing constriction
SIGN
• Observable malposition of the urethral orifice
TREATMENT
• For minor conditions in which the urethral opening is still on the glans, no treatment is needed
• Ureteroplasty for severe cases. Surgical repair is done when the child is about two to three years old (period of
toilet training), or before the child enters kindergarten school
NURSING CARE
• Careful and thorough assessment of the genitourinary system of the newborn
• Identify signs: misplaced urinary meatus and inability to make straight stream of urine
INGUINAL HERNIA
v Result from incomplete closure of the tube (processus vaginalis) between the abdomen and the scrotum leading
to the descent of intestinal portion
HYDROCELE
• Presence of abdominal fluid in the scrotal sac
NON-COMMUNICATING
• Seen at birth
• Residual peritoneal fluids is trapped within the lower segment of the processus vaginalis
• No treatment
COMMUNICATING
• Associated with hernia
• Processus vaginalis remains open from The scrotum to the abdominal cavity
Reference:
Hockenberry, M., Wilson, D (2015). Wong’s nursing care of infants and children, 10th edition. Canada: Elsevier Inc.

PSYCHIATRIC NURSING
FOUNDATIONS OF PSYCHIATRIC MENTAL NURSING
Mental Health
v It is a state of emotional, psychological, and social wellness evidenced by satisfying personal relationships, effective
behavior and coping, apositiveself-conceptand emotional stability
Mental Disorder
v A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and is associated
with present distress or disability or with significantly increased risk of suffering, death, pain, disability or an
important loss of freedom (APA, 2000)
Components of Mental Health

v Autonomy and Independence
v Maximizing one's potential
v Tolerating Life's Uncertainties
v Self-esteem
v Mastering Orientation
v Reality Orientation
v Stress Management
HISTORICAL PERSPECTIVES OF THE TREATMENT OF MENTAL ILLNESS

Ancient Times
v A belief that any sickness indicates displeasure of the gods and punishment for sins and wrongdoing
v Peoplewithmentaldisordersareeither viewed as divine or demonic
v Divine = worshipped and adored
v Demonic = punished and burned
v Aristotledeveloped atheoryaboutthe amounts of blood, water and yellow and black bile in the body
v Thesefoursubstancescorrespondwith happiness, calmness, anger, and sadness.
v Any imbalance from the four substances will cause mental disorders
v Treatment: bloodletting, starving and purging
Early Christian Times

v Primitive and superstitious beliefs
v All diseases were blamed to demons.
v Mentally ill personswere viewed as possessed
v Treatment: performance of exorcisms to rid evil spirits
v If thatfails = incarceration in dungeons, flogging and starving
Renaissance
v People with mental illness were distinguished from criminals
v Ifharmless = allowed to wanderthe countryside
v Harmful (dangerouslunatics) = thrownin prison, chained and starved
v Hospital of St.Mary of Bethlehem = first hospital for insane
v Inmates were viewed as animals
v Also during this period, mentally ill people were viewed as evil and possessed.
v Treatment = witchhunts were conducted; offenders were burned
Period of Enlightenment
v Philippe Pinel and William Tuke
• Formulated the concept of asylum (safe refuge)
v Dorothea Dix advocated adequate shelter, nutritious food and warm clothing to those who are mentally ill.
EmilKraepelin =classifiesmentaldisorders according to their symptoms.
Eugene Bleuler = coined the term schizophrenia.

THERAPEUTIC USE OF SELF

v Main tool used by the nurse in Psychiatric Nursing.
v Nurses use themselves as a therapeutic tool to establish therapeutic relationship with the client
v Introduced by Hildegard Peplau (1952)
v According to him, nurses must have a clear understanding of themselves to promote client's growth.
v Therapeutic use of self requires self-awareness
SELF-AWARENESS
v It is the processby which the nurse gains recognition of his or her own feelings, beliefs, and attitudes.
Goal: To know oneself so that one's values,attitudes, and beliefs are not projected to the client, interfering with nursing
care.
v Onetoolthat is useful in learning about oneself is Johari's Window
Four Quadrants of Johari's Window

ü Arena/Open/ Public Self
Quadrant I
ü Qualities known to oneself and others
ü Blind/Unaware Self
Quadrant II
ü Qualities known only to others, not to self
ü Façade/ Hidden/ Private Self
Quadrant III
ü Qualities known only to oneself
ü Unknown
Quadrant IV
ü An empty quadrant to symboliz equalities as yet undiscoveredby oneself or others
METHODS USED TO INCREASE SELF — AWARENESS

v Role Play
v Introspection
v Discussion
v Enlarging one's experience
THERAPEUTIC COMMUNICATION
v It is an interpersonal interaction between the nurse and client during which the nurse focuses on the client's specific
needs to promote effective exchange of information
Goals
• Establish a therapeutic nurse—client relationship.
• Identify the most important client concern at that moment (the client-centered goal).
• Assess the client's perception of the problem as it unfolded.
• Facilitate the client's expression of emotions.
• Teach the client and family necessary self-care skills.
• Recognize the client's needs.
• Implement interventions designed to address the client's needs.
• Guide the client toward identifying a plan of action to a satisfying and socially acceptable resolution.
THERAPEUTIC COMMUNICATION TECHNIQUES

Accepting
- Indicating reception
Examples: "Yes";"I follow what you said"; Nodding
Rationale:An accepting response indicates the nurse has heard and followed the train of thought. It does not indicate
agreement but is non-judgmental.
Broad Openings
- Allowing client to take the initiative in introducing the topic
Examples: "Is there something you'dlike to talk about?";'Where would you like me to begin?"
Rationale: Broad opening makes explicit that the client has the leadin the interaction;may stimulate him or her to take
the initiative

Consensual Validation
-Searching for mutual understanding, for accord in the meaning of the words.
Examples: "Tell me whether my understanding of it agrees with yours."; "Are you using this word to convey that?"
Rationale: For verbal communication to be meaningful, it is essential that the words being used should have the same
meaning for all participants.
Encouraging Comparison
-Helping the client to understand by looking at similarities and differences.
Examples:'Was it something like?"; "Have you had similar experiences?"
Rationale:Comparing ideas,experiences, or relationships brings out many recurring themes;
He or she might recall past coping strategies that were effective or remember the he or she has survived a similar
situation
Encouraging Description of Perceptions

-Asking client to verbalize what he or she perceives.
Examples:"Tell me when you feel anxious"; "What is happening?"; "What does the voice seem to be saying?"
Rationale: To understand the client. the nurse must see things from his or her perspective; may relieve the tension the
client is feeling and he or she might be less likely to take action on ideas that are harmful or frightening
Encouraging Expression
- Asking client to appraise the quality of his or her experience.
Examples:'Whatare your feelings in regard to?"
Rationale:Encourages the client to make his or her own appraisal rather than accepting the opinion of others.
Exploring
- Delving further into a subject or idea.
Examples; "Tell me more about that."; 'Would you describe it more fully'?"; 'What kind of work?"
Rationale: This can help them examine the issue more fully; If the client expresses an unwillingness to explore a
subject, however, the nurse must respect his or her wishes.
Focusing
- Concentrating on a single point.
Examples: "This point seems looking at more closely.";"Of all the concerns you have mentioned, Which is most
troublesome?"
Rationale: This encourages the client to concentrate his or her energies on a single point, which may prevent a
multitude of factors or problems from overwhelming the client; useful technique when a client jumps from one topic to
another.
Formulating a Plan of Action

- Asking the client to consider kinds of behavior likely to be appropriate in future situations.
Examples: 'What could you do to let your anger out harmlessly?"; "Next time this comes up, what might you do to
handle it?"
Rationale:It may be helpful for the client to plan in advance what he or she might do in future similar situations; making
definite plans increases the likelihood that the client will cope more effectively in a similar situation
General Leads
- Giving encouragement to continue.
Examples:"Goon.";"And then?";"Tell me about it."
Rationale:Thisindicates that the nurse is listening and following what the client is saying without taking away the
initiative for the interaction; encourage the client to continue if he or she is hesitant or uncomfortable about the
topic.
Giving Information
-Making available the facts that the client needs..
Examples:"My name is...";"Visiting hours are. . ."; "My purpose in being here is..."
Rationale: Informing the client of facts increases his or her knowledge about a topic or lets the client know what to
expect; builds trust with the client.
Giving Recognition
- Acknowledging, indicating awareness.
Examples:"Good morning,Mr.S...";"You've finished your list of things to do."' "I noticed that you've combed your hair."
Rationale: Greeting the client by name, indicating awareness of change, or noting efforts the client has made all show
that the nurse recognizes the client as a person, as an individual.
Making Observations
- Verbalizing what the nurse perceives.
Examples: "You appear tense."; "Areyou uncomfortable when . . ?"; "I notice that you are biting your
Rationale: Sometimes clients cannot verbalize or make themselves understood.
Offering Self
- Making oneself available.
Examples: "I will sit with you a while."; "I will stay here with you."; "I am interested in what you think."
Rationale: The nurse can offer his or her presence, interest, and desire to understand; It is important that this offer is
unconditional, that is, the client does not have to respond verbally to get the nurse's attention.
Placing event in Time Sequence

- Clarifying the relationship of events in time.
Examples: 'What seemed to lead up to?"; Was this before or after?"; 'When did this happen?"
Rationale: This helps both the nurse and client 'to see them in perspective;The client may gain insight into cause-and-
effect behavior and consequences, or perhaps some things are not related. The nurse may gain information about
recurrent patterns or themes in the client behavior relationship.
Presenting Reality
-Offering for consideration that which is real.
Examples: "I see no one else in the room."; "That sound was a car back firing."; "Your mother is not here.I am a
nurse."
Rationale:When it is obvious that a client is misinterpreting reality, the nurse can indicate what is real.
Reflecting
- Directing client actions, thoughts, and feelings back to the client.
Examples
Client: "Do you think I should tell the doctor?"
Nurse: "Do you think you should?"
Client: "My brother spends all my money and then has the nerve to ask for more."
Nurse: "This causes you to feel angry'?"
Rationale: This encourages the client to recognize and accept his or her own feelings.
Restating
- Repeating the main idea expressed.
Examples
Client: "I can't sleep. I stay awake all night." Nurse: "You have difficulty sleeping."
Client: "I am really mad. I am really upset." Nurse: "You're really mad and upset."
Rationale: Restatement lets the client know that heor she communicated the idea effectively; encourages the client to
continue
Seeking Information
-Seeking to make clear that which is not meaningful or that which is vague.
Examples: "I am not sure that I follow."; "Have I heard you correctly?'
'Rationale:This can help the nurse to avoid making assumptions that understanding has occurred when it has not;helps
the client to articulate thoughts,feelings,and ideas more clearly.
Silence
-Absence of verbal communication,which provides time for the client to put thoughts or feelings in towords,regain
composure, or continue talking.
Examples:Nurse says nothing but continues to maintain eye contact and conveys interest
Rationale: This often encourages the client to verbalize provided that it is interested and expectant; gives the client time
to organize thoughts, direct the topic of interaction, or focus on issues that are most important.
Suggesting Collaboration
- Offering to share, to strive, to work with the client for his or her benefit.
Examples:"Perhaps you and I can discuss and discover the triggers for your anxiety."; "Let's go to your room and I will
help you find what you are looking for."
Rationale:The nurseseeks to offer a relationship in which the client can identify problems in living with others, grow
emotionally, and improve the ability to form satisfactory relationships.
Summarizing
-Organizing and summing up that which has gone before.
Examples:"Have I got this straight?"; "You've said that. ."; "During the past hour, you and I have discussed.."
Rationale: This brings out the important points of the discussion and to increase the awareness and understanding of
both participants;omits the irrelevantand organizes the pertinent aspects of the interaction.
Translating Into Feelings

-Seeking to verbalize client's feelings that he or she expresses only indirectly.
Examples
Client: "I am dead."
Nurse: "Are you suggesting that you feel lifeless?"
Client: "I am way out in the ocean."
Nurse:"You seem to feel lonely or deserted."
Rationale: The nurse must concentrateon what the client might be feeling to express himself or herself this way.
Verbalizing the Implied

-Voicing what the client has hintedator suggested.
Examples
Client:"I can't talk to you or anyone.It is a waste of time."
Nurse: "Do you feel that no one understands?"
Rationale:This tends to make the discussion less obscure.
Voicing Doubt
-Expressing uncertainty about the reality of the client's perceptions.
Examples: "Isn't that unusual?"; "Really?"; "That is hard to believe."
Rationale:This permits the client to become aware that others do not necessarily perceive events in the same way or
draw the same conclusions.
NON-THERAPEUTIC COMMUNICATION
Examples: "I think you advising should."; 'Why don't you?"
Advising
Rationale: This implies that client what to do only the nurse knows what is
- telling the client what to do
best for the client.
Agreeing Examples: "That is right.” "I agree."
- indicates accord with the client Rationale: This indicates the agreeing
Example:
Client: “I have to live for…I wish I was dead”
Belittling feelings expressed Nurse: “Everybody gets down in the dumps” or “I have felt the way myself.”
- misjudging the degree of the client’s Rationale: When the nurse tries to equate in the intense and overwhelming
discomfort feelings the client has expressed to “everybody” or to the nurse’s own
feelings, the nurse implies that the discomfort is temporary, mild self-limiting,
or not very important
Example: ”But how can you be the president of the United State?” “if you
are dead, why is your heart beating
Challenging
Rationale: Often the nurse believe that if he or she can challenge the client
– demanding proof from the client
to prove unrealistic idea, the client will realize there is no “proof” and then
will recognize reality. Actually challenging causes the client to defend the

delusions or misconception
Defending Example:” the hospital has a fine reputation”; “ I am sure your doctors has
- attempting to protect someone or your best interest in mind.”
something from the verbal attack Rationale: this implies that he or she no right to express impression,
opinion or feeling
Example: ”that is wrong”; ”I definitely disagree with…”;”do not believe on
Disagreeing that…”
- opposing the client’s idea Rationale: this implies the client is “ wrong”; consequently the client feels
defensive about his or her point of view or ideas
Examples: "That is good."; "I am glad that."
Giving approval/ Agreeing Rationale:Saying what the client thinks or feels if "good" implies that the
- Sanctioning the client's behavior opposite is "bad"; tends to limit the client's freedom to think, speak, or act
or ideas in a certain way; can lead to the client's acting in a particular way just to
please the nurse.
Example:
Giving literal responses Client:"They are looking in my head with a television camera." Nurse: "Try
- Responding to a figurative comment as not to watch television." or 'What channel?"
though it were a statement of fact. Rationale:Often the client is at a loss to describe his or her feelings, so such
comments are the best he or she can do; usually it is helpful for the
nurse to focus on the client's feelings in response to such statements
Indicatingthe existence of an external Examples:'What makes you say that?"; 'What made you do that?";
source “Who told you that you were a prophet?"
-Attributingthe source of thoughts, feelings, Rationale: The nurse can ask, “What happened?" Or “What events led you
and behavior to others or to outside to draw such a conclusion?";But to question “What made you think that?"
influences. implies that the client was made or compelled to think in a certain way.
Interpreting Examples: “Whatyoureally meanis...";"Unconsciously you are saying ..."
- Asking to make conscious that which is Rationale: Client's thoughts and feelings are his or her own,
unconscious not tobe interpretedby the nurse or for hidden meaning.
Example:
Client: “I would like to die”
Introducing an unrelates topic
Nurse: “ did you have visitors last night?”
–change the subject
Rationale: the nurse takes the initiative for the interaction away from the
client
Example: “Now tell me about this problem. You know I have to find out”;”
Making stereotype comments
tell your psychiatric history”.
- offering meaningless clichés or tripe
Rationale: Tend to make the client feel used or invaded; clients have the
comments
right not to talk about issues or concerns if they choose.
Reassuring Example: “I would not worry about that”;” everything would be alright”;
- indicates that there is no reason for you are coming along just fine.”
anxiety or other feelings of discomfort Rationale: This is completely devalues the client’s feelings.
Rejecting Example: “ Let us not discuss…:”;”I do not want to hear about…”
- refusing to consider or showing contempt Rationale: Nurse closes it off exploring; in turn, the client will feel
for the client’s idea or behavior personally rejected along with his or her ideas
Requesting an explanation Example:“why do you think that?; “ why do you feel that way?’’
- asking the client to provide reasons for Rationale: using “ why” question is intimidating
thoughts, feelings, behaviors, events
Example: “ do you know what kind of hospital this is”; “do you still have the
Testing
idea that…?’’
– appraising the client’s degree of insight.
Rationale: This is forces the client to try to recognize his or her problems.
Example: Client: "I am nothing.
Nurse:"Ofcourseyou are something.Everybodyis something."
Client: "I am dead."
Using Denial
Nurse: "Do not be silly."
-Refusing to admit that problem exists.
Rationale:denies the client's feelings or the seriousness of
the situation by dismissing his or her comments without attempting to
discover the feelings or meaning behind them

DISTURBANCES IN THOUGHT PROCESS AND CONTENT

Circumstantial Thinking Example:
-a client gives out excessive unnecessary Nurse: "How have you been A client sleeping lately?"
details, but eventually gets to the point. Client: "Oh, I goto bed,so I can get plenty of rest. I like to listen to musicor
read books before bed. Right now I am reading a good mystery. Maybe I will
write a mystery someday. But is it isn’t helping reading, reading I mean. I have
been getting only 2 or 3 hours of sleep at night.”
Tangential Thinking Example:
-a client gives out excessive unnecessary Nurse: "How have you been A client sleeping lately?"
details and never gets to the point. Client: "Oh, I goto bed,so Ican get plenty of rest. I like to listen to musicor
read books before bed. Right now I am reading a good mystery. Maybe I will
write a mystery someday. But sometimes I also like drama or non-fiction.”
Word salad Example: “ corn, potatoes, jump up, play games, grass, cupboard.”
- It is a combination of jumbled words
and phrase that are disconnected or
incoherent and make no sense to the
listener
Verbigeration Example: “I want to go home, go home, go home.”
-stereotyped repetition of wordsor phase
that may or not have meaning to the
listener.
Perseveration Example:
-Persistent adherence to a single idea or Nurse: "How have you been sleeping lately?"
topicandverbal repetition of a sentence, Client:"Ithinkpeoplehave been following me."
phrase, or word, even when another Nurse: 'Where do you live?"
person attempts to change the topic. Client:"At my place people have been following
Nurse: 'What do you like to do in your free time?"
Client: "Nothing because people are following me."
Echolalia Example:
- Client's imitation or repetition of what Nurse: Can you tell me how you’re feeling?
the nurse says. Client: Can you tell me how you’re feeling,
Flight of Ideas Example: 'The sun is
Excessive amount andrate of speech shining.Where is my sun? I love Lucy. Let us play ball."
composedof fragmented or unrelated
ideas
Loosenessof Association Example:
- Disorganized thinking that jumps from Nurse: "Do you have enough money to buy that candy bar?"
one idea to another with little or no Client: "I have a real yen for chocolate. The Japanese have all the yen and
evident relation between the thoughts have taken all of our money and mark edit. You know,you have to be careful
of the Marxists because they are friends with the Swiss and they have all the
cheese and all the watches and that means they have taken all the time.The
worst thing about Swiss cheese is all the holes. People have to be careful
about falling into holes."
Delusion The client may claimtobe engaged to a famous movie star or related to some
-False belief which is inconsistent with public figure such as claiming to be the daughter of the President of the
one's knowledge and culture Philippines
Hallucination The client may claim to be speaking with an imaginary person commanding
- False sensory perceptions, or him to do something bad to another person.
perceptual experiences that do not really
exist.
Neologisms Example:
-Words invented by the client "I'm afraid of grittiz. If there are any grittiz here, I will have to leave. Are you a
grittiz?"

DISTURBANCES IN AFFECT
Inappropriate Affect
v Disharmony between the stimulus and the emotional reaction.
Blunted Affect
v Severe reduction in emotional reaction.
Flat Affect
v Absence or near absence of emotional/facial reaction that would indicate emotions or mood
Apathy
v Feelings of indifference toward people, activities, and events
Ambivalence
v Holding seemingly contradictory beliefs or feelings about the same person, event or situation. Presence of two
opposing feelings.
Depersonalization
v Clients feel detached from their behavior
v Feelings of strangeness towards oneself
v Although client can state his name correctly, he feels as if his body belongs to someone else, or that his spirit is
detached from is body.
Derealization
v Feeling of strangeness towards the environment
v Environmental objects become smaller larger, or seem unfamiliar.
v Individual feels that the outside world has changed.
v Everything may seem gray and dull
DISTURBANCES IN MOTOR ACTIVITY

Echopraxia
v The pathological imitation of posture or action of others
v Imitation of the movements and gestures of another person whom the client is observing
Waxy Flexibility
v Maintaining the desires position for long periods of time without discomfort even when it is awkward or
uncomfortable
DISTURBANCES IN MEMORY
Confabulation
v Filling a memory gap with detailed fantasy believed by the teller
v Purpose of confabulation: Maintainself-esteem
Example:
Nurse: "Do you know Gemma? (referring to one the residents at the patient's home)
Patient: "Yes, I know her. I used to play cards war her husband."Actually, Gemma's husband was dead for many years
and the patient had never met him.
Amnesia
v Inability to recall past events
BASIC ELEMENTS OF THE NURSE-PATIENT RELATIONSHIP

T — rust
R — apport
U — nconditional positive regard
S — etting limits
T — herapeutic communication

CHARACTERISTICS OF THE NURSE-PATIENT RELATIONSHIP

v Goal — directed
v Focused on the needs of the patient Planned
v Time-limited
v Professional
PHASES OF THE NURSE-PATIENT RELATIONSHIP

Pre-orientation Phase
v Begins when the nurse is assigned to a nurse
v Major task: Develop self-awareness
v Tasks include data gathering, planning for the first interaction
Orientation Phase
v Begins when the nurse and client meet
v Ends when the client begins to identify problems to examine.
v Tasks: establishing rapport, developing trust, assessment, establishing roles, purpose of the meeting, parameters of
subsequent
v Major Task: develop a mutually acceptable contract
Working Phase
v Longest and most productive phase of the nurse-patient relationship
v Limit-setting is employed
v Divided in two sub-phases
• Problem identification
ü Client identifies the issues or concerns causing problems
• Exploitation
ü Nurse guides the client to examine feelings and responses and to develop better coping skills and a more
positive self-image
• Transference
v Client unconsciously transfers his feelings to the nurse.
• Countertransference
v Therapist displaces on to the client attitudes or feelings from his / her past
• Resistance
v Development of ambivalent feelings toward self-exploration
• Termination Phase
v Also termed Resolution phase
v Begins when problems are resolved
v Ends when the relationship is ended.
v It involves feelings of anxiety, fear and loss.
PSYCHOTROPIC DRUG CATEGORIES
ANTI-PSYCHOTICS
v Also known as Neuroleptics
v Used to treat symptoms of psychosis.
v Primary treatment for schizophrenia
v Used in psychotic depression, acute mania and drug-induced psychosis
ANTIPSYCHOTIC DRUGS Clozapine

Haloperidol (Haldol) Risperidone
Chlorpromazine (Thorazine) Atypical Olanzapine
Perphenazine (Trilafon) Quetiapine
Typical
Fluphenazine (Prolixin) Ziprasidone
Thioridazine (Mellaril) New Generation Aripiprazole
Mesoridazine (Serentil) Antipsychotic
Trifluoperazine (Stelazine)

Side Effects
1. Extrapyramidal Symptoms (EPS)
v Major side effects of antipsychotic agents
v Includes acutedystonia, PseudoParkinsonism, akathisia, tardive dyskinesia
v EPS happen when there is blockade of dopamine (D2) receptors in the midbrainregion of the brain stem.
Treatment for EPS

GENERIC NAME DRUG CLASS
(TRADE)
Amantadine (Symmetrel) Dopaminergic Agonist
Benztropine (Cogentin) Anticholinergic
Biperiden (Akineton) Anticholinergic
Diazepam (Valium) Benzodiazepine
Diphenhydramine (Benadryl) Antihistamine
Procyclidine (Kemadrin) Anticholinergic
Propranolol (Inderal) Beta-blocker
Trihexyphenidyl (Artane) Anticholinergic
Acute Dystonia
• Torticollis
• Opisthotonus
• Oculogyric crisis
• Acute muscular rigidity and cramping
• Stiff or thick tongue
• Difficulty swallowing
• Laryngospasm
• Respiratory difficulties
Treatment
• Intramuscular Benztropine mesylate (Cogentin)
• IM or IV Diphenhydramine (Benadryl)
PseudoParkinsonism
• Stiff, stooped posture
• Mask-like facies
• Decreased arm swing
• Shuffling, festinating gait
• Cogwheel rigidity
• Drooling
• Coarse pill-rolling movements of the thumbs and fingers while at rest.
Treatment
• Changing antipsychotic medication that has lower incidence of EPS
• Adding an anti-cholinergic agent or
Amantadine.
Akathisia
• Inability to sit still
• Restless/anxious
• Rigid posture or gait
• Lack of spontaneous gestures
Treatment
• Change of antipsychotic medication
• Addition of an oral agent (Beta-blocker,
Anticholinergic, Benzodiazepine)

Tardive Dyskinesia
• Vermiform (Worm-like) tongue movements
• Sucking, smacking movements of the lips
• Involuntary movements of the body
• Permanent, irreversible
• Appears after at least 8 months of antipsychotic therapy
Treatment
• Valbenazine
• Deutetrabenazine
• Progression can be arrested by decreasing the antipsychotic medication
2. Neuroleptic Malignant Syndrome

v Potentially fatal, idiosyncratic reaction to an antipsychotic
v Rigidity
v High fever
v Autonomic instability (unstable blood pressure, diaphoresis, pallor, delirium)
v May fluctuate from agitation to stupor
v Increasedrisk for: dehydration and poor nutrition
Treatment
• Immediate discontinuance of all antipsychotic medications
• Treatment of dehydration and
hyperthermia
3. Anticholinergic Side Effects

v Often occurs with the use of antipsychotics
v Side effects usually decrease within 3 to 4 weeks but do not entirely remit
MANIFESTATIONS
Orthostatic hypotension
Dry mouth
Constipation
Urinary hesitance or retention
Blurry vision
Dry eyes
Photophobia
Nasal congestion
Decreased memory
• Stool softeners
• Calorie-free beverages
• Adequate fluid intake
• Inclusion of grains and fruits in the diet
NURSING ALERT
Droperidol, Thioridazine, Mesoridazine
These drugs may lengthen the QT interval to potentially life-threatening cardiac dysrhythmia or cardiac arrest
NURSING RESPONSIBILITIES: ANTI-PSYCHOTIC DRUGS

Dry mouth • Drink sugar-free fluids
• Sugar-free hard candy
Constipation • Increase OFI
• Eat bulk-forming food
• Exercise
• Stool softeners but laxatives

Photosensitivity • Use sunscreen
• Avoidlongperiods time in the sun
•Wear protective covering
Orthostatic Hypotension • Rising slowly from sitting or lying postings
Drowsiness •Avoid driving a car or performing other dangerous activities
Dizziness • Wait to walk until any dizziness has subsided
Medication Compliance • If you forget a dose of antipsychoticmedication, take it if the dose is only 3 to 4
hours late. If the missed dose is more than 4 hours late or the next dose is due,
omit the forgotten dose
• If you have difficult remembering your medication, use a chart to record doses
when taken, or use a pill box labelled with dosage times and/or days of the week
to help you remember when to take medication.
NURSING ALERT
Clozapine
ü May cause agranulocytosis
ü Clients should have a baseline WBC count anddifferential before initiation of treatment
ü WBC count everyweek throughout treatment and for 4 weeks after
discontinuation of clozapine
ANTI-DEPRESSANT DRUGS
v Primarily used in the treatment of:
• Major depressive illness
• Anxiety disorders
• Depressedphaseofbipolar disorder
• and psychotic depression
TYPES OF ANTIDEPRESSANT DRUGS

1. Selective Serotonin Reuptake Inhibitors (SSRI)
2. Tricyclic Antidepressant (TCA)
3. Monoamine Oxidase Inhibitors (MAOI)
Tricyclic Antidepressant Drugs (TCA)

• First choice of drugs to treat depression
• Available since 1950's
Nursing Alert
• Potentially lethal if taken in an overdose.
• Depressed or impulsive clients who are taking these drugs need to have prescriptions and refills in limited
amounts to decrease the risk.
TRICYCLIC DRUGS
Imipramine (Tofranil) Side Effects
Desipramine (Norpramin) • Dry mouth
Amitriptyline (Elavil) • Constipation
Nortriptyline(Pamelor) • Urinary retention
Doxepin (Sinequan) • Dry nasal passages
Trimipramine (Surmontil) • Blurred vision
Protriptyline (Vivactil) • Orthostatic hypotension
Maprotiline (ludiomil) • Sedation
Mirtazapine (remeron) • Weight gain
Amoxapine (ascendin) • Tachycardia
Clomipramine (anafranil)
• Agitation
• delirium

Selective Serotonin Reuptake Inhibitor (SSRI)
• Replacedthe tricyclic drugs as the first choice in treating depression because they equalin efficacy and
produce fewer side effects
• Effective in the treatment of obsessive-compulsive disorder
• Safest drug to give during panic attack
SSRI DRUGS Side Effects

Fluoxetine (Prozac) • Agitation
Fluvoxamine (Luvox) • Akathisia
Paroxetine (Paxil) •Nausea
Sertraline (Zoloft) •Insomnia
Citalopram (Celexa) • Sexual dysfunction
Escitalopram (Lexapro) • Weight gain (less)
• Sedation
•Sweating
•Headaches
Monoamine Oxidase Inhibitors

• With low incidence of sedation
• Can cause hypertensive crisis
• This drugshould not be givenwith other MAOIs, tricyclic antidepressants, Meperidine (Demerol), CNS
depressants
MAOI DRUGS Side Effects
Phenelzine (Nardil) • Daytime sedation
Tranylcypromine (Parnate) • Insomnia
lsocarboxazid (Marplan) • Weight gain
• Dry mouth
• Avoid tyramine foods
• No mature or aged cheeses or dishes made with cheese, such as lasagna, pizza (exceptcottage cheese. cream
cheese, ricotta cheese, and processed cheese slices)
• No aged meats such as pepperoni, salami, mortadella, summer sausage, beef logs, and similar products.
• No Italian broad beans (fava) pods or banana peel.Banana pulp and all other fruits and vegetables are permitted
• Avoid all tap beers and microbrewery beer.Drink no more than two cans or bottles of beer (including non-
alcoholic beer) or 4 ounces of wine per day
Side Effect of the other Antidepressant

Sedation Nefazodone
Trazodone
Mirtazapine
Headache Nefazodone
Trazodone
Dry mouth & nausea Nefazodone
Loss of appetite Bupropion venlafaxine

Nausea
Agitation
Insomnia
Dizziness Venlafaxine
Sweating
Sedation
priapism Trazodone

Nursing Alert
v Bupropion
• Can cause seizures at rate 4 times that of other antidepressants
NURSING RESPONSIBILITIES
SIDE EFFECTS INTERVENTION
Nausea Take the medication with food
Insomnia Take daily doses in the morning.
Do not use alcohol to inducesleep because this will worsen
insomnia
Motor restlessness / hand Ask the physician for a medication such as
tremor Propranolol or Benzodiazepine
Dry mouth Usecalorie-free beverages or sugar-free candy
Excessive Weight Gain Balanced Diet
Constipation Increase OFI
Stool Softeners
Mood-stabilizing Drugs
v Used to treat bipolar disorder
v Functions to:
• Stabilize client's mood
• Preventing or minimizing the highs and lows that characterize bipolar illness
• Treat acute episodes of mania
Lithium is the most established mood stabilizer; this normalizes the reuptake of serotonin, NE, acetylcholine &
dopamine.
- Other drugs that are effective in stabilizing the mood:
• Carbamazepine (Tegretol)
• Valproic acid (Depakote, Depakene)
• Gabapentin (Neurontin)
• Lamotrigine (Lamictal)
Lithium
- Available in tablets, capsules, liquid sustained-released form.
- No parenteral forms
- Normal level: 0.5 — 1.5 mEq/L
- Therapeutic level: 0.6 – 1.2 mEq/L
- Common side effects:
• Mild nausea/diarrhea
• Anorexia
• Fine hand tremor
• Polydipsia
• Polyuria
• Metallic taste in the mouth
• Fatigue
• Lethargy
TOXIC EFFECTS
• Severe diarrhea
• Severe vomiting
• Muscle weakness
• Lack of coordination
If left untreated, symptoms mayworsen and can lead to renal failure, coma and death
Lithium levels exceed 3.0 mEq/L = Dialysis
NURSING ALERT
Valproic acid can cause hepatic failurein fatality

Carbamazepine can cause aplastic anemia and agranulocytosis
Lamotrigine can cause Steven-Johnsons Syndrome
MOOD STABILIZING DRUGS: NURSE RESPONSIBILITIES

• Have serum levels monitored periodically
• Take the medication with food to minimize nausea
• For the fine hand tremors ask the physician to prescribe a beta-blocker such as propranolol (Inderal)
• To helpminimize weight gain,get a balance diet and get regular exercise. Expect some weight gain.
• Normal sodium intake (2-3days)
• Minimize side effects of sedation and drowsiness from anticonvulsant medications by taking larger dosesat
bedtimeand smaller doses during the day
• If you are takinglithium, keep water intake in a normal rangeand avoid heavy sweating, because this
increases serum lithium levels rapidly
ANTI-ANXIETY DRUGS (ANXIOLYTICS)

v Used to treat:
• Anxiety disorders
• Insomnia
• OCD
• Depression
• Post-traumatic stress disorder
• Alcohol withdrawal
v Benzodiazepines have proved to be most effective in relieving anxiety
ANTI-ANXIETY DRUGS
Alprazolam (Xanax)
Chlordiazepoxide (Librium)
Clonazepam (Klonopin)
Diazepam (Valium)
Flurazepam (Dalmane)
Lorazepam (Ativan)
Oxazepam (Serax)
Temazepam (Restoril)
Triazolam (Halcion)
Buspirone (BuSpar)
ANTI-ANXIETY DRUGS: NURSING RESPONSIBILITIES

v It is important for clients to know that antianxiety agents are aimed at relieving symptoms, such as anxiety or
insomnia; it does not treat the underlying problems that cause the anxiety.
v Benzodiazepines strongly potentiate the effects of alcohol
v One drink may have the effect of three drinks (alcohol)
v Avoid driving (drowsiness)
v Benzodiazepine withdrawal can be fatal: once a course of therapy has been started, benzodiazepines should
never be discontinued abruptly without the supervision of the physician.
v Take anxiolytic drugs only as prescribed.
Stimulants
• First used to treat psychiatric disorders
• Before, they were used to treat depression
• At present,they are used for attention deficit/hyperactivity disorder in adolescents and children
DRUGS SIDE EFFECTS
Methylphenidate (Ritalin) • Anorexia • Dizziness
Dextroamphetamine (Dexedrine) • Weight loss • Dry mouth
Pemoline (Cylert) • Nausea • Blurred vision
• Irritability • Palpitations

NURSING ALERT
Pemoline
• Can cause life-threatening liver failure
• May require liver transplantation in 4 weeks from the onset of symptoms
STIMULANT: NURSING RESPONSIBILITIES

v Never leave the supply of medication in a place the child can reach
v Nausea & vomiting: Take medication at meal time.
v Growth suppression: Monitor thechild's weight and height
v Try a dosage schedule that provides a dose of medication before beginning routine tasks of concentration such as
nightly homework.
v Dry mouth: Calorie-free beverages or sugar-free candy
v Caffeine-free beverages; avoid chocolate & excessive sugar.
v Medications should be given in a manner that is not intrusive,nor should it draw undue attention to the child.
Disulfiram (Antabuse)
• Sensitizingagent that causes anadverse reaction when mixed with alcohol in the body.
• Usefulfor persons who are motivated to abstain from drinking and who are not impulsive.
• Symptoms begin to appear after five to ten minutes and may last from 30 minutes to 2 hours
ü Facial and body flushing
ü Throbbing headache
ü Sweating
ü Dry mouth
ü Nausea
ü Vomiting
ü Dizziness
ü Weakness
• In severe cases, there may be chest pain,dyspnea, severe hypotension, confusion and even death
Other side effects:

• Fatigue
• Drowsiness
• Halitosis
• Tremor
• Impotence
Common products that may contain alcohol:
• Shaving cream
• Aftershave lotion
• Cologne
• Deodorant
• OTC drugs (cough preparations)
• Client must read the products carefully and select items that are alcohol-free
ELECTROCONVULSIVE THERAPY
Functions:
• Treat depression in select groups such as clients who do not respond to antidepressants
• Indicated to clients who are actively suicidal while waiting weeks for full effects of antidepressant medication
Preparation:
• NPO after midnight
• Void prior to the procedure
• I.V should be started for the administration of the medication

Procedure
• Client receives short acting anesthetic so she is not awake during the procedure
• Receives muscle relaxant to reduce outward signs of seizure
• The brain is monitored with EEG while the electrical stimulation is delivered
• Following ECT the client may be mildly confused, disoriented and may have short term memory impairment.
Voltage of electrical current administered to the
70-50 volts
client
Length of electrical shock applied to the patient 0.5 to 2.0 seconds
Usual number of treatments needed to produce a
6 -12 treatments(up to 15)
therapeutic effect
There should be an interval of 48 hours for each
Frequency of treatments
treatment
Indication of effectiveness of ECT The occurrence of generalized tonic-clonic seizure
-Depression
-Mania
Indication for ECT
-Catatonic
-Schizophrenia
Very High Risks

• Increased intracranial pressure
• Recent Fracture
• Cardiac Condition
• Retinal detachment
• Pregnancy
Need for consent prior to ECT

• Yes, consent is needed
Atropine sulfate To decrease secretions
Succinylcholine (Anectine) Topromote muscle relaxation
Methohexital Sodium(Brevital) Serve as an anesthetic agent
Common complications of ECT
• Loss of memory
• Headache
• Apnea
• Fracture
Nursing Responsibilities After ECT

• The nurse or anesthesiologist mechanically ventilates the patient with 100% oxygen until the patient can
breathe unassisted.
• The nurse monitors for respiratory problems.
• ECTcausesconfusionand disorientation; thus, it is important to help with reorientation (time, place, person) as
the patient emerges from this unconscious state.
• Nurse might need to administer a benzodiazepine, as needed.
• Observation is necessary until the patient is oriented and steady, particularly when the patient first attempts
to stand.
• All aspects of the treatment should be carefully documented for the patient's record.
PERSONALITY STRUCTURE
v Freud conceptualized personality structure as having three components
ID
v Seeks instant gratification; causes impulsive, unthinking behavior; and has no regard for rules or social
convention
SUPER EGO
v Values, and parental and social expectations, therefore, it is in direct opposition to the id.
EGO
v Balancing or mediating force between the id and the superego.The ego represents mature and adaptive behavior
that allows a person to function successfully in the world
EGO DEFENSE MECHANISM
RATIONALIZATION
v Excusing own behaviorto avoid responsibility, conflict, anxiety, or loss of self-respect
Examples: Student blames failure on teacher being mean; Man says he beats his wife because she does not listen to
him.
REACTION FORMATION
v Acting the opposite of what one thinks are feels.
Examples:Woman who never wanted to have children becomes a super-mom;Person who despises the boss tells
everyone what a great boss she is.
REGRESSION
v Moving back to previous developmental stage in order to feel safe or have needs met.
Examples: Five-year-old asks fora bottle when new baby brother is being fed; Man pouts like a four-year-old if he is not
the center of his girlfriend's attention.
REPRESSION
v Excluding emotionally painful or anxiety-provoking thoughts and feelings
v Unconscious forgetting
Examples: Woman has no memoryof themugging she suffered yesterday; Woman has no memorybefore age 7 when
she was removed from abusive parents.
SUPRESSION
v Excluding emotionally painful or anxiety-provoking thoughts and feelings
v Conscious forgetting
Examples: Woman has tried to forget her memoryof the financial problems she had in the past.
DISPLACEMENT
v Ventilation of intense feelings toward persons less threatening than the one who aroused those feelings.
Examples: A person who is mad at the boss yells at his or her spouse
COMPENSATION
v Over achievement in one area to offset real or perceived deficiencies in another area
Examples: Napoleon complex: Diminutive man becoming an emperor; Nurse with low self-esteem works double shifts so
her supervisor will like her
CONVERSION
v Expression of an emotional conflict through the development of a physical symptom usually sensorimotor in nature.
Example: A teenager forbidden to see x-rated movies is tempted to do so by friends and develops blindness, and the
teenager is unconcerned about the loss of sight
DENIAL
v Failure to acknowledge an unbearable condition; failure to admit the reality of a situation, or how one enables the
problem to continue
Examples: Diabetic eating chocolate candy; spending money freely when broke; Waiting 3 days to seek help for severe
abdominal pain
DIVISIONS OF THE MIND OR LEVELS OF AWARENESS

v Freud believed that the human personality functions at three levels of awareness: Conscious; Preconscious;
Unconscious
Conscious
v Perceptions,thoughts,and emotions that existin the person's awareness such as being aware of happy feelings or
thinking about a loved one
v Part of the mind focused on awareness
Preconscious
v Not currently in the person's awareness, but he or she can recall them with some effort.
v Part of the mind that contains information that can be recalled at will
Example: An adult remembering what he or she did, thought, or felt as a child.
Unconsciousness
v Realm of thoughts and feelings that motivate a person, even though he or she is totally unaware of them.
v This realm includes most defense mechanisms and some instinctual drives or motivations.
v It is the largest part of the mind; contains materials and information that can never be recalled
COMMON PSYCHOTHERAPEUTIC INTERVENTIONS

1. Remotivation Therapy
v Promotes expression of feelings through interactions facilitated by discussion of neutral topics
v Reality orientation for rehabilitative patients only and not for activetly psychotic patients
2. Music Therapy
v Use of music to facilitate relaxation, expression of feelings and outlet of tension
3. Play Therapy
v Enables the patient to experience intense emotion ina safe environment with the use of play
Example:For victims of child abuse, give dolls.
4. Group Therapy
v Therapeutic interactions of three or more patients with a therapist to relieve emotional difficulties, increase self-
esteem, develop insight and improve behavior in relation with others
v Minimum number of members in a group is 3, while the ideal number is 8 —10
Types of Group
v Therapeutic Group
• To gain insight into their problems (i.e. Alcoholic Anonymous)
v Socialization Group
• To enhance interaction among patients
v Life Review / Reminiscing Group
• To lessen isolation
5. Milieu Therapy
v Treatment by means ofcontrolled modification of the patients' environment to facilitate positive behavioral change
v Nurse identifies what each patient needs from the therapeutic milieu, while keeping in mind the needs of the
larger patient group
6. Family Therapy
v Focuses on the total family as an interactional system
v Best suited for families where there is domestic violence
7. Psychoanalysis
v Focuses on the exploration of the unconscious, to facilitate identification of the patient's defenses
v Behavioral disorders are related to unresolved anxiety-provoking childhood experiences that are repressed into
the unconscious
v Goal is to bring repressed experiences into conscious awareness and to learn healthier means of coping with
anxiety.
v Utilizes dream analysis and free association (verbalization of thoughts without censorship)
8. Hypnotherapy
v Involves various methods and techniques to induce a transtate where the patient becomes submissive to
instructions

9. Humor Therapy
v Use of humor to facilitate expression of feelings and to enhance interaction
v Therapeutic laughing lessens the high levels of tension that often as company discussions of serious matters.
10. Behavior Modification

v Application of learning principles in order to change maladaptive behavior
v It attempts to streng then a desired behavior or response by reinforcement, either positive or negative
Positive reinforcement
• If the desired behavior is assertiveness, whenever the client uses assertiveness skills in a communication group,
the group leader provides positive reinforcement by giving the client attention and positive feedback.
• For example, a teacher praises her student for getting high grades, so that the student will be motivated to get
high grades again the next time.
Negative reinforcement
• Involves removing a stimulus immediately after a behavior occurs so that the behavior is more likely to occur
again.
• For example, if a client becomes anxious when waiting to talk in a group, he may volunteer to speak first to avoid
the anxiety.
CRISIS AND CRISIS INTERVENTION

v Turning point in an individual's life that produces an overwhelming emotional response
Characteristics of a Crisis State

• Highly individualized
• Lasts for 4 — 6 weeks
• Person affected becomes passive and submissive
• Affects a person's support system
Types of Crisis
v Maturational or Developmental Crisis
• Expected, predictable and internally motivated events in the normal course of life such as:
ü Leaving home for the first time; Getting married
ü Having a baby; Beginning a career
ü Growth; Parenthood
v Situational or Accidental Crisis

• Unanticipated or sudden, unexpected, Unpredictable and externally motivated events that threaten the
individual's integrity such as:
ü Death of a loved one
ü Loss of a job
ü Physical and emotional illness in the individual family or member; Car accident
v Social or Adventitious Crisis

• Includes natural disasters and acts 0 nature like:
• Floods Earthquakes Hurricanes
• War, Terrorist attacks; Riots
• Violent crimes such as rape or murder
Phases of a Crisis
1. Denial - Initial reaction
2. Increased Tension
• Person recognizes the presence of a crisis and continues to do activities of daily living
3. Disorganization
• Person is pre-occupied with the crisis and is unable to do activities of daily living
4. Attempts to Reorganize
• Individual mobilizes previous coping mechanisms
CRISIS INTERVENTION
v A way of entering into the life situation of an individual, family, group, or community to help them mobilize their
resources and to decrease the effect of a crisis inducing stress
Goal: To enable the patient to attain an optimum level of functioning
Types of Crisis Intervention

v Authoritative Crisis Intervention
• Designed to assess the person's health status and promote problem- solving such as:
ü Offering the person new information, knowledge or meaning
ü Raising the person's self- awareness by providing feedback about behavior
ü Directing the person's behavior by offering suggestions or courses of action
v Facilitative Crisis Intervention
• Aim at dealing with the person's needs for empathetic understanding such as:
ü Encouraging the person to identify and discuss feelings
ü Serving as a sounding board for the person
ü Affirming the person's self-worth
Primary Role of the Nurse in Crisis

• Active and directive, the nurse has to assist the patient
RAPE
v It is a crime of violence and humiliation of the victim expressed through sexual means
v It is the penetration of an act of sexual intercourse with a female against her will and without her consent,
whether her will is overcome by force, fear of force, drugs, or intoxicants
v It is also considered rape if the woman is incapable of exercising irrational judgment because of mental deficiency
or when she is below the age of consent.
v According to Republic Act 8353, it refers to the insertion of the penis into the mouth. vagina, anus of a victim
v It is generally considered as an act of hostility, anger or violence
POWER RAPE
v The intent of the rapist is not to injure the victim but to command and master another person sexually
v The rapist has an insecure self-image and feelings of incompetence and inadequacy,
v The rape is the vehicle for expressing power and potency.
v This is done to prove one's masculinity
SADISTIC RAPE
v Involves brutality
v The use of bondage and torture is not an expression of anger but necessary for the rapist's sexual excitement
v The assault is often eroticized and is sexually stimulating
v This is done to express erotic feelings
RAPE TRAUMA SYNDROME

v Group of signs and symptoms experienced by a victim in reaction to a rape
Phases of the Rape Trauma Syndrome
v Acute Phase - shock, numbness and disbelief
v Denial Phase - victim's refusal to talk about the event
v Heightened Anxiety- fear, tension, and nightmares
v Stage of Reorganization - victim's life normalizes
Nursing Care for Rape Victims

v In the emergency setting, provide immediate emotional support
v The nurse should allow the woman to proceed at her own pace and not rush her through any interview or
examination
v Give as much control back to the victim as possible by allowing her to make decisions, when possible, about whom to
call, what to do next, what she would like done, etc.

v It is the victim's decision about whether or not to file charges and testify against the perpetrator and the victim must
sign consent forms before any photographs of hair and nail samples are taken for future evidence
v The priority in the care of a rape victim is the preservation of evidence
v Prophylactic treatment for STDs is offered
v Prophylaxis can be offered to prevent pregnancy
• In some areas, HIV testing is strongly encourage
• Referrals to rape crisis centers are encourage
AUTISM SPECTRUM DISORDER

v Disorder characterized by impairment in communication skills, or the presence of stereotyped behavior, interests and
activities with associated impairment in social interactions
v More prevalent in boys than girls
v Identified no later than 3 years of age.
v It is treatable but not curable
v Does have a genetic link
Main Problem: Impaired Interpersonal Functioning
Manifestations
• Display little eye contact
• Few facial expressions towards others
• They do not use gestures to communicate
• Do not relate to peers and parents
• Lack spontaneous enjoyment
• No moods or emotional affect
• Little intelligible speech
• Stereotyped motor behaviors (hand-flapping body twisting, head-banging)
• Acts as deaf
• No fear of danger
Common Problems and Appropriate Management

v Drug
• Low-dose Antipsychotic
v Tantrums
• Involves head-banging
• Provide safety
• Helmet
• Padded walls
• Monitor behavior (1:1)
v Communication
• All vowels
• Use of short sentences when talking to the child
v Nutrition: Less Than Body Requirements
• Provide well-balanced diet
• Small frequent feedings
v Routines
• Provide consistency
v Love & Belongingness
• Family Therapy
v Priority Nursing Diagnosis
• Risk for Injury
ATTENTION-DEFICIT HYPERACTIVITY DISORDER

v Characterized by inattentiveness, overactivity, and impulsiveness.
v Common in boys
v Identified and diagnosed when the child begins preschool or school (before the age of 7)

Common Etiological Factors
• UNKNOWN
• Neurologic impairment
• Early malnutrition
• Frontal lobe hypoperfusion
• Use of drugs and exposure to alcohol and tobacco during pregnancy
Risk Factors
• Family history of ADHD
• Male relatives with antisocial personality disorder
• Lower socioeconomic status
• Gender (Male)
• Marital or Family Discord
INATTENTIVE BEHAVIORS
Misses details
Makes careless mistakes
Has difficulty sustaining attention
Doesn't seem to listen
Dos not follow-through on chores
Has difficulty with organization
Avoids tasks requiring mental effort
Often loses necessary things
HYPERACTIVE BEHAVIOR
Fidgets
Often leaves seat (during a meal)
Runs or climbs excessively
Can’t play quietly
Is always on the go; driven
Talks excessively
Blurts out answers
Interrupts
Can’t wait for turn
Is intrusive with siblings/playmates
Treatment
DRUGS NURSING CONSIDERATIONS
Methylphenidate (Ritalin) • Monitor for appetite suppression and growth delays
• Give regular tablet after meals
• Alert client that full drug effect takes 2 days
Dextroamphetamine (Dexedrine) • Monitor for insomnia
• Give last dose early afternoon
• Full drug effect takes 2 days
Pemoline (Cylert) • Monitor for elevated liver function
• Drug may take 2weeks for full effect
Nursing Interventions for ADHD

1. Ensuring the child’s safety and that of others.
• Stop unsafe behavior
• Provide close supervision
• Give clear direction about acceptable and unacceptable behavior
2. Improved role performance
• Give positive feedback for meeting expectations
• Provide a quiet place free of distractions for ask completion.

3. Simplifying instructions/ directions
• Get the child’s full attention
• Break complex tasks into small step
• Allows break
4. Structured daily routine
• Establish a daily schedule
• Minimize changes
5. Nutrition
• Provide finger foods
6. Client/Family education and support
• Listen to parent’s feelings and frustration
MENTAL RETARDATION
v Below-average intellectual functioning
v IQ less than 70
v Significant limitations in areas of adaptive functioning
Causes
• Hereditary (Tay-Sachs Disease; Trisomy 21)
• Pregnancy/Perinatal problems (fetal malnutrition)
• Medical conditions of infancy
Levels of Mental Retardation IQ What can be done

Mild 55 – 69 Educable
Moderate 40 – 54 Trainable
Severe 25 – 39 Need Close Supervision
profound < 25 Custodial Care
v Educable
• Patient can be thought how to read and write.
v Trainable
• Vocational skills (cooking, sewing, etc.)
v Close Supervision
• Activities of daily living (brushing, wearing clothes)
v Custodial Care
• Client is totally dependent
Nursing Care
• Repetition
• Role modelling
• Restructuring the environment
Focus of Education for Mentally Retarded Patient

• Reading
• Writing
• Basic Arithmetic
ANXIETY
v Stage of uneasiness or discomfort experienced to varying degrees frequently coupled with doubts, fears, and
obsessions.
v Feeling of terror or dread; the most uncomfortable feeling a person can experience
MILD ANXIETY Positive states of heightened awareness and sharpened
senses, allowing the person to learn new behaviors and solve
problems,
The person can take in all available stimuli (enlarged

perceptual field)

MODERATE ANXIETY Decreased perceptual field (focus on immediate task only)
The person can learn new behavior or solve problems only

with assistance
SEVERE ANXIETY Feelings of dread or terror
The person cannot be redirected into a task; he or she

focuses only on scattered details and has physiological
symptoms of tachycardia, diaphoresis, and chest pain.
People with severe anxiety often go to emergency

departments, believing they are having a heart attack.
PANIC ANXIETY Loss of rational thoughts, delusion, hallucinations, and
complete physical immobility and muteness
The person may bolt and run aimlessly, often exposing himself
or herself to injury
PRIORITY NURSING DIAGNOSES FOR ANXIETY

v Ineffective individual coping
v Anxiety
PRINCIPLES OF NURSING CARE IN ANXIETY

v Calm
v Administer medications
v Listen to the patient’s concern
v Minimized environment stimuli
ANXIETY DISORDER
v Emotional illness characterized by fear, automatic nervous system symptoms and avoidance behavior
v Diagnosed when anxiety no longer functions as a signal of danger or a motivation for needed change but become
chronicand permeates major portions of the person’s life, resulting in maladaptive behaviors and emotional
instability
Symptoms of Anxiety Disorder

• Agoraphobia
• Anxiety about or avoidance of places or situation from which escape might be difficult or help might be unavailable
Symptoms:
ü Avoids being outside alone or at home alone
ü Avoids travelling in vehicles; impaired ability to work
ü Difficulty meeting daily responsibilities (e.g., grocery shopping, going to appointments)
• Panic Disorder
• It is characterized by recurrent, unexpected panic attacks that cause constant concern.
• Panic attack
• It is the sudden onset of intense apprehension, fearfulness, or terror associated with feelings of impending doom
Symptoms: A discrete episode of panic lasting 15 to 30 minutes with four or more of the following:
• Palpitations • Nausea
• Sweating • Derealisation/depersonalization
• Trembling or shaking • Dear of dying or going crazy
• Shortness of breath • Paresthesias
• Choking • Chills or hot flashes
• Chest pain or discomfort

• Social Phobia
• It is characterized by anxiety provoked by certain types of social or performance situations, which of leads to
avoidance behavior
Symptoms
• Fear of embarrassment or inability to perform
• Avoidance or dreaded endurance of behavior or situation
• Belief that others are judging him or her negatively
• Significant distress or impairment in relationship, work, or social life
• Anxiety can be severe or panic level.
Management
• Anti-anxiety medications
• Social skills training
GENERAL ANXITY DISORDER

• It is characterized by at least 6 month of persistent and excessive worry and anxiety
Symptoms
• Apprehensive expectation more days than not for 6 months or more about several events or activities
• Incontrollable worrying
• Significant distress or impaired social or occupational functioning
• Three of the following symptoms:
ü Restlessness
ü Easily fatigued
ü Difficulty concentrating of mind going blank
ü Irritability
ü Muscle tension
ü Sleep disturbance
Management
• Buspirone (Buspar) and SSRI antidepressants
ACUTE STRESS DISORDER

• It is the development of anxiety, dissociative, and other symptoms within 1 month of exposure to an extremely
traumatic stressor; it last 2 days to 4 weeks
Symptoms
• Exposure to traumatic events causing intense fear, helplessness, or horror, marked anxiety symptoms or increased
arousal;
• Significant distress or impaired functioning
• Persistent re-experiencing of the event
• Three of the following symptoms:
ü Sense of emotional numbing or detachment
ü Feeling dazed
ü Derealisation
ü Depersonalization
ü Dissociative amnesia (inability to recall important aspect of the event)
POST-TRAUMATIC STRESS DISORDER

• It is characterized by the re-experiencing of an extremely traumatic events, avoidance of stimuli associated with
the event, numbing of responsiveness, and persistent increased arousal
Symptoms
• Flashbacks and nightmares
• Exposure to traumatic events involving intense fear, helplessness or horror;
• Avoidance of memory-provoking stimuli and numbing of general responsiveness
• Increased arousal (sleep disturbance, irritability or angry outbursts, difficulty concentrating, hypervigilance,
exaggerated startle response)
• Significant distress or impairment

Management
• Anti-anxiety Medication Diazepam ( Valium)
ü Oxazepam (Serax)
ü Chlordiazepoxide (Librium)
ü Clorazepate dipotassium
ü Alprazolam (Xanax)
• Anti-depressant Medications
• Group Therapy
When to Administer Anxiolytic Drug

• Best taken before meals, food in the stomach delays absorption
Side Effects of Anxiolytic Drugs

• Drowsiness; Sedation; Poor coordination; Impaired memory and clouded sensorium
Client Teaching on Anxiolytic Drugs

• Intake of alcohol and caffeine-containing foods alter the effect of the drugs.
• It potentiates the effect of the alcohol
• Administer separately, it is incompatible with any drugs.
Priority Nursing Diagnosis for Anxiety Disorder

• Ineffective Individual Coping
Treatment
Cognitive Behavioral Techniques
v Positive Reframing
• Turning negative message into positive messages
• Instead of thinking , “My heart is pounding. I think I am going to die” the client thinks, “I can stand this. This just
an anxiety. It will go away”.
v Decatastrophizing
• Involves the therapist’s use of the questions to more realistic appraise the situation
• The therapist may ask: ‘What is the worst thing that could happen? Is that likely? Could you survive that? Is that
as bad as you imagine?”
v Thought-stopping
• The client uses thought stopping and distraction techniques to jolt himself from focusing on the negative
thoughts
• Techniques that can break the cycle of negative thoughts includes:
ü Splashing the face with water
ü Snapping a rubber band worn on the wrist
v Assertiveness Training
• Helps the person take more control of the situation
• Techniques help the person negotiate interpersonal situation and foster self-assurance
• They involve using “I” statement to identify feelings and to communicate concerns or the needs of others
Example: “I feel angry when you turn your back while I’m talking”, ‘I want to have five minutes of your time for an
uninterrupted conversation about something important
SPECIFIC PHOBIA
v Characterized by significant anxiety provoked by a specific feared object or situation which leads to avoidance
behavior.
Symptoms
• Marked anxiety response to the object or situation
• Avoidance or suffered endurance of object or situation
• Significant distress or impairment of daily routing, occupation or social functioning
• Adolescent and adults recognize their fear as excessive or unreasonable
Management
• Anti-anxiety Medications
• Systematic Desensitization
ü The therapist progressive exposes the client to threatening object in a safe setting until the client’s
anxiety decreases
PERSONALITY
v Defined as an ingrained, enduring pattern of behaving and relating to self, other, and the environment; personality
includes perception, attitudes, and emotions.
Categories of Personality Disorders

1. Cluster A
• Odd and eccentric behavior
• Includes paranoid, schizoid, and schizotypal personality
2. Cluster B
• Includes people appear dramatic, emotional, or erratic
• Includes antisocial, borderline , histrionic, and narcissistic personality disorder
3. Cluster C
• Includes people who appear anxious or fearful
• Includes avoidant, dependent, and obsessive –compulsive personality disorder
CLUSTER A
Paranoid Personality Disorder
Symptoms / Characteristics
• Mistrust and suspicion of others
• Uses the defense mechanism of projection, which is blaming other people, institutions or events for their own
difficulties
• Approach these clients in a formal, business –like manner and refrain from chi-chat and jokes (serious and
straight forward approach)
• Involve the client in treatment planning
• Teach client to validate ideas before taking action.
Schizoid Personality Disorder

• Detached from social relationships
• Restricted affect and little, if any emotion; aloof and indifferent, appearing emotionally cold, uncaring, or
unfeeling
• Report no leisure or pleasurable activities because they rarely experience enjoyment
• Involve themselves more with things than people
• Focus in improved functioning of the client in the community
• Assist the client to find a case manager one who helps the client to obtain services and health care, manage
finances, etc.
Schizotypal Personality Disorder

• Has social and interpersonal deficits marked by acute discomfort with andreduced capacity for close relationships
• Clothes are ill fitting, do not match, and may be strained or dirty
• Cognitive distortions include ideas of reference, magical thinking that he has special powers, unfounded beliefs
• Development of self-care skills
• Nurse encourage clientto establish a daiy routine for hygiene and grooming
• Improve community functioning and provide social skills training

CLUSTER B
Antisocial Personality Disorder
• Violation of the right of others
• Lying
• Rationalization of own behavior
• Thrill-seeking behaviors
• Poor work history;
• Consistent irresponsibility
• Promote responsible behavior
• Limit setting
• Consistent adherence to rules and treatment plan\the nurse should not become angry or respond to the client
harshly or punitively
• Confrontation – technique designed to manage manipulative or deceptive behavior.
Example:
Nurse: “You’ve said you’re interested in learning to manage angry outbursts, but you’ve missed the last three group
meetings.”
Client: “Well, I can tell no one in the group likes me. Why should I bather?”
Nurse: “The group meetings are designed to help you and the others, but you can’t work on issues if you are not there.”
Borderline Personality Disorder

• Fear of abandonment, real or perceived
• Unstable and intense relationship
• Recurrent self-mutilating behavior or suicidal threats or gestures
• Transient psychotic symptoms such as hallucinations, demanding self-harm
• Promote client’s safety
• Helping clients to cope and control emotions
• Cognitive restructuring techniques
• Structure the time
• Teach social skills
Histrionic Personal Disorder

• With a pervasive pattern of excessive emotionality and attention-seeking
• Clients are overly concerned with impressing others with their appearance
• Dress and flirtatious behavior are not limited to social situations or relationships but also occur in occupation and
professional settings
• It would be more acceptable to stand at least 2 feet away from them and to shake hands,
• Teaching social skills and role-playing those skills in a safe, non-threatening environment can help clients to gain
confidence in their ability to interact socially
• Provide factual feedback about behavior.
Narcissistic Personality Disorder

• Has a pervasive pattern of grandiosity, need for admiration, and lack of empathy for others
• Provide matter-of-fact approach
• The nurse must not internalize such criticism or take it personally
• She sets limits to rude or verbally abusive behavior and explains his or her expectations from the clients.
• Teach client any needed self-care skills

CLUSTER C
Avoidant Personality Disorder
• Pervasive pattern of social discomfort and silence, low self- esteem and hypersensitivity to negative evaluation
• They fear rejection, criticism, shame or disapproval
• They remain aloof in their relationship and feel inferior to others
• Require much support and reassurance from the nurse
• The nurse can help them to explore positive self-aspects, positive responses from other, and possible reasons for
self-criticism
Dependent Personality Disorder

• Pervasive and excessive need to be taken care of which leads to submissive and clinging behavior and fears of
separation
• Foster client’s self-reliance and autonomy
• Teach problem-solving and decision-making skills
• Cognitive-restructuring techniques
Obsessive – Compulsive Personality Disorder

v Involves obsessions (thoughts, impulses or image) that cause marked anxiety and/or compulsions (repetitive
behaviors or mental acts) that attempt to neutralize anxiety
• Preoccupation with orderliness, perfectionism and control
OBSESSIONS COMPULSION
Fear of Dirt and Games Excessive Hand Washing
Fear of Burglary or Robbery Repeated Checking of Door and window locks
• Encourage negotiation with others
• Assist clients to make timely decisions and complete work
• Cognitive restructuring techniques
EATING DISORDERS
ANOREXIA NERVOSA
v Life-threatening eating disorder characterized by:
• Client’s refuse or inability to maintain a minimally normal body weight
• Intense fear of gaining weight or becoming fat
• Significant disturbed perception of the shape or size of the body
• Refusal to acknowledge the seriousness of the problem
• Body weight that is 85% less than expected for their age and height
• Fear of gaining weight • Cold intolerance
• Body image disturbance • Lethargy
• Amenorrhea • Emaciation
• Depressed mood • Dec BP, Dec Temperature, Dec PR
• Social withdrawal • Hypertrophy of salivary glands
• Insomnia • Elevated BUN
• Feelings of ineffectiveness • Leukopenia & mild anemia
• Limited spontaneity • Elevated liver function studies
• Complaints of constipation & abdominal pain

Sub types:
v Binge eating
• Consuming large amount of food in a discrete period of usually 2 hours or less
v Purging
• Compensatory behavior designed to eliminate food by means of self-induced vomiting or misuse of laxatives,
enemas and diuretics
Note: Some clients with anorexia do not binge but engage in purging behavior after ingesting small amounts of food
Treatment
v Focus on:
• Weight restoration
• Nutritional rehabilitation
• Rehydration
• Correction of electrolyte imbalance
v Drugs
• Amitriptyline (Elavil) & Cyproheptadine (Periactin) for weight gain
• Olanzapine (Zyprexa) = promotes weight gain and produces antipsychotic effect
v Individual therapy
BULIMIA NERVOSA
v Eating disorder characterized by recurrent episode (at least twice a week for 3 months) of binge eating followed by
inappropriate compensatory behaviors to avoid weight gain such as purging, use of laxatives, diuretics, enemas,
and fasting.
v Weight usually in normal range, although some clients are overweight or underweight.
v Low-self-esteem
• Recurrent episodes of binge eating and purging
• Selection of low-calorie foods
• Depressive and anxiety symptoms
• Substance use (alcohol and stimulants)
• Loss of dental enamel
• Chipped ragged or moth-eaten appearance to teeth
• Increased dental carries
• Menstrual irregularities
• Dependence in laxatives
• Esophageal tears
• Metabolic alkalosis (vomiting)
• Metabolic acidosis (diarrhea)
• Mildly elevated serum amylase levels
Common Nursing Diagnoses related to Eating Disorders

• Body Image Disturbance
• Self –esteem Disturbance
• Ineffective Individual Coping
• Promote improved nutrition
• Assume a calm, matter-of-fact attitude and positive expectation of the client
• Behavior modification therapy
• Promote effective individual coping with anxiety
• Improved fluid volume
• Drugs: desipramine (Norpramin), Imipramine (Tofranil), Amitriptyline (Elavil), Nortriptyline (Pamelor), Phenelzine
(Nardil)

SEXUAL DISORDERS
Paraphilias
v Group of psychosexual disorders characterized by unconventional sexual behaviors
v Abnormal expressions of sexuality
Non-Coercive Paraphilias
v Fetishism
• Sexual arousal elicited by inanimate objects (shoes, leather and rubber) or specific body parts (feet, hair)
v Autoerotic Asphyxia
• Constriction of the neck to enhance masturbation experience
• Often leads to accidental death
v Sexual Masochism
• Erotic interest in receiving psychological or physical pain, real or fantasized
v Transvestitism
• Erotic interest is achieved by using the apparel of the opposite sex
Coercive Paraphilias
v Exhibitionism
• International exposure of the genitals to a stranger
• May be accompanied by arousal and masturbation either during or after the exposure
v Voyeurism
• Secret observation of an unsuspecting person (usually a woman) engaged in a private act (e.g.
undressing, having sex, etc.)
• Voyeur often masturbates during or after the viewing
v Frotteurism
• Intense sexual arousal elicited by rubbing the genitals a non-consenting person
v Pedophilia
• Sexual interest in a child
v Urophilia
• Urinating on the sexual partner
v Coprophilia
• Smearing feces on the partner
v Sadism
• Erotic interest in inflicting physical pain
• Diversional activities
• Limit-setting
• Behavior modification
SCHIZOPHRENIA
v Coined by Bleuler to describe a lack of integration of the patient’s functions
v Distorted and bizarre thoughts perceptions, emotions, movements and behavior
v Disturbance in thought process and perception for at least 6 months.
v Usually diagnosed in late adolescence and early adulthood
v Main Problem: Altered thought Process
Two major categories

v Positive/Hard symptoms
v Negative/soft Symptoms
POSITIVE/HARD SYMPTOMS NEGATIVE/SOFT SYMPTOMS

Hallucination Alogia
Delusions Anhedonia
Ambivalence Apathy
Associative Looseness Blunted affect
Echopraxia Catatonia

Flight of ideas Flat affect

Ideas of reference Lack of volition (Avolition)
Perseveration
General Manifestations
1. Perceptual changes
v Perceptions may either be heightened or blunted
v May occur in all senses or in just one or two.
v Hallucinations (hallmark of Schizophrenia)
v May be visual, olfactory, gustatory, tactile or auditory
2. Disturbances in Thought
v Clang associations
• Ideas that are related to one another based on sound or rhyming rather than meaning.
Example: “I will take a pill if I go up to the hill but not if my name is Jill, I don’t want to kill.”
v Delusions
• Disturbances in the content rather than the form of thought.
Types
• Persecutory/Paranoid Delusions
ü Involve the client’s belief that “other” are planning to harm the client or are spying, following, ridiculing
or belittling the client in some way.
Example: The client may think that food has been poisoned or that rooms are bugged with listening devices.
• Grandiose Delusions
ü Characterized by the client’s claim to association with famous people or celebrities, or the client’s belief
that he or she is famous or capable of great feats.
• Religious Delusions
ü Often center around the second coming of Christ or another significant religious figure or prophet.
Example: client claims to be the Messiah or some prophet sent from God; believes that God communicates directly to him
or her, or that he or she has a “special” religious mission in life or special religious powers.
• Somatic Delusion
ü Generally vague and unrealistic beliefs about the client’s health or bodily functions.
Examples: A male client may say that he is pregnant, or a client may report decaying intestines or worms in the brain.
• Referential delusion / Ideas of Reference

ü Involve the client’s belief that television broadcasts, music, or newspaper articles have special meaning for him or her.
Examples: The client may report that the president was speaking directly to him on a news broadcast or that special
messages are sent through newspaper articles.
3. Changes in Communication
A. Circumstantial Communication
B. Tangential Communication
C. Thought Disorganization
ü Responses are inappropriate to the situation
D. Thought Blocking
ü Stopping abruptly in the middle of a sentence or train of thoughts
ü Sometimes unable to continue the idea
E. Alogia
ü Poverty of content describes the lack f any real meaning are substance in what the client says
Example:
Nurse: ”How have you been sleeping lately?”
Client: “Well, I guess, I do not know... it’s hard to tell.”
v Thought Broadcasting
• A delusion belief that other can hear or know what the client is thinking

v Thought Insertion
• A delusional belief that others are taking the client’s thoughts away and the client is powerless to stop it.
v Neologisms
v Echolalia
v World salad
Treated for schizophrenia

v Antipsychotic ( Atypical & typical)
• Best taken after meals
• Provide adequate communication
• Promote compliance with medical regime
• Assist with grooming and hygiene
• Promote organized behavior
• Promote social interaction and activity
• Social skills training
• Promote reality-based perceptions as hallucinations and illusions often frighten clients
MOOD / AFFECTIVE DISORDERS

v Pervasive alterations in emotions that are manifested by depression, mania or both.
Common Etiological Theories of Mood Disorders

v Genetic Theory
• If one parent has a bipolar these is 25% chance of transmission to the child
v Aggression Turned Inward Theory
• Overdeveloped superego leads to depression
v Object Loss Theory
• Loss of parent before age 11 increases the risk of depression
v Personality Organization Theory
• Obsessive-compulsive, oral-dependent, hysterical personalities have higher redisposition to moon disorders
v Cognitive Theory
• mood disorder result from:
ü Negative views of the self and future
ü Negative interpretation of experiences
v Learned Helplessness Theory
• Mood disorder is caused by a belief that one has no control over his environment.
v Biologic factors
• Mania is related to increased levels of norepinephrine while depression is related to low norepinephrine levels.
Precipitating Factor
• Major life events
• Decrease coping resources
• drastic Physiological changes
• Loss of a loved one
Categories of Mood Disorder

1. Major depressive Disorder
v Last at least 2 weeks
v Person experience a depressed mood or loss of pleasure in nearly all activities
v Four of the following symptoms are present:
• Changes in appetite or weight
• Changes in sleep or psychomotor activities
• Decreased energy
• Feelings of worthlessness or guilt
• Difficult thinking, concentrating or making decisions
• Suicidal ideation, plans or attempts
v Symptoms must be present every day for 2 weeks

2. Bipolar Disorder
v It is diagnosed when a Person's mood cycles between extremes of mania and depression
3. Mania
• It is a distinct period during which mood is abnormally and persistently elevated expansive or irritable
• Period lasts for 1 week
• At least 3 of the following symptoms
accompany the manic episode:
ü Inflated self-esteem 'grandiosity
ü Decreased need for sleep Pressured speech
ü Flight of ideas
ü Distractibility
ü Psychomotor agitation Hallucinations
Hypomania
• Period of abnormally and persistently elevated expansive or irritable mood tasting 4 days and including three or four
of additional symptoms
• Difference: Hypomanic episodes do not impairthe person's ability to function and there are no psychotic features
(hallucinations & delusions)
• Less severe than mania
Mixed episode
• Also termed as rapid-cycling
• Diagnosed when the person
• experiences both mania and depression nearly every day for at least 1 week.
•With history of mania
Bipolar I Disorder
•One or more manic or mixed episodes usually accompanied by major depressive episode
•No history of mania
Bipolar II Disorder
•One or more major depressive episode accompanied by at least one hypomanic episode
ü Other disorders that are classified as mood disorders but lacks symptoms that required for a bipolar or depressive
disorder:
v Dysthymic Disorder
• Less severethan major depression
• Characterized by at least 2 years of depressed mood for more days than with some additional less severe
symptoms that do not meet the criteria for a major depressive episode
v Cyclothymic Disorder
v Characterized by 2 years of numerous periods of both hypomanic symptoms that do not meet the criteria
of bipolar disorder
3. Substance-Induced Mood Disorder

v Characterized by a prominent and persistent disturbance in mood that is judged to be a direct physiological
consequence of ingested substances such as alcohol and other drugs, or toxins
Other Disorders that involve changes in mood include the following:

v Seasonal Affective Disorder (SAD)
Winter-Depression
• Fall-onset SAD
• People experience increased sleep
• Appetiteand carbohydratecravings
• Weight gain
• Interpersonal conflict beginning in the late autumn and a bating in spring and summer
Spring-onset
• Less common
• Insomnia, weight loss, and poor appétit
• Lasts from late spring or early summer until early fall.

v Postpartum Blues
• Frequent normal experienceafter delivery of a baby
• Characterized by labile mood and affect, sadness. insomnia and anxiety.
• Peak in 3 to 7 days
• Disappear rapidlywithnomedical
Treatment
v Postpartum Depression
• Meets allthecriteria for a depressive episode with onset with. weeks of delivery
v Postpartum psychosis
• Psychotic episode developing within 3 weeks of delivery.
• Begins with fatigue, sadness, emotional lability, poor memory, and confusion sod progressing to delusions &
hallucinations.
GRAPHIC REPRESENTATION OF CYCLES OF BIPOLAR DISORDER
TREATMENT
v Lithium carbonate
• Can stabilized bipolar disorder by reducing the degree and frequency of cycling or eliminating manic episode
• Mechanism of action is unknown
• Works in the synapses to hasten destruction of catecholamines, inhibit neurotransmitter releases & decrease the
sensitive of postsynaptic receptors
• Crosses the blood-brain barrier and placenta
• Not used during pregnancy
LITHIUM THERAPHY: NURSING RESPONSIBLITY
Medication Administration Best taken after meals
Normal level 0.5- 1.5 mEq/L
Toxicity Report: Severe nausea, vomiting diarrhea, muscle weakness & tremors
Management: Administration of Mannitol
Therapeutic Effects Take 10 -14 days before therapeutic effect becomes evident
Fluids Adequate amount of fluid (2-3 L/day)
Sodium Salt intake (2-3 L/day)
Weight Monitor daily weights and the balance between intake and output and checking for
dependent edema
Other Information If there is too much water, lithium is diluted and the lithium level will be too low to be
therapeutic
Drinking too little amount of water or losing fluid through excessive sweating, vomiting or
diarrhe will increase the lithium level, which may result in toxicity
• provide for client's physical safety and safety of those around the client
• Assess client for suicidal Ideation. plans or thoughts of hurting others
• Clients in the manic phase have little insight into their anger and agitation and how their behaviors affect others
• Set limits on clients behavior when needed and remind client to respect distances between self and others
• Clarity the meaning of client's communication
• Frequently provide finger foods that are high in calories and protein
• Promoterestandsleepby decreasing environmental stimulation
• Establishing bedtime routine
• Nurse should handle behavior in a matter-ot tact approach and non-judgmental manner
• It is Important to treat clients with dignity ,us, s respect despite their Inappropriate behavior

Treatment Modalities for Depression
• Electroconvulsive Therapy
• psychopharmacology
ü Tricyclic Antidepressant
ü MAOI
ü SSRI
SOMATOFORM DISORDER
v Description: it can be characterized as the presence of physical symptoms that suggest a medical condition without
a demonstrable organic basis to account fully for them:
v Three Central Features:
• Physical complaints suggest major medical illness but have no demonstrable organic basis
• Psychological factor and conflicts seems important in initiating, exacerbating, and maintaining the symptoms.
• Symptoms or magnified health concerns are not under the client’s conscious control.
v Somatoform disorder:
Ø Somatoform disorder- Characterized by multiple physical symptoms. It begins by 30 years of age, extends
over several years, and includes a combination of pain and gastrointestinal, sexual, and pseudo-neurologic
symptoms.
SYMPTOMS OF SOMATIZATION DISORDER
Pain symptoms: complaints of headaches; pain in the abdomen, head, Joints, back, chest, rectum, pain during
urination, menstruation, or sexual intercourse
Gastrointestinal symptoms: nausea, bloating, vomiting (other than during pregnancy), diarrhea, or Intolerance of
several foods
Sexual symptoms: sexual Indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual
bleeding, vomiting through-out pregnancy
Pseudo-neurologic symptoms: conversion symptoms such as Impaired coordination or balance, paralysis or

localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, loss of touch or
pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of
consciousness other than fainting
• Conversiondisorders-sometimes called conversion reaction,involves unexplained, usually sudden deficits insensory

or motor function (e.g., blindness, paralysis)
ü These deficits suggest a neurologic disorder but are associated with psychological factors.
ü La belle in difference, a seeming lack of concernor distress, is a key feature.
• Pain disorder- has the primary physical symptom of pain,which generally is unrelieved by analgesics and greatly
affected by psychological factors interms of onset,severity, exacerbation and maintenance.
• Hypochondriasis
ü Disease conviction- is preoccupation with the fear that one has a serious disease
ü Disease phobia- one will get a serious disease
ü It is thought that clients with this disorder misinterpret bodily sensations or functions.
• Body dysmorphic disorder

ü It is preoccupation with an imagined or exaggerated defect in physical appearance such as thinking one's nose is
too large or teeth are crooked and unattractive.
v Other Related Disorders

• Malingering
ü it is the intentional production of false or grossly exaggerated physical or psychological symptoms
ü it is motivatedby incentives suchasavoiding work, evading criminal prosecution, obtaining financial
compensation, or obtaining drugs.
ü People who malinger can stop the physical symptoms as soon as they have gained what they wanted
• Factitious disorder occurs when a person intentionally produces or feigns physical or psychological symptoms
solely to gain attentions.
ü Munchausen’s syndrome- people with factitious disorder may even inflict injury to themselves to receive
attention
ü Munchausen's by proxy- Occurs when a person inflicts illness or injury on someone else to gain the
attention of emergency medical personnel or to be a "hero" for saving the victim.
v Psychosocial Theories
• Internalization- people with somatoform disorders keep stress, anxiety, frustration inside rather than
expressing them outwardly.
• Somatization-clients express these internalized feelings and stress through physical symptoms
• Both internalization and somatization are unconscious defense mechanisms.
• Primary gains are the direct external benefits that being sick provides such as relief of anxiety, conflict, or
distress.
• Secondary gains are the internal or personal benefits received from others because one is sick such as
attention from family members
v Biologic Theories
• Clients cannot sort relevant from irrelevant stimuli and respond equally to both types.
• They may experience a normal body sensation such as peristalsis and attach a pathologic than a normal meaning
to it
• Awareness of physical symptoms and exaggerates response to bodily sensations.
• This amplified sensory awareness causes the person toexperience somatic sensations as more intense, noxious,
and disturbing
v Management:
• Treatment focuses on managing symptoms and improving quality of life.
• The health care provider must show empathy and sensitivity to the clients physical complaints
• A trusting relationship will help to ensure that clients stay with and receive care from one provider instead of
"doctor shopping.'
• The nurse should never try to confront the client about the origin of these symptoms until the client has learned
other coping strategies.
• Selective serotonin re-uptake inhibitors are used most commonly for the accompanying depression
ü Fluoxetine (Prozac)
ü Sertraline (Zoloft)
ü Paroxetine (Paxil)
Pain
• Pain management such as visual imaging and relaxation.
• Services such as physical therapy to maintain and build muscle tone help to improve functional abilities.
• Providers should avoid prescribing and administering narcotic analgesics to these clients because of the risk of
dependence or abuse
• Clients can use non-steroidal anti-inflammatoryagents to help reduce pain. Involvement in therapy groups is
beneficial for some people with somatoform disorders
Health teaching:
• Establish a daily routine.
• Promote adequate nutrition and sleep.
• Expression of emotional feelings
• Recognize relationship between stress/coping and physical symptoms.
• Keep journal
• Limit time spent on physical complaints
• Limit primary and secondary gains.
• Coping strategies
• Emotion-focused coping strategies such as relaxation techniques, deep breathing, guided imagery, and distraction
• Problem-focused coping strategies such as problem-solving strategies and role playing

v Two categories of coping strategies:
• Emotion-focused coping strategies,which help clients relax and reduce feeling of stress
ü Progressive relaxation
ü Deep breathing
ü Guided imagery
ü Distractions
v Problem-focused coping strategies: which help to resolve or change a client’s behavior and situation or manage
life stressor
ü Problem-solving method
ü Applying the process to identified problems
ü Role-playing interactions with others.
Substance Abuse
v Terminologies:
• Intoxication- use of a substance that results In maladaptive behavior
• Withdrawal syndrome- refers to the negativepsychological and physical reactions that occur when use of a
substance abuse ceases or dramatically decreases
• Detoxification- the process of safely withdrawing from a substance
• Substance abuse- defined as using a drug in a way that is inconsistent with
medical or social norms and despite negative consequences. Itdenotes problems in social, vocational, or legal
areas of the person's life.
• Substance dependence- includes problems associated with addiction such as tolerance, withdrawal and
unsuccessful attempts to stop using the substance.
• Black-out- a episode during which the
person continues to function but has no consciousawarenessof his or her behavior
• Tolerance- the patient needs more of the substance (alcohol) to produce same effect.
• Tolerance break- after continued heavy drinking, the person experiences intoxication in a very small amount of
the substance (alcohol).
• Spontaneous remission- also known as natural recovery. Some people with alcohol problems can modify or
quit drinking on theirownwithouta treatment program
v Biological factors
• Generic/ hereditary- children of alcoholic parents are at higher risk for developing alcoholism and drug
dependence than are children of non-alcoholicparents.
• Distribution of the substance throughout the brain alter the balance of neurotransmitter that modulate
pleasure, pain, and reward responses
v Psychologic factors
• Inconsistency in the parent’s behavior, poor role modelling, and lack of nurturing pave the way for the child
to adopt a similar style of maladaptive coping, stormy relationship, and substance abuse.
v Social and environmental factors

• Cultural factors, social attitudes, peer behaviors, laws, cost, and availability all influence initial and continued
use of substance.
ALCOHOLISM
v Intoxication:
• Clinical manifestations
ü Slurred speech
ü Unsteady gait
ü Lack of coordination
ü impaired memory. and judgment
ü Aggressive or display inappropriate sexual behavior
ü Blackout
• Treatment:
ü Gastric lavage
ü Dialysis
ü Support of respiratory and cardiovascular functioning in an intensive care unit.
ü The administration of central nervous system stimulants is contraindicated
v Withdrawal and Detoxification

• Symptoms of withdrawal usually begin 4
to 12 hours after cessation or marked reduction of alcohol intake
• Withdrawal may take 1 to 2 weeks.
Clinical manifestations:
ü Coarse hand tremors
ü Sweating
ü Elevated pulse and blood pressure
ü Insomnia
ü Anxiety
ü Nausea or vomiting
ü Transient hallucinations, seizures, or delirium— delirium tremens (DTs).
Treatment:
ü Administration of benzodiazepines such as:
Ø Lorazepam (Ativan),
Ø Chlordiazepoxide (Librium)
Ø Diazepam (Valium).
• Detoxification:
ü Disulfiram- Antabuse
PHYSIOLOGIC EFFECTS OF LONG-TERM ALCOHOL USE

• Cardiac myopathy
• Wernicke's encephalopathy
• Korsakoff's psychosis
• Pancreatitis
• Esophagitis
• Hepatitis
• Cirrhosis
• Leukopenia
• Ascites
Sedatives, Hypnotics And Anxiolytics

v This class of drugs includes all central nervous system depressants:
• Barbiturates
• Nonbarbiturate
• Hypnotics
• Anxiolytics
v Intoxication:
• Clinical manifestations:
ü Slurred speech
ü unsteady gait
ü Labile mood
ü Impaired attention or memory
ü Stupor and coma
v Benzodiazepines
ü rarely fatal
ü lethargic and confused

v Barbiturates
ü Can be lethal
ü Coma
ü Respiratory arrest
ü Cardiac failure
ü Death
v Treatment:
ü Benzodiazepines:
Ø Gastric lavage
Ø Ingestion of activated
Ø charcoal
Ø Saline cathartic
Ø Dialysis.
ü Barbiturates:
Ø Intensive care unit
Ø Lavage or dialysis
Ø Support respiratory and cardiovascular function

• The onset of withdrawal symptoms depends on the half-life of the drug
ü Autonomic hyperactivity (Increased pulse, blood pressure, respirations and temperature)
ü Hand tremors
ü Insomnia
ü Anxiety
ü Nausea
ü Psychomotor agitation
ü Seizures
ü Hallucinations
v Detoxification:
• Managed medically by tapering the amount of the drug the client receives over a period of days or weeks,
• Tapering, or administering decreasing doses of a medication, is essential with barbiturates to prevent coma
and death that willoccur if the drug is stopped abruptly.
STIMULANTS (AMPHETAMINE, COCAINE AND OTHERS)

• Stimulants are drugs that stimulate or excite the central nervous system.
• Amphetamines ("uppers") were popular in the past;they were used by people who wanted to lose weight or to stay
awake
• Cocaineanillegal drug with virtually no clinical use in medicine, is highly addictive and a popular recreational drug
because of the intense and immediate feeling of euphoria it produces.
• Methamphetamine is particularly dangerous. It is highly addictive and causes psychotic behavior. Brain damage
related to its use is frequent, primarily as a result of the substances used to make it.
• Intoxication and overdosage
ü High or euphoric feeling
ü Hyperactivity
ü Hypervigilance
ü Talkativeness
ü Anxiety
ü Grandiosity
ü Hallucinations
ü Stereotypic or repetitive behavior
ü Anger
ü Fighting
ü Impaired judgment
ü Tachycardia
ü Anorexia/ Loss of appetite
ü Elevated blood pressure
ü Dilated pupils, perspiration or chills, nausea, chest pain, confusion, and cardiac dysrhythmias.
ü Overdoses of stimulants can result in seizures and coma ; deaths
v Treatment with Chlorpromazine (Thorazine), an antipsychotic,controlshallucinations, lowers blood pressure, and

relieves nausea

• Withdrawal from stimulants occurs within a few hours to several days after cessation of the drug and is not life
threatening.
• Marked dysphoria is the primary symptom andisaccompaniedby fatigue, vivid and unpleasant dreams, insomniaor
hypersomnia, increased appetite, and psychomotor retardation or agitation
• Marked withdrawal symptoms are referred to as "crashing symptoms;"
• The person may experience depressive symptoms including suicidal ideation for several days.
• Stimulant withdrawal is not treated Pharmacologically.
Cannabis (Marijuana)
v Cannabis sativa is the hemp plant that is widely cultivated for its fiber used to make rope and cloth and for oil from
its seeds.
v Marijuanarefers tothe upper leaves, floweringtops,and stems of the plant; hashish is the dried resinous exudate from
the leaves of the female plant.
v Cannabis is most often smoked in cigarettes (“joints”), but it can be eaten.
v Effects:
• Cannabis begins to act less than 1 minute after inhalation.
• Peak effects usually occur 20 to 30 minutes and last at least 2 to 3 hours
ü Impaired motor coordination
ü Inappropriate laughter
ü Impaired judgement and short-term memory
ü Distortion of time and perception.
ü Anxiety
ü Dysphoria
ü Social withdrawal
ü Increased appetite
ü Conjunctive injection (bloodshot eyes)
ü Dry mouth
ü Hypotension
ü Delirium
ü Cannabis-induced psychotic disorder

• No clinically significant withdrawal syndrome is identified
• Cannabis does not cause intoxication.
Opioids
v Populardrugsofabusebecausethey desensitize the user to both physiologic and psychological pain and induce a sense
of euphoria and well being
v Opioids:
• Morphine
• Meperidine (Demerol)
• Codeine
• Hydromorphone
• Oxycodone
• Methadone
• Oxymorphone
• Hydrocodone
• Propoxyphene
• Heroin
• Normethadone
v Intoxication
• Clinical manifestation
ü Euphoric feeling
ü Apathy
ü Lethargy
ü Listlessness
ü Impaired judgement
ü Psychomotor retardation or agitation
ü Constricted pupils
ü Drowsiness
ü Slurred speech
ü Impaired attention and memory
ü Coma
ü Respiratory depression
ü Papillary constriction
ü Unconsciousness
ü Death
• Treatment
ü Administration of Naloxone (Narcan)
Ø An opioid antagonist
Ø Is the treatment of choice because it reverses all signs of opioid intoxication.
Ø Naloxone is given every few hours until the opioid level drops to nontoxic
v Withdrawal and Intoxication
• Clinical Manifestations:
ü Anxiety
ü Restlessness
ü Aching back and leg
ü Cravings for more opioids
ü Nausea
ü Vomiting
ü Dysphoria
ü Lacrimation
ü Rhinorrhea
ü Sweating
ü Diarrhea
ü Yawning
ü Fever
ü Insomnia.
• Treatment:
ü Do not require pharmacologic intervention to support life or bodily functions.
ü Methadonecanbeusedasa replacement for the opioid
Hallucinogens
v Substances that distort the user's perception of reality and produce symptoms similar to psychosis including
hallucinations (usually visual) and depersonalization.

v Examples of hallucinogens:
• Mescaline
• Psilocybin
• Lysergic acid
• Lysergic acid Diethylamide (LSD)
- "Designer drugs" such as Ecstasy.
• Phencyclidine (PCP)
v Intoxication and Overdose

• Clinical Manifestations
ü Anxiety
ü Depression
ü Paranoid ideation
ü Ideas of reference
ü Fear of losing one's mind
ü Potentially dangerous behavior such as jumping out a window in the belief that one can fly.
ü Sweating
ü Tachycardia
ü Palpitations
ü Blurred vision
ü Tremors
ü Belligerence
ü Aggression
ü Impulsivity
ü Unpredictable behavior
• Treatment:
ü These drugs are not a direct cause of death although fatalities have occurred from related accidents,
aggression and suicide
ü Treatment is supportive.
ü Psychotic reactions are managed best byisolationfrom external stimuli
ü Physical restraints
ü Cooling devices such as a hyperthermia blanket are used and mechanical ventilation is used to support
respirations

ü No withdrawal syndrome has been identified for hallucinogens,although some people have reported a craving for
the drug.
ü Hallucinogens can produce flashbacks, which are transientrecurrencesof perceptual disturbances
Inhalants
v Diverse group of drugs including anesthetics, nitrates, and organic solvents that are inhaled for their effects.
v Inhalants can cause significant brain damage, peripheral nervous system damage, and liver disease.
v Inhalants:
• Gasoline
• Glue
• Paint thinner
• Spray paint
• Cleaners
• Correction fluid
• Spray can propellants
• Esters
• Ketones
• Glycols

v Intoxication
ü Dizziness
ü Nystagmus,
ü Slurred speech
ü Unsteady gait,
ü Tremors
ü Muscle weakness
ü Blurred vision
ü Stupor and coma can occur
ü Belligerence
ü Aggression
ü Apathy
ü Impaired judgment
ü Inability to function.
• Acute toxicity:
ü Anoxia
ü Respiratory depression
ü Vagal stimulation
ü Dysrhythmias
ü Death- bronchospasm,cardiac arrest, suffocation, aspiration of the compound or vomitus
• Treatment
ü Supporting respiratory and cardiac functioning until the substance is removed from the body
ü There are no antidotes or specific medications to treat inhalants toxicity.
v Withdrawal and detoxification

• There are no withdrawal symptoms or detoxification procedures foe inhalants
• Persistent dementia
• Inhalant-including disorders- psychosis, anxiety, or mood disorder
MANAGEMENT
v Alcoholics Anonymous (AA)
• Founded in the 1930’s by alcoholics
• Self-help group developed the 12 step program model for recovery which is based on the philosophy that
total abstinence is essential and that alcoholics need help and support of others to maintain sobriety.
v AA meetings
• "Closed" - only those who are pursuing recovery can attend
• "Open"- anyone can attend
ü Narcotics Anonymous
ü Al-Anon-Asupport group for spouses, partners, and friends of alcoholics
ü AlaTeen- A group for children of parents with substance problems.
v Nursing Alert:
• Alcohol
ü VitaminB1 (thiamine) often is prescribed to prevent or to treat Wernicke's syndrome and Korsakoff's
syndrome,which are neurologic conditions thatcan result from heavy alcohol use.
ü Cyanocobalamin (Vitamin B12) and folic acid often are prescribed for client with nutritional deficiencies.
ü Disulfiram (Antabuse) may be prescribed to help to deter clients from drinking.
Ø If aclient taking disulfiram drinks alcohol, a severe adverse reaction occurs:
o Flushing
o Throbbing headache
o Sweating
o Nausea and vomiting
o Severe hypotension
o Confusion
o Coma
o Death
• Opiates
ü Methadone
Ø A potent syntheticopiate is used as a substitute for heroin in some maintenance programs
Ø Meets the physical need for opiates but does not produce cravings for more
ü Levomethadyl
Ø Is a narcotic analgesic whose only purpose is the treatment of opiate dependence
ü Naltrexone (ReVia)
Ø It is an opioid antagonist often used to treat overdose.
Ø It blocks the effects of any opioids that might be ingested
Ø Negating the effects of using more opioids used in the same manner as methadone.
ü Clonidine (Catapres)
Ø Is analpha-2-adrenergic agonist used to treat hypertension.
Ø It is given to clients with opiate dependence to suppress some effects of withdrawal or abstinence
Ø It is most effective against nausea, vomiting, and diarrhea but produces modest relief from muscle aches,
anxiety, and restlessness
ü Ondansetron (Zofran)
Ø A 5-HT3 antagonist that blocks the vagal stimulation effects of serotonin inthe small intestine
Ø It is used as an antiemetic.
NURSING INTERVENTIONS FOR CLIENTS WITH SUBSTANCE ABUSE
• Health teaching for the client and family

• Dispel myths surrounding substance abuse
• Decrease codependent behaviors among family members
• Make appropriate referrals for family members
• Promote coping skills
• Role-play potentially difficult situations
• Focus on the here-and-now with clients
• Set realistic goals such as staying sober today
DISSOCIATIVE DISORDERS
Ø Dissociation-is a subconscious defense mechanism that helps a person protect is or her emotional self from
recognizing the full effects of some horrific or traumatic event by allowing the mind to forget or remove itself
from the painful situation or memory.
Ø Dissociative disorders-essential feature of a disruptionintheusually integrated functions of consciousness,
memory,identity or environmental perception
TYPES OF DISSOCIATIVE DISORDER

v Dissociative amnesia
• The client cannot remember important personal information usually of a traumatic or stressful nature.
v Dissociative fugue
• The client has episodes of suddenly leaving the home or place of work without any explanation, traveling to
another city,and being unable to remember his or her past or identity. He or she may assume a new identity
v Dissociative identity disorder

• Formerly multiple personality disorder

• The client displays two or more distinct identities or personality states that recurrently take control of his or her
behavior.
• This is accompanied by the inability to recall important personal information.
v Depersonalization disorder
• The client has a persistent or recurrent feeling of being detached from his or her mental processes or body.
• Thisis accompanied by intact reality testing
• The clientis not psychotic or out of touch with reality.
ASSESSMENT FINDINGS
v General Appearance and Motor Behavior
• Appears hyperalert and reacts to even small environmental noises with a startle response.
• He or she may be very uncomfortable if the nurse is too close physically
• The client may appearanxious or agitated and may have difficulty sitting still
• Pace or move around the room.
• Curl up with arms around knees
v Mood and Affect

• Look frightened or scared, or agitated
• May cry, scream, or attempt to hide
v Thought process
• Self-destructive thoughts and impulses
• Intermittent suicidal ideation
v Sensorium and Intellectual Process

• Memory gaps-periodsfor which they have no clear memories
v Self-concept
• Clients will have low self-esteem. They may believe they are bad people who somehow deserve or provoke the
abuse.
v Roles and Relationships

• Close relationships are difficult or impossible
• Ability to trust others is severely compromised.
v Physiologic signs
• Difficulty sleeping because of nightmares or anxiety over anticipating nightmares
• Overeating or lack of appetite
• Clients use alcohol or other drugs to attempt to sleep or to blot out intrusive thoughts or memories
MANAGEMENT
v Pharmacologic management:
• Paroxetine (Paxil)
• Sertraline (Zoloft)
v Psychotherapy:
• Group or individual therapy
• Cognitive behavioral therapy
• Focuses on re-association or putting the consciousness back together
v Nursing Management:
• Assess the client's potential for self harm or suicide
• Help the client learn to go to a safe place during destructive thoughts and impulses so that he or she can calm
down and wait until they pass
• Grounding techniques remind the client that he or she is in the present, as an adult and is safe.
• Getting the client to standand walk around helps to dispel the dissociative or flashback experience.
• The nurse encourages the client to write down feelings throughout the day at specified intervals
• Deep breathing and relaxation
• Focus on sensory information or stimuli in the environment
• Engage in positive distractions
ü Physical exercise
ü Listening to music
ü Talking to others,
ü Engaging in a hobby or activity
• Often it is useful to view the client as a survivor of trauma or abuse rather than a victim.

ONCOLOGIC NURSING
Cancer
v Disease process that begins when an abnormal cell is transformed by the genetic mutation of the cellular DNA.
v Cells lose their normal growth controlling mechanisms
SURGICAL ONCOLOGY
v Branch of medicine that uses manual and instrumental means to deal with the diagnosis and treatment of cancer
NEOPLASM
v “New growth”
v Uncontrolled cell growth that follows no physiologic demand
TUMOR
v Solid neoplasm when used in Oncology Nursing
FREQUENTLY USED SUFFIXES & PREFIXES

Neo New
Plasia Growth
Plasm Substance
Trophy Size
Oma Tumor
Statis Location
A None
Ana Lack
Hyper Excessive
Meta Change
Dys Bad, Deranged
CHARACTERISTICS OF TUMOR
Criteria Benign Malignant
Cell Character Normal Abnormal
Growth Expands Infiltrates
Rate Slow Fast
Metastasis No Yes
DIFFERENCES BENIGN TUMOR MALIGNANT (CA)

Differentiation Well Poor
Encapsulation (+) (-)
Metastasis (-) (+)
Prognosis Good Poor
Tx Modalities Surgery Surgery, Irradiation. Chemo Bone Marrow Transplant
Benign Tumors (-oma) Malignant Tumors

(carcinoma/sarcoma)
Adipose tissue = Lip0MA Liposarcoma
Bone = osteOMA Osteosarcoma
Muscle = myOMA Myosarcoma
Blood vessels = hemangiOMA Hemangiosarcoma
Fibrous tissue = fibrOMA Fibrosarcoma
Glands = adenOMA Adenocarcinoma
Nerve cell = neurOMA Neuroblastoma
Cartilage = chondrOMA Chondrosarcoma
Meninges = meningiOMA Meningeal sarcoma
Nerve sheaths = neurilemmOMA Neurilemmal sarcoma
Glial tissue = gliOMA Glioblastoma

GRADING VS. STAGING

Grading
v Refers to the classification of tumor cells
v Seeks to define the type of tissue from which the tumor originated and the degree to which the tumor cells retain the
functional and histologic characteristics of the tissue of origin
Staging
v Determines the size of the tumor and the existence of local invasion and distant metastasis
v TNM system:
o Tumor: extent of primary tumor
o Node: lymph node involvement
o Metastasis: extent of metastasis
THEORIES OF CANCER
Cellular Transformation Theory
v Normal cells become cancer cells because of exposure to chemicals
Failure of Immune Response Theory

v Immune system's failure to destroy cancer cells
Initiation
CARCINOGENESIS
Cancer Development Process
v Initiation
• Carcinogens escape normal enzymatic mechanisms and alter general structure of cellular DNA
v Promotion
• Repeated exposure to promoting agents causes the expression of abnormal or mutant genetics information
v Progression
• Altered cells exhibit increased malignant behavior
• Invade adjacent tissues and metastasize
Warning Signs (CAUTION US)

• Change in bowel and bladder habits
• A sore that does not heal
• Unusual bleeding or discharge
• Thickening of lump
• Indigestion
• Obvious change in wart or mole
• Nagging cough or hoarseness
• Unexplained Anemia
• Sudden Weight Loss
DIAGNOSTIC TESTS USED TO DETECT CANCER

Tumor Marker Identification
v Analysis of substances found in body —tissues, blood, or other body fluids that are made by the tumor
v Breast, colon, lung, ovarian, testicular, prostate cancer
Mammography
v Breast cancer
Magnetic Resonance Imaging
v Neurologic, pelvic, abdominal, thoracic, breast cancers
Fluoroscopy
v Use of x-rays that identify contrasts in body tissue
v Skeletal, lung, GI cancers
Positron Emission Tomography
v Lung, colon, liver, pancreatic; Hodgkin & non-Hodgkin lymphoma
Endoscopy
v For diagnostic & therapeutic purposes
v Bronchial, GI cancers
v Pernicious anemia
• Management: IM Vitamin B12 injection
Biopsy
v Obtaining tissue sample for analysis of cells.
SURGERY
Surgery
v Surgical removal of the cancer (totally or partially).
Surgical Approaches
v Local excision: removal of the mass and some normal tissue
v Radical excision: removal of primary tumor, lymph nodes, and surrounding tissues
Other surgical interventions:

v Electrosurgery: electrical current to destroy tumor.
v Cryosurgery: liquid nitrogen is used to freeze tissue to cause cell destruction.
v Chemosurgery: topical chemotherapy and surgical removal of tissue
Nursing Interventions:
v Pre-procedure:
o Provide health education, especially what to expect after surgery.
o Provide emotional support to allay anxiety.
v Post-procedure:
o Monitor for possible complications:
§ Infection
§ Bleeding
§ Thrombophlebitis
§ Wound dehiscence
§ Fluid and electrolyte imbalance
§ Organ dysfunction
RADIATION THERAPY
Radiation Therapy
v Use of ionizing radiation to interrupt cell growth.
Types of Radiotherapy
v External Radiation (Teletherapy)
v Internal Radiation (Brachytherapy)
External Radiation (Teletherapy)

v X-rays used to destroy cancer cells at the skin surface or deeper in the body.
v Radiation source is positioned far from the client.
v The higher the energy, the deeper the penetration into the body.
v Client is NOT radioactive (does not emit radiation).
o Watch out for the effects of teletherapy:
§ Radiodermatitis (skin changes)
§ Fatigue
o Avoid using ointments, lotions, or powders on the area.
o Do not remove the markings on the area.
o Provide gentle oral hygiene.
Internal Radiation (Brachytherapy)

v Delivery of a high dose of radiation to a localized area.
v Radiation source is implanted into the body.
v Client is radioactive during and after the procedure.

v Types of Implantation:
o Sealed – radiation source stays in place
§ Needles
§ Seeds/Beads
§ Catheter
§ Intracavitary (gynecologic cancers)
§ Note: Body fluids are NOT radioactive.
o Unsealed – radiation source absorbed in the system

§ Intravenous
§ Oral (Iodine131 for thyroid cancer)
§ Note: Body fluids are RADIOACTIVE.
v Nursing Interventions
o Initiate radiation precautions (STD):
§ Shielding: Wear lead gown and dosimeter badge (to measure radiation exposure).
§ Time: Maximum of 30 minutes per shift, 5 minutes per visit.
§ Distance: Maintain six (6) feet away from client.
o Assign to a private room.
o Never assign a pregnant hospital staff to the client. Never let a child visit the client.
o Intracavitary Brachytherapy:
§ Promote bladder and bowel emptying before procedure.
§ Complete bed rest.
§ Low-residue/Low-fiber diet: to slow down bowel movement and prevent defecation.
§ Insert indwelling urinary catheter.
o Unsealed Brachytherapy:
§ Flush the toilet 3 times after voiding/defecating.
§ Visitors must not share toilet with the client.
CHEMOTHERAPY
v The use of antineoplastic drugs to promote tumor cell destruction
Cell Cycle
G1 phase — RNA and protein synthesis occur
S phase — DNA synthesis occurs
G2 phase — Pre-mitotic phase
M phase — Mitosis
Go phase — Resting/Dormant phase
CELL CYCLE SPECIFIC DRUGS

v Therapeutic effect of the drugs only works on a specific phase of the cell cycle
Anti-metabolites
v Block enzymes needed for DNA synthesis
Examples:
• Methotrexate
• 6 — Mercaptopurine
• 6 — Thioguanine
• Cytarabine
• Fludarabine
• Hydroxyurea
• Pentostatin
Topoisomerase Inhibitors
v Block enzymes needed for DNA synthesis

Examples:
• Irinotecan (Camptosar)
• Topotecan (Hycamtin)
Mitotic Inhibitors
v Arrest metaphase by inhibiting mitotic tubular formation
Examples:
• Vincristine (Oncovin)
• Vinblastine
• Vinorelbine (Navelbine)
• Teniposide
• Paclitaxel
CELL CYCLE NON-SPECIFIC DRUGS

v Therapeutic effect of the drugs affects all phases of the cell cycle
Alkylating Agents
v Break DNA helix, thereby interfering with DNA replication
Examples:
• Busulfan
• Carboplatin
• Cyclophosphamide
• Ifosfamide
• Cisplatin
• Thiotepa
Antibiotics (-cin)
v Interfere with DNA synthesis
v Prevent RNA synthesis
Examples:
• Bleomycin
• Dactinomycin
• Daunorubicin
• Doxorubicin
• Plicamycin
Nitrosoureas
v Similar to the alkylating agents
v Cross the blood-brain barrier
Examples:
• Carmustine
• Lomustine
• Semustine
• Streptozocin
Hormonal Agents
v Bind to hormone receptor sites that alter cellular growth
v Block binding of estrogens to receptor sites
Examples:
• Androgens & anti-androgens
• Estrogen & anti-estrogens
Monoclonal Antibodies
v Destroy cancer cells and spare normal cells

Examples
• Rituximab
• Trastuzumab
• Alemtuzumab
• Gemtuzumab
Routes of Chemotherapy
v Oral (most convenient)
v IV (most common)
v Intramuscular
v Intrathecal (Ommaya reservoir)
v Intro arterial
v Intracavitary
v Intravesical
v Topical
SAFE ADMINISTRATION OF CHEMO DRUGS

v Chemo drugs are DANGEROUS.
v There should be no CONTACT with it.
v Pregnant women should NOT undergo chemotherapy.
PREPARING CHEMO DRUGS

v Prepare in a well-ventilated area.
v Wash hands before and after procedure.
v Wear gloves at all times.
v Wear a gown.
v Wear face shields.
v Wrap gauze or alcohol pads around ampules neck.
v Label prepared medications as hazardous.
v Wrap gauze around injection site when withdrawing syringe.
v Dispose in a leak and puncture proof.
v Do not eat, chew and smoke when preparing medications.
HANDLING WASTE
v Wear clean gloves.
v Discard gloves and gown in a leak proof container.
v Linens with excreta should have a separate container.
v Wash with hot water.
v In case of spillage of chemotherapeutic drugs, use a spill kit for clean-up.
NURSING MANAGEMENT OF SIDE EFFECTS OF CHEMOTHERAPY

NAUSEA & VOMITING
v Most common side effects of chemotherapy
v May persist for as long as 24 to 48 hours
v Delayed nausea and vomiting (1 week after chemotherapy)
v Cause is unknown but is linked to the following:
• Activation of receptors
• Stimulation of the peripheral autonomic & vestibular pathways
• Serotonin
Nursing Care
v Provide good oral hygiene.
v Assess for dehydration (anti-emetics).
v Offer ice chips.
v Round-the-clock medications.
ALOPECIA
v Give accurate information about alopecia before the chemotherapy.
v Begins 2 to 3 weeks
v Ends after 3 months/ regrowth of hair may begin at 8 weeks

v Wigs (female), Caps (male)
v Pre-emptive hair cut
STOMATITIS AND XEROSTOMIA

v Stomatitis: Mouth sores
v Xerostomia: Dry mouth
v Interventions:
v Inspect mouth routinely.
v Perform oral care.
v Avoid spicy and citrus foods.
v Provide ice chips/popsicles.
v Soft bland diet.
v Provide soft toothbrush.
v Saline mouth rinse. Never use alcohol-based commercial mouthwash.
v Viscous lidocaine (for adults)
• Contraindicated: Child (suppressed gag reflex)
ANOREXIA
v Chemo has effect on TASTEBUDS.
v Makes food taste metallic (especially MEAT).
v Place patient in comfortable position.
v Maintain good hygiene.
v Serve food attractively.
v Provide general comfort.
ANEMIA
v Assess for Skin Pallor.
v Schedule activities with rest periods.
v Administer erythropoietin as ordered.
NEUTROPENIA
v Assess signs of infection.
o Fever
o Abnormal lung sounds
o Cough
v Practice cleanliness.
v Hand washing before and after procedures.
v Neutropenic diet: No flowers, fresh fruits, vegetables, raw food.
THOMBOCYTOPENIA
v Assess skin and mouth for signs of bleeding.
v Check stools, urine and emesis.
v Avoid anticoagulant and antiplatelet medications.
v No shaving using straight razors. Use electric razor.
v Gentle oral care with soft-bristle toothbrush.
v No suppositories and enema. Use stool softeners.
v Encourage use of water-based lubricant before sexual activity.
v Platelet transfusion as prescribed.
C Check for phlebitis and Extravasations

H High Calorie and High Protein Diet
E Encourage hydration
M Monitor CBC
O Oral examination for Stomatitis
T Teratogenic
H Hair loss is a concern

E Encourage counseling
R Report complications
A Administer Antiemetics
P Practice Aseptic technique at all times
Y You should wear gloves, gown and mask
when handling chemo drugs
ADVERSE EFFECTS OF CHEMOTHERAPY
Source: med-source.blogspot.com
PANCREATIC CANCER
v Rapid growing cancer
v Very rare before the age 45
v Increase incidence in 70 — 80 y/o
v Poor prognosis
Risk Factors
v Smoking
v Diabetes Mellitus
v Gastrectomy
v High-fat/meat Diet
v Family History
v Chronic Pancreatitis
v Exposure to industrial chemicals/toxins
v Alcoholism
Manifestations
v Abdominal pain
v Nausea & vomiting
v Blood sugar problems
v Rapid profound, and progressive weight loss
v Clay-colored stools (Acholic stools)

Diagnosis
v Endoscopic Retrograde Cholangiopancreatography (ERCP)
Surgery
v Whipple Procedure
• Also termed as pancreaticoduodenectomy
• Removal of the gallbladder, common bile duct, part of the duodenum and head of the pancreas
v Total Pancreatectomy
v Pancreatic resection
Nursing Management
v Pain management
v Improve fluid & nutritional requirements
v Skin care (pruritus)
HEPATOCELLULAR CANCER
v Liver has several functions:
• Protein synthesis
• Bile production
• Drug metabolism
• Hormone metabolism
• Storage of glucose
• Clotting factors
Diagnosis: Liver Biopsy

Risk Factors
v Hepatitis B infection
v Liver cirrhosis
v Aflatoxin
v Oral contraceptives
v Insulin therapy
v Alcohol
v Smoking
v Clonorchis sinensis (parasitic worm)
Surgery
v Only curative treatment
v Liver resection
v Liver transplant
v Cryosurgery
• Use of liquid or a very cold probe to freeze tissue and cause destruction
v Ethanol injection
GALLBLADDER CANCER
v Most common cancer of the biliary tract
v Poor prognosis
Risk Factors
v Female
v Age (65 y/o)
v Cholelithiasis
Diagnosis
v Ultrasound
v CT Scan
v Endoscopic Retrograde
Cholangiopancreatography (ERCP)
Surgery
v Cholecystectomy
Care of Patient after Gallbladder Surgery

v Position: low- fowler’s position
v DOC: Morphine
v Splinting/Deep Breathing Exercises /Coughing/ Use of pillow
v NPO/NGT as prescribed
v Water & other fluids are administered within hours after laparoscopic procedures.
v Soft diet (low fat)
v T tube care
• Maintains patent bile duct
• Report sudden increase of drainage
• Clamp tube before meal
• Unclamp if N/V develops
v Report the following signs:
• Right upper abdominal pain
• N/V
• Clay/pale — colored stools
• Change in vital signs
• Jaundice
• Dark urine
• Pruritus
• Signs of inflammation
COLORECTAL CANCER
v Equally occurring in men and women (>40b y/o)
Risk Factors
v Increasing age
v Family History
v Previous colon cancer / polyps
v High consumption of alcohol

v Cigarette smoking
v Obesity
v History of gastrectomy
v History of inflammatory bowel disease
v Diet (high-fat, high-protein, low-fiber diet)
v Genital cancer
v Changes in bowel habits (most common presenting symptom)
v Passage of blood in/on stools (2" common)
v Pencil-like stool
v Unexplained anemia
v Anorexia
v Weight loss
v Fatigue
v Dull abdominal pain
v Melena
v Constipation
v Distention
Diagnosis
v Digital Rectal Exam: Annually (>40 y/o)
v Occult Stool Exam: Annually (>50 y/o)
v Colonoscopy
v Proctosigmoidoscopy
v Carcinoembryonic antigen (CEA)
v CT Scan
Complications
v Partial / complete bowel obstruction
v Hemorrhage/ GI bleeding
v Perforation
v Abscess formation
v Peritonitis
v Sepsis
v Shock
Surgery
v Hemicolectomy
• Surgical removal of the right or left side of the colon.
v Transverse Colectomy
• It is performed when the part of the colon that crosses from the right to the left side (transverse colon) is
removed.
v Sigmoidectomy
• Surgical removal of the sigmoid colon,
v Mile's procedure
• Removal of the tumor and a portion of the sigmoid and all of the rectum and anal sphincter
Pre-operative Nursing Interventions

v Bowel cleansing
v Low residue 3-5 days before
v Clear liquid then NPO post-midnight + Laxative and cleansing enema
v Pre-op antibiotic: Neomycin tablet
Postoperative Operation
v Warm sitz bath
v Stoma care
• Normal: red & protruding 1/2 inch
• Abnormal: Dark, dusky brown — black; these suggest necrosis
• Flatus & fecal drainage: 4-7 days
• Empty pouch 1/3 to % full.
• Use Karaya paste as skin barrier; talc/cornstarch
• Never use mineral oil
• No touch/pain sensation
• Use statin powder for Candida albicans
COLOSTOMY IRRIGATION
v 1st stimulate peristalsis
v 2 time evacuation of feces
v Semi-fowler's position
v Warm normal saline
v Start with 200 ml
v Clean gloves: dilate stoma
v Lubricate catheter (water-based) 2-4 inches insertion
v Hang solution 12-18 inches above the stoma
v Retain catheter for 5-10 minutes
v Drain after 15-20 minutes
v Stop irrigation momentarily when cramps are felt; continue the irrigation slowly

DIET
v Avoid gas-forming foods (cabbage nuts,eggs, cauliflower, gum, carbonated drinks)
BLADDER CANCER
v Men > Women (4:1)
v More related to industrial workers
Risk Factors
v Cigarette Smoking
v Exposure to environmental carcinogens
v Bladder stones
v High urinary pH
v High cholesterol intake
v Pelvic radiation therapy
Manifestations
v Painless hematuria (earliest and most common sign)
v Dysuria
v Hesitancy
v Pelvic / back pain
Diagnosis
v Cystoscopy
v CT Scan
v Ultrasonography
v Bimanual examination
Treatment
Surgery What’s done
Ileal Conduit Ileum used as stoma
Ureterostomy Ureters used for stoma
Vesicostomy Bladder used for stoma
Nephrostomy Kidney tube created for stoma
Surgery What’s done

Ureterosigmoidostomy Ureters attach to Sigmoid colon
Neobladder Ascending colon attached to urethra
Kock pouch Ileum used as a bladder with valve
Indiana pouch Ascending colon used as bladder
Mitrofanoff Appendix and ileocecal valve used as bladder
Nursing Care
v Administering IV fluids
v Pain Management
v Comfort measures:
• Providing small frequent meals
• Decreasing fluid intake
• Providing rest
SKIN CANCER
Exposure to the sun (leading cause of skin cancer)
Basal Cell Carcinoma
• Most common type; rarely metastasize
• Good prognosis
Squamous Cell Carcinoma
• Can metastasize

Malignant melanoma
• Deadliest
• 3" most common type
• Arise from birthmarks or moles in any place
Skin Cancer Parameters
v Asymmetry
v Border, Color
v Diameter
v Elevation
Risk Factors
v Fair-skinned, Fair-haired, Blue-eyed people
v People who sustain sunburn
v Chronic sun exposure
v Exposure to chemical pollutants
v Sun-damaged skin (elderly)
v History of x-ray therapy
v Immunosuppression
v Genetic factors
Treatment
v Electrosurgery
• Destruction or removal of tissue by electrical energy.
v Cryosurgery
• Destroys the tumor by deep freezing the tissue.
v Radiation Therapy
Nursing Management
v Health Teaching
• Dressing change
• WOF: excessive bleeding & tight dressings
• Ointment: emollient cream (reduces dryness)
• Follow up examinations (every 3 months)

HEMATOLOGIC SYSTEM
v The hematologic system consists of the blood and the sites where blood is produced, including the bone marrow and the
reticuloendothelial system (RES).
v Blood is a specialized organ that differs from other organs in that it exists in a fluid state. Blood is composed of plasma and various
types of cells.
v Plasma is the fluid portion of blood; it contains various proteins, such as albumin, globulin, fibrinogen, and other factors
necessary for clotting, as well as electrolytes, waste products, and nutrients. About 55% of blood volume is plasma.
v Serum is plasma minus the clotting factors.
BLOOD CELLS
Cell Type Major Function

WBC (Leukocyte) Fights infection
Normal: 4500-
11,000/mm3
Granulocytes
Neutrophil Essential in Preventing or limiting bacterial infection via phagocytosis
Eosinophil Involved in allergic reactions (neutralizes histamine), digests foreign proteins
Agranulocytes Enters tissue as macrophage; highly phagocytic, especially against fungus; immune surveillance
Monocyte
Responsible for cell- mediated immunity
T lymphocyte
Secretes immunoglobulin (Ig/ antibody)
Plasma Cell Most mature form of B lymphocytes
RBC (Erythrocyte) Carries hemoglobin to provide oxygen to tissues; average lifespan is 120 days
Hemoglobin
Male: 13-18 g/dL
Female: 12-16 g/dL
Hematocrit
Male: 42-52%
Female: 35-47%
Platelet Fragment of megakaryocyte; provides basis for coagulation to occur; maintains hemostasis; average
(Thrombocyte) lifespan is 10 days.
Normal: 150,000
450,000/ mm3
IRON DEFICIENCY ANEMIA (IDA)

v Results when the intake of dietary iron is inadequate for hemoglobin synthesis
v Predisposing Factors
• Chronic blood loss due to trauma, menorrhagia, GI bleeding (hematemesis, melena, hematochezia)
• Inadequate Fe+2 in the diet
• Impaired Fe+2 absorption due to
ü Chronic diarrhea
ü Malabsorption syndrome
ü Gastrectomy
ü Celiac disease
v Clinical Manifestations
• Fatigue/Easy fatigability – hallmark sign
• Brittle hair, spoon-shaped nails (koilonychia) due to atrophy of epidermal cells
• Palpitations, cold sensitivity
• Pallor, fatigue
• Smooth, sore tongue
• Plummer Vinson's Syndrome - atrophic glossitis, stomatitis, dysphagia due to atrophy of papilla of the tongue, mouth and
pharyngeal cells
• Pica- due to neuronal degeneration that affects cognitive functions
• Angular cheilosis- ulceration of the corner of the mouth
• Cerebral hypoxia- dizziness, dyspnea

v Diagnostic Procedures
• RBC, Hemoglobin, Hematocrit, Reticulocyte count, Serum Fe+2, Ferritin
v Management
• Correction of chronic blood loss.
• Oral or parenteral iron therapy
v Nursing Management
• Monitor all signs of bleeding
• CBR
• Increase intake of Fe+2 rich foods such as:
ü Green, leafy, vegetables,
ü Organ liver meat
ü Egg yolk
ü Legumes
ü California raisins
ü Red Meats
ü Molasses
• Administer Iron preparation as ordered.
ü FeSO4, Fe+2 gluconate, Fe+2 Fumarate
ü Taken with Vit C to increase absorption
ü Instruct the patient to avoid taking antacids and dairy products (it decreases iron absorption)
ü Best absorbed on an empty stomach, in between meals to prevent GI upset
ü Monitor S/E: anorexia, N/V, abdominal pain, diarrhea/constipation, black stools
MEGALOBLASTIC ANEMIA: PERNICIOUS ANEMIA

v Most dangerous of all chronic anemia due to deficiency of intrinsic factor leading to Vit. B12 malabsorption
v Predisposing factors
• Unknown cause
• Subtotal gastrectomy
• Hereditary
• Inflammation disorders of the ileum
ü Crohn's Disease
• Absence of intrinsic factor
• Strict vegetarian diet
• Headache, dizziness, dyspnea, palpitations, cold sensitivity, general body malaise, extreme pallor
ü Sore mouth, anorexia, nausea, vomiting, loss of weight, indigestion, epigastric discomfort, recurring diarrhea or
constipation.
ü Red-beefy tongue/ Glossitis - pathognomonic sign
ü Paresthesia in the extremities, difficulty maintaining their balance, lose position sense (proprioception)
v Diagnostic procedures
ü CBC and blood smear decreased hemoglobin and hematocrit
ü Schilling's test for absorption of vitamin B12 —patient receives small amount of radioactive B12 orally and 24-hour urine
collection is obtained
o Positive: Vitamin B12 absent in urine
o Negative: Vitamin B12 present in urine
• Enforce CBR and ensure safety
• Administer Vit. B12 injections at monthly intervals for lifetime as ordered.
• Diet
ü Small frequent bland soft food
ü Increase CHO, CHON, iron & Vit C
• Avoid irritating mouthwashes. Use of soft bristled toothbrush is encouraged
• Avoid excessive heat and cold temperature
• Administer parenteral Iron preparation as ordered
ü Administer using Z-tract method to prevent discoloration and leakage to tissues
ü Do not massage the injection site, encourage ambulation instead
ü Monitor S/E such as:
Ø Pain at injection site
Ø Localized abscess
Ø Lymphadenopathy
Ø Fever and chills
Ø Skin rashes
ü Watch out for anaphylaxis due to parenteral Iron supplement

MEGALOBLASTIC ANEMIA: FOLIC ACID DEFICIENCY
v Occurs if there is folic acid deficiency within 4 months
v Risk Factors
• People who rarely eat uncooked vegetables
• Alcoholism
• Chronic hemolytic anemia
• Pregnancy
• Malabsorptive diseases of the small bowel such as sprue
• Fatigue, weakness
• Pallor, dizziness, headache
• Tachycardia.
• Sore tongue, cracked lips
v Diagnostic Procedure
• CBC will show decreased RBC, hemoglobin, and hematocrit with increased mean corpuscular volume and mean corpuscular
hemoglobin concentration
v Management
• Administer 1mg of folic acid daily
• Folic acid intramuscular for patients with malabsorption problem
• Small frequent meals of bland, soft food
if sore mouth and tongue are present
• Diet: food rich in folic acid such as beef liver, peanut butter, red beans, oatmeal, broccoli, asparagus
APLASTIC ANEMIA
ü A rare disease caused by a decrease in or damage to marrow stem cells, damage to the microenvironment within the marrow,
and replacement of the marrow with fat resulting in pancytopenia (decreased RBCs, WBCs' and platelets)
• Chemicals (Benzene & its derivatives, pesticides)
• Radiation
• Immunologic injury
• Drugs causing bone marrow depression
• Broad spectrum antibiotic
ü Chloramphenicol
ü Sulfonamides — Bactrim
• Chemo therapeutic agents
ü Methotrexate
ü Nitrogen mustard
ü Vincristine
• Attack of T-cells against bone marrow
• Infections and pregnancy
• Signs of such as pallor, weakness, fatigue, exertional dyspnea, palpitations, fatigue
• Infections associated with Leukopenia: fever, headache, malaise, abdominal pain, diarrhea, erythema, pain, exudate at wounds
or sites of invasive procedures, Lymphadenopathies and Splenomegaly
• Thrombocytopenia: bleeding from gums, nose, GI or GU tracts; purpura, petechiae, ecchymoses, retinal hemorrhage, oozing of
blood from venipuncture site
• Bone Marrow Aspiration shows an extremely hypoplastic or even aplastic (very few to no cells) marrow replaced with fat.
• CBC and peripheral blood smear shows decreased RBC, WBC and platelets (pancytopenia)
Management
• Removal of causative agent or toxin.
• Bone Marrow Transplantation (BMT) or Peripheral Blood Stem Cell Transplant (PBSCT)
• Immunosuppressive therapy
• Supportive treatment includes platelet and RBC transfusions, antibiotics, and antifungal administration
Nursing Management
• Administration of immunosuppressants as ordered
• Blood transfusion as ordered
• Complete bed rest
• O2dministration
• Teach patient how to minimize risk of infection

• Reverse isolation due leukopenia
• Monitor signs of infection
• Avoid SQ, IM injections Use only soft toothbrush for mouth care and electric razor for shaving
SICKLE CELL ANEMIA

v Is a severe hemolytic anemia that results from inheritance of the sickle hemoglobin gene. This gene causes the hemoglobin
molecule to be defective. The abnormal sickle hemoglobin (HbS) acquires a crystal-like formation when exposed to low
oxygen tension.
• Severe pain in various parts of the body
• Tachycardia, murmurs & cardiomegaly
• Chest pain, dyspnea
• Jaundice
• Enlarged skull & facial bones due to bone marrow expansion
v Complications
• Hypoxia, ischemia, infection, poor wood healing
• Impotence
• Cerebrovascular accident
• Renal failure
• Heart failure
v Sickle Cell Crisis

• Sickle crisis - most common and very painful
ü Results from tissue hypoxia and necrosis due to inadequate blood flow to a specific region of tissue or organ
• Aplastic crisis - results from infection with the human parvovirus
• Sequestration crisis - results when other organs pool the sickled cells
v Treatment
• Bone marrow transplant
• Hydroxyurea = Increases production
• Long term RBC transfusion
• Splenectomy
• Peripheral Blood Stem Cell Transplant
• MANAGING PAIN
ü Treat the triggering factors.
o Hypoxia: Provide oxygen support.
o Dehydration: Infuse intravenous fluids. Encourage increased oral fluid intake.
o Infection: Administer antibiotic medications as prescribed.
ü Support & elevate acutely inflamed joint
ü Relaxation techniques
• PREVENT AND MANAGE INFECTION

ü Monitor patient for signs and symptoms of infection
ü Initiate prompt antibiotic therapy
• MONITOR AND PREVENT POTENTIAL COMPLICATIONS

ü Always provide adequate hydration
ü Avoid cold temperature that may cause vasoconstriction
ü Protect leg from trauma and contamination to prevent leg ulcer
ü Aseptic technique
THALASSEMIA
v Group of hereditary anemias characterized by hypochromia (an abnormal decrease in the hemoglobin content of erythrocytes),
extreme microcytosis (smaller-than-normal erythrocytes), destruction of blood elements (hemolysis), and variables degrees of
anemia
v Associated with defective synthesis of hemoglobin; the production of one or more globulin chains within the hemoglobin molecule
is reduced

v 2 classifications:
• Alpha-thalassemia occur mainly in people from Asia and the Middle East
ü Milder than the beta forms and often occurs without symptoms; the erythrocytes are extremely microcytic, but
the anemia, if present, is mild
• Beta-thalassemia are most prevalent in people from Mediterranean regions
ü Patients with mild forms have microcytosis and mild anemia
ü Severe beta-thalassemia (i.e., thalassemia major or Cooley’s anemia) can be fatal within the first few years of
life if untreated
v Management
• Bone Marrow Transplant
• Blood transfusion of Packed RBSs
v Thalassemia Major (Cooley’s Anemia)
• Characterized by severe anemia, marked hemolysis, and ineffective erythropoiesis
• With early regular transfusion therapy, growth and development through childhood are facilitated
• Management: PBSCT before liver damage occurs
• Watch out for iron overload which results from excessive iron in multiple packed RBC
ü Management: regular chelation therapy
POLYCYTHEMIA VERA (PRIMARY POLYCYTHEMIA)

v Proliferative disorder of the myeloid stem cells
v The bone marrow is hypercellular.
v Elevated levels of blood cells (erythrocyte, leukocyte, platelets)
• Ruddy complexion
• Splenomegaly
• Headache and dizziness
• Tinnitus, fatigue and paresthesia
• Blurred vison
• Increased blood viscosity: angina, claudication, dyspnea and thrombophlebitis
• Elevated blood pressure
• Uric acid maybe elevated resulting in gout and renal stone formation
• Generalized pruritus
• Erythromyalgia (burning sensation in fingers and toes)
• CBC
• Bone Marrow Aspiration
v Complications
• Cerebrovascular Accident
• Myocardial Infarction
• Bleeding due to dysfunctional large amount of platelet
v Management
• Phlebotomy – removing enough blood (initially 500 mL once or twice weekly) to reduce blood viscosity and to deplete the
patient’s iron stores
• Chemotherapeutic agents (eg, hydroxyurea) can be used to suppress marrow function
• Anagrelide (Agrylin) – inhibits platelet aggregation
• Interferon alfa-2b (Intron-A) – for management of pruritus (WOF: flulike syndrome and depression)
• Antihistamine
• Allopurinol
• Instruct the patient to avoid sedentary behaviours, crossing of legs, wearing tight or restrictive clothing
• Avoid aspirin and aspirin-containing medications
• Minimize alcohol intake
• Instruct the patient to avoid iron supplements
• For pruritus:
• Bathing in tepid or cool water
• Avoiding vigorous toweling off after bathing
• Use of cocoa butter or oat meal-based lotions and bath products
• Dissolved baking soda in bath water

HEMOPHILIA
v Inherited bleeding disorder
v Hemophilia A – caused by genetic disease that results in deficient or defective factor VIII
v Hemophilia B (Christmas Disease) – genetic defect that causes deficient or defective factor IX
v Both types of hemophilia are inherited as X-linked traits, so almost all affected people are males; females can be carriers
v Recognized in early childhood, usually in the toddler age group
• Hemorrhages into various parts of the body
• Hemarthroses and hematomas
• 75% of all bleeding occurs into joints
• Chronic pain or ankylosis (fixation) of the joint occurs
• Spontaneous hematuria and GI bleeding
• Intracranial or extracranial bleeding – most dangerous
v Management
• Administration of factor VIII and factor IX concentrates
• Infusion of fresh frozen plasma
• Plasmapheresis or concurrent immunosuppressive therapy
• Aminocaproic acid inhibits fibrinolysis and therefore stabilizes the clot
• Desmopressin (DDAVP) – induces a significant but transient rise in factor VII levels
• Assist the child in coping with the condition
• Encouraged to be self-sufficient and to maintain independence by preventing unnecessary trauma that
can cause acute bleeding episodes
• Instruct the patient to avoid OTC medications such as aspirin, NSAIDs, herbs, nutritional supplements
and alcohol
• Nasal packing should be avoided, because bleeding frequently resumes when the packing is removed
• All injections should be avoided
• Splints and other orthopedic devices may be useful in patients with joint or muscle hemorrhages
• Warm baths promote relaxation, improve mobility, episodes
• Provide genetic testing and counselling to female carriers

CARDIOVASCULAR NURSING
THE HEART
v Hollow, muscular organ
v Weight approximately 300 g
v It occupies the space between the lungs (mediastinum) and rests on the diaphragm
v The heart pumps blood to the tissues supplying them with oxygen and other nutrients.
THREE LAYERS OF THE HEART

• Endocardium-lines the inside of the heart and valves
• Myocardium-made up of muscle fibers and is responsible for the contraction
• Epicardium- Exterior layer of the heart in which pericardium can be found
ü Outermost
ü Essential coronary arteries are located
Pericardium- thin layer of fibrous tissue that contains pericardial fluid that lubricates the lining of the heart, it consists of
two layers:
• Adhering to the epicardium is the visceral pericardium.
• Enveloping the visceral pericardium is the parietal pericardium, which supports the heart in the mediastinum.
"The pumping action of the heart is accomplished by the rhythmic relaxation and contraction"
Systole- refers to the events in the heart during, contraction of the two top chambers (atria) and two lower chambers
(ventricles)
Diastolic- is characterized by relaxation of the lower chambers which allows the ventricles to fill in preparation for
contraction
2 CHAMBERS
UPPER
v ATRIUM
v Collecting/ Receiving chamber
LOWER
v VENTRICLES
v Pumping/ Contracting chamber
Apical impulse (also called the point of maximal impulse [PMI]) located at the 15th intercostal space (ICS), left
mid-clavicular line.
MECHANICAL PROPERTIES OF THE HEART

CARDIAC OUTPUT
v Volume of blood (liters) ejected by the heart each minute 5 L/min
v During exercise the total cardiac output may increase fourfold, to 2 L/min.
v Cardiac Output = Heart Rate x Stroke Volume
• CO = HR x SV
PULSE RATE/ HEART RATE

v Number of times the ventricles contract each minute
v 60-100 beats/min
v Controlled by the ANS
STROKE VOLUME
v Volume of blood ejected by the left ventricle during each systole
v Affected by 3 factors:
o Preload
o Contractility
o Afterload
PRELOAD
v Degree of myocardial stretch at the end of diastole & just before contraction
v Determined by the amount of blood returning to the heart from venous & pulmonary system
STARLING'S LAW
v The more the heart is filled during diastole, the more forcefully it contracts
v The higher the preload, the higher the stroke volume.
CONTRACTILITY
v Force generated by the contracting enhanced by myocardium
v Catecholamines, sympathetic activity and with medications such as the 3 D's
• Digoxin, Dopamine, Dobutamine
v The higher the contractility, the higher the stroke volume.
AFTERLOAD
v Pressure or resistance that the ventricles must overcome to eject blood through the semi-lunar valves
v Directly proportional to the BP & Diameter of blood vessels
v The higher the afterload, the lower the stroke volume.
HEART SOUNDS
1. The first heart sound (S1) is heard as the atrioventricular valves close and is heard loudest at the apex of the heart.
2. The second heart sound (S2) is heard when the semilunar valves close and is heard loudest at the base of the heart.
3. A third heart sound (S3) may be heard if ventricular wall compliance is decreased and structures in the ventricular wall
vibrate heart; this can occur in conditions such as congestive heart failure or valvular regurgitation. However, a third
heart sound may be normal in individuals younger than 30 years.
4. A fourth heart sound (S4) may be heard on atrial systole if resistance to ventricular filling the is present; this is an
abnormal finding, and causes include cardiac hypertrophy, disease, or injury to the ventricular wall.
CARDIAC ELECTROPHYSIOLOGY
Automaticity: ability to initiate an electrical impulse by itself
Excitability: ability to respond to an electrical impulse
Conductivity: ability to transmit an electrical impulse from one cell to another
SINOATRIAL (SA) NODE

v Location: Junction of Superior vena cava & Right Atrium
v Function: Pacemaker of heart
v Initiates 60-100 bpm
ATRIOVENTRICULAR (AV) NODE

v Location: Interatrial septum
v Delays the electric impulse to allow ventricular filling of 0.8 milliseconds
v 40-60 beats/min
BUNDLE OF HIS
v Location: Interventricular septum
v Branches out into:
• Right main Bundle Branch
• Left main Bundle Branch
PURKINJE FIBERS
v Location: Walls of ventricles
v Ventricular contractions
v Fastest conduction is: 20 - 40 beats/min
v It can function as a backup pacemaker if all other pacemakers fail
FACTS:
v “The parasympathetic impulses, which travel to the heart through the Vagus nerve, can slow the cardiac rate,
whereas sympathetic impulses increase it.”

v Baroreceptors are specialized nerve cells located in the aortic arch and in both right and left internal carotid arteries.
The baroreceptors are sensitive to changes in blood pressure.
v Hypotension can result in less baroreceptor stimulation, which prompts a decrease in parasympathetic inhibitory
activity in the SA node, allowing for enhanced sympathetic activity. The resultant vasoconstriction and increased heart
rate elevate the blood pressure.
ELECTRICAL CONDUCTION THROUGH THE HEART

P WAVE
❖ The P wave represents atrial muscle depolarization. It is normally small, smoothly rounded, and no wider than 0.12
second
QRS COMPLEX
v The QRS complex represents ventricular muscle depolarization
v Normal QRS width is 0.04 to 0.10 second.
v Atrial repolarization happens simultaneously.
T WAVE
v The T wave represents ventricular repolarization
v T waves are not normal more than 5 mm
PR INTERVAL
v The PR interval is measured from the beginning of the P wave to the beginning of the QRS complex and
represents the time required for the impulse to travel through atria, AV junction, and Purkinje system. The
normal PR interval is 0.12 to 0.20 seconds.
QT INTERVAL
v It represents the total time for ventricular depolarization and repolarization.
v QT interval is usually 0.32 to 0.40
v If QT interval becomes prolonged, the patient may be at risk for a lethal ventricular dysrhythmia called torsades de
pointes.
PP INTERVAL
v The duration between the beginning of one P wave and the beginning of the next P wave
v Used to calculate atrial rate and rhythm
RR INTERVAL
v The duration between the beginning of one QRS complex and the beginning of the next QRS complex; used to
calculate ventricular rate and rhythm
U WAVE
v The part of an ECG that may reflect Purkinje fiber repolarization: usually it is not seen unless a patient's serum
potassium level is low (Hypokalemia)
CORONARY ARTERY DISEASE

v Coronary artery disease (CAD) is the most prevalent type of cardiovascular disease in adults.
v Most common cause of cardiovascular disease is atherosclerosis- (abnormal accumulation of fats)
CLINICAL MANIFESTATIONS
• Symptoms and complications according to the location and degree of narrowing of the arterial lumen, if impediment
to the blood flow has occurred, inadequate supply to cardiac cells will lead to a condition known as ischemia.
MODIFIABLE RISK FACTORS

• Hyperlipidemia
• Cigarette smoking, tobacco use
• Hypertension
• Diabetes mellitus
• Metabolic syndrome
• Obesity
• Physical inactivity
NON-MODIFIABLE RISK FACTORS

• Family history' of CAD (first-degree relative with cardiovascular disease at 55 years of age or younger for men and at
65 years of age or younger for women)
ü Increasing age '4 More than 45 years for men
ü More than 55 years for women
• Gender (men develop CAD at an earlier age than women)
• Race (higher incidence of heart disease in African Americans than in Caucasians)
CLINICAL MANIFESTATION
• Possibly normal asymptomatic periods
• Chest pain
• Palpitations
• Dyspnea
• Syncope
• Excessive fatigue
SURGICAL PROCEDURES
v PTCA to compress the plaque against the walls of the artery and dilate the vessel
v Laser angioplasty to vaporize the plaque
v Atherectomy to remove the plaque from the artery
v Vascular stent to prevent the artery from closing and to prevent restenosis
v Coronary Artery Bypass Grafting (CABG) to improve blood flow to the myocardial tissue at risk for ischemia or
infarction because of the occluded artery
MEDICATIONS
v Nitrates to dilate the coronary arteries and decrease preload and afterload
v Calcium channel blockers to dilate coronary arteries and reduce vasospasm
v Cholesterol-lowering medications to reduce the development of atherosclerotic plaques
v Beta-Blockers to reduce the BP in individuals who are hypertensive
*All adults 20 years of age or older should have a fasting lipid profile (total cholesterol, LDL, HDL, and triglyceride I
performed at least once every 5 years and more often if the profile is abnormal"
*HDL, (high density lipoprotein) is known as good cholesterol because it transports other lipoproteins such as LDL to the
liver, where they can be degraded and excreted. Because of this, a high HDL level is a strong protective factor for heart
disease.
*Mediterranean diet another diet that promotes the ingestion of vegetables and fish and restricts red meat, is also
reported to reduce mortality from cardiovascular disease"
*Cholesterol is present in all body tissues and is a major component of low-density lipoproteins, brain and nerve cells, cell
membranes, and some gallbladder stones
*Increased cholesterol levels, LDL (Low density lipoprotein) levels, and triglyceride levels place the client at risk for
coronary artery disease
INSTRUCT THE CLIENT REGARDING DIET COMPOSED OF:

v Low-calorie
v Low-sodium
v Low-cholesterol
v Low-fat diet
v Increase in dietary fiber

VALUES
v Cholesterol: 140 to 199 mg/dL
v Low-density lipoproteins: Lower than 130 mg/dL
v High-density lipoproteins: 30 to 70 mg/dL
v Triglycerides: Lower than 200 mg/dL
HEART FAILURE (HF)

v HF is the inability of the heart to pump enough blood to meet the needs of tissues for oxygen and nutrients.
v Decreased heart contractility/ Pump failure
v Inadequacy of the heart to pump blood throughout the body
v Insufficient perfusion of body tissues (decreased cardiac output)
COMMON CAUSES OF HEART FAILURE

• Hypertension
• CAD
• Cardiomyopathy
• Substance abuse (Alcohol, Cocaine, Amphetamines)
• Valvular disease
• History of myocardial infarction
• Congenital defects
• Cardiac infections & inflammations
• Hyperkinetic conditions
ACC/AHA CLASSIFICATION OF HEART FAILURE
STAGE A Patients at high risk for Developing left ventricular

Dysfunction but without structural heart disease or symptoms of heart failure
STAGE B Patients with left ventricular dysfunction or structural heart disease who have not developed symptoms of
heart failure
STAGE C Patients with left ventricular dysfunction or structural heart disease with current or prior symptoms of heart
failure
STAGE D Patients with refractory end-stage heart failure requiring specialized interventions
TWO MAJOR TYPES OF HEART FAILURE

v Systolic heart failure- alteration in ventricular contraction which is characterized by weakened heart muscle
v Diastolic heart failure- characterized by a stiff and non- compliant heart muscle making it difficult for the ventricle to
fill. The signs and symptoms of HF can be related to which ventricle is affected.
LEFT-SIDED HEART FAILURE

v Pulmonary venous blood volume and pressure increase, forcing fluid from the pulmonary capillaries into the
pulmonary, tissues and alveoli, causing pulmonary„' interstitial edema and impaired Bas exchange.
v Pulmonary congestion occurs
v Signs and symptoms: Pulmonary/Lung (Left=Lung)
o Dyspnea, cough, pulmonary crackles/rales, and low oxygen saturation levels.
o Orthopnea, difficulty breathing when lying flat.
o Frothy, pink (blood-tinged) sputum: pulmonary congestion (pulmonary edema)
v An extra heart sound, the S3, or "ventricular gallop," may he detected on auscultation.
v The dominant feature in HF is inadequate tissue perfusion
Compensatory Mechanisms
v Compensatory mechanisms act to restore cardiac output to near-normal levels.
• Sympathetic nervous system stimulation
ü Arterial vasoconstriction
ü Increases afterload
ü Increased left cardiac workload
ü Increased heart rate
ü Improved stroke volume
ü Arterial vasoconstriction
• Renin-angiotensin system activation
v A decrease in renal perfusion due to low cardiac output causes the release of renin by the kidneys.
v Renin promotes the formation of Angiotensin I, a benign, inactive substance.
v Angiotensin- converting enzyme (ACE) in the lumen of pulmonary blood vessels converts angiotensin I to angiotensin
II a potent vasoconstrictor, which then increase blood pressure and afterload.
v Angiotensin II also stimulates the release of aldosterone from the adrenal cortex, resulting in sodium and fluid
retention by the renal tubules and stimulation of antidiuretic hormone. These mechanisms lead to the fluid volume
overload commonly seen in HF.
COMMON NURSING DIAGNOSES

• Impaired gas exchange related to ventilation perfusion imbalance
• Decreased CO related to altered contractility, preload & afterload
• Activity intolerance related to an imbalance between 02 supply and demand
• Potential for pulmonary edema, pneumonia, dysrhythmias
MANAGEMENT
• Patients with orthopnea usually prefer not to lie flat. They may need pillows to prop themselves up in bed, or they
may sit in a chair and even sleep sitting up.
• Monitor vital signs and look for changes.
• Record fluid intake and output—weigh daily to assess for fluid overload.
• Position patient in semi-Fowler's position to oxygen as ordered because it ease breathing
• Administer oxygen as ordered because it helps to decrease workload of heart.
• Administer diuretic as prescribed.
• Tell the patient:
✓Eat foods low in sodium to avoid fluid retention.
RIGHT-SIDED HEART FAILURE

v Right side of the heart cannot eject blood and cannot accommodate all the blood that normally returns to it from the
venous circulation
v Increased venous pressure leads to Jugular vein distention and increased capillary hydrostatic pressure throughout
the venous system
v Edema of the lower extremities (dependent system edema)
v Hepatomegaly (enlargement of the liver)
v Ascites (accumulation of fluid in the peritoneal al cavity)
v Weight gain due to retention of fluid.
"Inability of the right heart to empty its blood volume results in blood backing up into the systemic circulation. LV failure
is the most common cause of right ventricular (RV) failure. Sustained pulmonary hypertension also causes RV failure".
• Monitor heart rate and for dysrhythmias by using a cardiac monitor.
• Assess for edema in dependent areas and in the sacral, lumbar, and posterior thigh regions in the client on the bed
rest.
• Avoid the unnecessary IV administration of fluids.
• Monitor weight to determine a response to treatment.
• Assess for hepatomegaly and ascites, and measure and record abdominal girth.

PHARMACOLOGIC MANAGEMENT FOR HF
Administer diuretics for symptom control Furosemide, bumetanide, metolazone,

resulting in patient comfort by reducing blood hydrochlorothiazide, spironolactone-be aware of
volume electrolyte imbalance-these medications may alter the
K+ level
Administer ACE inhibitors to decrease Captopril, enalapril, lisinopril

afterload
Administer beta blocker, which help to raise Metoprolol (Lopressor, Toprol)
ejection fraction, and decrease ventricular Atenolol (Tenormin) Carvedilol (Coreg)
size
Administer inotrope to strengthen myocardial Digoxin
contractility
Administer vasodilator to reduce preload, Nitroprusside,
relieve dyspnea Nitroglycerin ointment
ARTERIOSCLEROSIS
v Thickening or hardening of the arterial wall
ATHEROSCLEROSIS
v Type of arteriosclerosis where a fatty plaque as formed within the arterial wall
v Leading contributor of CAD (coronary artery disease) and CVA (cerebrovascular accident)
VALVULAR HEART DISEASE

v Valvular heart disease occurs when the heart valves cannot fully open (stenosis) or closes inwards causing a leak
(insufficiency or regurgitation).
TYPES:
v Mitral Stenosis: Valvular tissue thickens and narrows the valve opening, preventing blood from flowing from the left
atrium to the left ventricle.
v Mitral Insufficiency, regurgitation: Valve is incompetent, preventing complete valve closure during systole.
v Mitral Valve Prolapse: Valve leaflets protrude into the left atrium during systole.
v Aortic Stenosis: Valvular tissue thickens and narrows the valve opening, preventing blood from flowing from the left
ventricle into the aorta.
v Aortic Insufficiency: Valve is incompetent, preventing complete valve closure during diastole.
MITRAL STENOSIS
v Usually due to rheumatic endocarditis
v Causing valve thickening by fibrosis and calcification
v Mitral valve opening narrows
v Left atrial pressure rises and dilates

v Pulmonary artery pressure increases
v Can cause right ventricular failure
• A Iow-pitched, rumbling, diastolic murmur is heard at the apex
• Dyspnea on exertion
• Orthopnea
ü Difficulty Breathing When Lying Flat
• Paroxysmal nocturnal dyspnea
ü Shortness of Breath that occurs suddenly during sleep
• Dyspnea and dry cough
• Hemoptysis and pulmonary edema
• Right sided heart failure may occur late
• Atrial dysrhythmias
MEDICAL MANAGEMENT
• Patients with mitral stenosis may benefit from anticoagulants to decrease the risk for developing atrial thrombus
• Surgical intervention consist of valvuloplasty
• Percutaneous transluminal valvuloplasty
• Mitral valve replacement
NURSING MANAGEMENT
• Place patient in a nigh Fowler's position to ease breathing
• Monitor for:
ü Pulmonary edema because it may be a complication of surgery
ü Thrombus because of a valve.
ü Arrhythmias because of an imitated heart- patient may feel palpitations, anxiety.
ü Arterial Blood Gas (ABG) to monitor for oxygenation, acidosis, alkalosis.
ü Weigh the patient daily to determine fluid balance
• Explain to the patient:
ü Signs and symptoms to look for and to report changes in condition.
ü Restrict diet to low-sodium and low-fat foods
MITRAL REGURGITATION (INSUFFICIENCY)

v Mitral regurgitation involves blood flowing back from the left ventricle into the left atrium during systole. Often the
edges of the mitral valve leaflets do not close during systole
v Most common cause is mitral valve prolapse and rheumatic heart disease
• Dyspnea, fatigue, and weakness are the most common symptoms.
• Palpitations, shortness of breath on exertion, and cough from pulmonary congestion also occur.
• Systolic murmur is heard as a high- pitched, blowing sound at the apex
MANAGEMENT
• Patients with mitral regurgitation and heart failure benefit from afterload reduction (arterial dilation)
• Angiotensin-converting enzyme (ACE) inhibitor
• Surgical intervention consists of mitral valvuloplasty (ie, surgical repair of the valve) or valve replacement
AORTIC REGURGITATION
v Aortic regurgitation is the flow of blood back into the left ventricle from the aorta during diastole"
v Blood from the aorta returns to the left ventricle during diastole"
ETIOLOGY
• Inflammatory lesions that deform the leaflets
• Rheumatic endocarditis,
• Congenital abnormalities
• Syphilis
• Dissecting aneurysm
“In many cases, the cause is unknown and is classified as idiopathic"
• Patients experience forceful heart beats especially in the head and neck
• Marked arterial pulsations that are visible or palpable at the carotid or temporal arteries
• Palpable at the carotid or temporal arteries
• Exertional dyspnea and fatigue
• A diastolic murmur is heard as a high-pitched, blowing sound at the third or fourth intercostal space at the left sterna
border.
• Widening of pulse pressure
• One characteristic sign of the disease is the water-hammer (Corrigan's) pulse
SURGICAL MANAGEMENT
• The treatment of choice is aortic valvuloplasty or valve replacement, preferably performed before left ventricular
failure occurs.
• Surgery is recommended for any patient with left ventricular hypertrophy regardless of the presence or absence of
symptoms
NURSING MANAGEMENT
• Patient is advised to avoid physical exertion
• Vasodilators such as calcium channel blockers (eg. nifedipine [Adalat, Procardia))
• Ace inhibitors (eg. Captopril, enalapril, lisinopril, ramipril). or hydralazine
AORTIC STENOSIS
• Narrowing of the orifice between the left ventricle and the aorta,
CAUSE
• Degenerative calcifications caused by inflammatory changes that occur in response to years of normal mechanical
stress.
PATHOPHYSIOLOGY
• Progressive narrowing of the valve orifice occurs, the left ventricle contracts more forcefully and consumes more
energy. It compensates by thickening its walls or hypertrophies.
• Exertional dyspnea caused by increased pulmonary venous pressure
• Pulmonary edema may also occur
• Syncope and dizziness because decreased circulation to the brain
• Angina pectoris from increased demands of the left ventricle
• Loud rough systolic murmur heard over the aortic area
• Blood pressure is normal
TREATMENT
• Surgical replacement of the aortic valve or Percutaneous valvuloplasty procedures
INFECTIVE ENDOCARDITIS
• Microbial infection of the endothelial surface of the heart, it usually develops in people with prosthetic heart valves or
structural heart defects
• Hospital acquired infective endocarditis occurs in patients with indwelling catheters
PATHOPHYSIOLOGY
• A deformity or injury of the endocardium brought about by infectious organisms leads to accumulation on the
endocardium of fibrin and platelets. The infection may erode through the endocardium into underlying structures
(valves /leaflets) causing deformity.
ASSESSMENTS
• Cluster of petechiae may be found on the body
• Small painful nodules (Osiers nodes) may be present in pads of fingers or toes
• Irregular red, purple, painless, flat macules (Janeway Lesions) may be present on the palms fingers and toes.
• Hemorrhages with pale centers in the eyes caused by emboli (Roth spots) caused by emboli may be observed in the
fundi of the eyes
• Splinter hemorrhages (ie, reddish-brown lines and streaks) may be seen under the fingernails and toenails,
PREVENTION
v Antibiotic prophylaxis is recommended for high-risk patients immediately before and sometimes after the following
procedures
• Dental procedures
• Tonsillectomy or adenoidectomy
• Bronchoscopy
• Cystoscopy
• Surgery involving infected skin musculoskeletal tissue
MEDICAL MANAGEMENT
• Antibiotic therapy is usually administered parenterally in a continuous IV infusion for 2 to 6 weeks. penicillin is usually
the medication of choice
• In fungal endocarditis, an antifungal agent, such as amphotericin B (eg, Abelcet, Amphocin, Fungizone), is the usual
treatment
Nurse Home Care Instructions for the Client with Infective Endocarditis
• Teach the client to maintain aseptic technique during setup and administration of intravenous antibiotics.
• Instruct the client to monitor intravenous catheter sites for signs of infection and report this immediately to the
physician.
• Instruct the client to record the temperature daily for up to 6 weeks and report fever.
• Encourage oral hygiene at least twice a day with a soft toothbrush and rinse well with water after brushing
• Client should avoid use of oral irrigation devices and flossing to avoid bacteremia.
MYOCARDITIS
v Myocarditis is an inflammation of the myocardium. It is usually diagnosed when it leads to significant cardiac
dysfunction. Myocarditis can cause considerable morbidity and mortality
v Infection could be bacterial, protozoal, fungal parasitic
v Viral myocarditis is the most common type
v Characterized by necrosis and cell injury associated with inflammation of the heart muscle
ASSESSMENT FINDINGS
• Non-specific symptoms: fatigue, dyspnea and palpitation
• If the disease has progressed, symptoms of heart failure present, such as tachycardia, pulmonary edema,
diaphoresis, neck vein distention, and cardiomegaly.
• In myocarditis, the ECG can show low-voltage QRS complexes, ST segment elevation, or heart block
• An S4 and systolic ejection murmurs may be heard on auscultation
• Patients may also sustain sudden cardiac death or quickly develop severe congestive heart failure
MEDICAL MANAGEMENT
• Patient are given specific treatment for the underlying cause if it is known (eg, penicillin for hemolytic streptococci)
• lnotropic support of cardiac function with dopamine, or dobutamine may be used Netroprusside and nitroglycerine
may be used to decrease afterload
• Beta Blocker are avoided because they decrease the strength of ventricular contraction (have a negative inotropic
effect)
• Sedation may be necessary to decrease cardiac workload
• Intra-aortic balloon pulsation and left ventricular assists devices have been used to improve cardiac output
myocarditis
NURSING ALERT
Patients with myocarditis are sensitive to digitalis. Nurses must closely monitor these patients for digitalis toxicity, which
evidenced by dysrhythmia, anorexia, nausea, vomiting, headache, and malaise,
Pericarditis
v Pericarditis refers to an inflammation of the pericardium, the membranous sac enveloping the heart. It may be a
primary illness or it may develop during various medical and surgical disorders.

PATHOPHYSIOLOGY
• The inflammation process of pericarditis may lead to an accumulation of fluid in the pericardial (pericardial effusion)
and increased pressure on the heart leading to cardiac tamponade
• Prolonged episodes of pericarditis may lead to thickening and decreased elasticity of pericardium. These conditions
restrict the heart's ability to fill with blood (constrictive pericarditis)
• Restricted filling may result in increased systemic venous pressure
ASSESSMENTS
• Chest pain- located beneath the clavicle, in the neck or in the left scapular region, may worsen with deep inspiration
and may be relieved with a forward leaning or sitting position. (Tripod Position)
• Most characteristic sign of pericarditis is a creaky or scratchy friction rub heard most clearly at the left lower sternal
border (pericardial friction rub)
MEDICAL MANAGEMENT
• Administer therapy for treatment and symptom relief, and detect signs and symptoms of cardiac tamponade.
• Analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs
• Indomethacin (Indocin) is contraindicated because it may decrease coronary blood flow
• A pericardial window, a small opening made in the pericardium
• May be performed to allow continuous drainage into the chest cavity.
• Surgical removal of the tough encasing pericardium (pericardiectomy) may be necessary to release both ventricles
from the constrictive and restrictive inflammation scarring.
PERICARDIOCENTESIS
v Procedure in which some of the pericardial fluid is removed
• Emergency resuscitation should be readily available
• The head of the bed is elevated to 45 to 60 degrees, placing the heart In proximity to the chest wall so that the
needle can be directly inserted into the pericardial sac
• Slow iv infusion is started in case it becomes necessary to administer emergency medications or blood products
• Ultrasound imaging is used to guide placement of the needle into the pericardial space
v Desired effect
• Decrease in central venous pressure
• Increase in blood pressure
• Withdrawal of pulsus paradoxus
ü >10 mm Hg drop in blood pressure during inspiration
• Disappearance of prominent neck veins due to increased venous pressure
COMPLICATIONS OF PERICARDIOCENTESIS
• Coronary artery puncture
• Myocardial trauma
• Dysrhythmias
• Pleural laceration
• Gastric puncture
NURSING MANAGEMENT
• Patients with acute pericarditis require pain management with analgesics, positioning, and psychological support
caring for patients with pericarditis must be alert to cardiac tamponade
• After pericardiocentesis, the patient's heart rhythm, blood pressure, venous pressure, and heart sounds are
monitored to detect possible recurrence of cardiac tamponade
NURSING ALERT
• A pericardial friction rub is diagnostic feature of pericarditis. It has a creaky or Scratchy sound and is louder at the
end of exhalation.
• Nurses should monitor for the pericardial friction rub by placing the diaphragm of the stethoscope tightly against the
thorax and auscultating the left sternal edge in the fourth intercostal space, the site where the pericardium comes
into contact with the left chest wall.
• The rub may be heard best when a patient is sifting and leaning forward.

CARDIAC TAMPONADE
v A condition where the heart is unable to pump blood due to accumulation of fluid in the pericardial sac (pericardial
effusion)
v This condition restricts ventricular filling resulting to decreased cardiac output
v Acute tamponade happens when there sudden accumulation of more than 50 ml fluid in the pericardial sac
CAUSES
• Cardiac trauma
• Complication of Myocardial infarction
• Pericarditis
ASSESSMENT FINDING
• BECK's Triad
ü Jugular vein distention
ü Hypotension
ü Distant/muffled heart sound
• Pulsus paradoxus
o >10 mm Hg drop in blood pressure during inspiration
• Increased Central Venous Pressure
• Decreased cardiac output
• Anxiety
• Dyspnea
LABORATORY FINDINGS
• Echocardiogram= shows accumulation of fluid in the pericardial sac
• Chest X-ray
NURSING MANAGEMENT
• The client needs to be placed in a critical care unit for hemodynamic monitoring.
• Administer fluids intravenously as prescribed to manage decreased cardiac output.
• Prepare the client for pericardiocentesis to withdraw pericardial fluid if prescribed.
• Monitor for recurrence of tamponade following pericardiocentesis.
• If the client experiences recurrent tamponade or recurrent effusions or develops adhesions from chronic pericarditis,
a portion (pericardial window) or all of the pericardium (pericardiectomy) may be removed to allow adequate
ventricular filling and contraction.
ANGINA PECTORIS
v Angina pectoris is a clinical syndrome usually characterized by episodes or paroxysms of pain or pressure in the
anterior chest
v The cause is insufficient coronary blood flow, resulting in a decreased oxygen supply when there is increased
myocardial demand for oxygen
PATHOPHYSIOLOGY
• Angina is usually caused by atherosclerotic disease and associated with a significant obstruction of at least one major
coronary artery
TYPES OF ANGINA
v Stable angina: predictable and consistent pain that occurs on exertion and is relieved by rest and/or nitroglycerin
v Unstable angina (also called pre-infarction angina or crescendo angina): symptoms increase in frequency and
severity; may not be relieved with rest or nitroglycerin
v Intractable or refractory angina: severe incapacitating chest pain
v Variant angina (also called Prinzmetal’s angina): pain at rest with reversible ST-segment elevation; thought to be
caused by coronary artery vasospasm
v Silent ischemia: objective evidence of ischemia (such as electrocardiographic changes with a stress test), but patient
reports no pain

TRIGGERING FACTORS
• Exertion
• Exposure to cold
• Eating a heavy meal, which increases the blood flow to the mesenteric area for digestion, thereby reducing the blood
supply available to the heart muscle;
ü In a severely compromised heart, shunting of blood for digestion can be sufficient to induce anginal pain
• Stress or any emotion-provoking situation, causing the release of catecholamine's, which increases blood pressure,
heart rate, and myocardial workload
MANIFESTATIONS
• Heavy sensation in the upper chest that ranges from discomfort to agonizing pain
• Severe apprehension and a feeling of impending death.
• Retrosternal pain
• Pain radiates to the neck, jaw, shoulders, and inner aspects of the upper am-is, usually the left arm
“An important characteristic of angina is that it subsides with rest or administering nitroglycerin. In many patients, anginal
symptoms follow a stable, predictable pattern."
ASSESSMENT AND DIAGNOSTIC FINDINGS

• ECG may show changes indicative of ischemia such as T-wave inversion
• Nuclear scan or invasive procedure (eg, cardiac catherization, coronary angiography).
• ST depression
MEDICAL MANAGEMENT
• The objectives of the medical management of angina are decrease the oxygen demand of the myocardium and to
increase the oxygen supply
• Percutaneous transluminal coronary angioplasty (PTCA)
ü Balloon-tipped catheter is used to open blocked coronary vessels and resolve ischemia. The purpose of PTCA is to
improve blood flow within the coronary artery by compressing and “cracking” the atheroma
• Intracoronary stents
ü A Stent is a metal mesh that provides structural support to vessel at risk of acute closure.
• Atherectomy
ü Atherectomy removes plaque from a coronary artery by the use of a cutting chamber on the inserted catheter of
a rotating blade that pulverizes the plaque.
• CABG (Coronary Artery Bypass Graft)
ü Surgical procedure in which a blood vessel is grafted to an occluded artery so that blood can flow beyond the
occlusion
PHARMACOLOGIC MANAGEMENT
• Nitroglycerine causes dilation of the veins the result is venous pooling of blood throughout the body. As a result, less
blood returns to the heart, decreasing the cardiac workload
• Facts about nitroglycerine
ü Can be given:
o Sublingual tablet
o Spray
o Topical agent,
o Intravenous I.V. administration
MEDICATIONS USED TO TREAT ANGINA

NITRATES
• Nitroglycerin (Nitrostat, Nitro-Bid): Short-term and long-term reduction of myocardial oxygen consumption through
selective vasodilation
Beta-Adrenergic Blocking Agents (beta- blockers)

• Metoprolol (Lopressor, Toprol) Reduction of myocardial oxygen consumption by blocking beta-adrenergic
• Atenolol (Tenormin) stimulation of the heart

Calcium Ion Antagonists (calcium channel blockers)
• Amlodipine (Norvasc) Negative inotropic effects; indicated in patients not responsive to beta-blockers;
• Diltiazem (Cardizem, Tiazac) used primary treatment for vasospasm
• Felodipine (Plendil)
Antiplatelet Medications
• Aspirin Prevention of platelet aggregation
• Clopidogrel (Plavix)
• Glycoprotein agents:
• Abciximab (ReoPro)
• Tirofiban (Aggrastat)
• Eptifibatide (Integrilin)
Anticoagulants
• Heparin (unfractionated): Prevention of thrombus formation
• Low-molecular-weight heparins (LMWHs): Enoxaparin (Lovenox)
• Dalteparin (Fragmin)
MYOCARDIAL INFARCTION
v In an MI, an area of the myocardium is permanently destroyed, typically because plaque rupture and subsequent
thrombus formation result in complete occlusion of the artery.
v The ECG usually identifies the type and location of the MI, and other ECG indicators such as a Q wave and patient
history identify the timing. Regardless of the location, the goals of medical therapy are to prevent or minimize
myocardial tissue death and prevent complications
RISK FACTORS
Non-modifiable Risk Factor
• Age
ü Average age of a person having a first heart attack is 65.8 yrs (male) and 70. 4 yrs (female) - AHA 2003
• Family history
• Ethnic background
ü African-Americans has a higher risk for developing M.I.
Modifiable Risk Factor

• Hypertension
• Smoking
• Hyperlipidemia
• Obesity
• Impaired glucose tolerance (DM)

• Physical inactivity
• Stress
ASSESSMENT
SUBSTANTIAL CHEST PAIN
• The pain associated with an MI usually lasts longer than 30 minutes
• Radiating to the left arm, back or jaw
• Occurring w/o a cause usually in the morning
• Relieved only by opioids associated with nausea, diaphoresis, dyspnea, fear & anxiety, palpitations, fatigue, shortness
of breath.
• Decreased left ventricular function
• Decreased cardiac output
• Cardiovascular system compensates by increasing heart rate (Frank-Starling law)
CG AND CARDIAC ENZYMES ASSESSMENTS

• T-wave in
• ST-segment elevation
• Abnormal Q wave
• Elevated CKMB assessed by mass assay is an indicator of acute MI
• An increase in the level of troponin in the serum can be detected within a few hours during acute MI.
• Enzymes that indicate Myocardial Infarction
ENZYMES TIME OF DESCRIPTION

ELEVATION
MYOGLOBIN First 1-3 hours First enzyme to elevate due to decreased oxygenation
TROPONIN I 2-4 hours Released at the mentioned time frame
AST (aspartate amino transferase) 8 hours Is also used for liver damage
CK-MB 24 hours Cardiac- specific isoenzyme; it is found mainly in cardiac
cells and therefore increases only when there has been
damage to these cells
LDH (Lactic Dehydrogenase) 72 hours Reflects tissue breakdown and hemolysis
MEDICAL MANAGEMENT
v The goals of medical management are to minimize myocardial damage, preserve myocardial function, and prevent
complications this can be achieved by:
• Reperfusing the area with the emergency use of thrombolytic medications
• Reducing myocardial oxygen demand and increasing oxygen supply with medications, oxygen administration, and
bed rest
PHARMACOLOGIC THERAPY
v Drug of choice: Morphine I.V.
o Potent vasodilator: Increases oxygen supply to myocardial tissues
o Decreases oxygen demand
v (ACE) inhibitors decreases blood pressure thus decreasing the workload of the heart
v Thrombolytics dissolve (ie, lyse) the thrombus in a coronary artery (thrombolysis), allowing blood to flow through
the coronary artery again
v THROMBINS2 – “the new MONA (Morphine, Oxygen, Nitroglycerin, Aspirin)”

o Thienopyridines: Antiplatelet drugs (Clopidogrel, Prasurgel)
o Heparin: Anticoagulant
o RAAS Inhibitors: ACE-Inhibitors (-pril) or ARBs (-sartan)
o Oxygen
o Morphine
o Beta-blockers: -olol
o Invasive interventions
o Nitroglycerin: vasodilator
o Statin: reduces cholesterol levels (Atorvastatin, Rosuvastatin)
o Salicylate: aspirin/acetylsalicylic acid (ASA)
Common Physical Presentation of the Patient with Acute Myocardial Infarction

General Alert anxious, Restless often fatigued
Skin Cool, clammy; diaphoretic
Heart Cardiovascular S3 or S4 gallop may or may not be present; dysrhythmias or murmurs.
Jugular venous distention May be seen in the presence of pump failure
Lungs Dyspnea, tachypnea, rales (crackles) suggest pulmonary congestion and heart failure
Circulatory Peripheral pulses may be pounding or thready, regular or irregular
Gastrointestinal Nausea and vomiting
CARDIOMYOPATHY
v A heart muscle disease associated with cardiac dysfunction.
TYPES
• Dilated
• Hypertrophic
• Restrictive

DILATED CARDIOMYOPATHY
v Extensive damage to the myofibrils & interference with myocardial metabolism
v Normal ventricular wall thickness but dilation of both ventricles & impairment of systolic function
v Decreased CO- inadequate heart pumping
v Dyspnea on exertion fatigue and palpitation
CAUSES
• Alcohol abuse
• Chemotherapy
ASSESSMENT
• Fatigue, weakness
• HF (left side)
• Dysrhythmias
• Moderate to severe cardiomegaly
HYPERTROPHIC CARDIOMYOPATHY
v Asymmetric ventricular hypertrophy and disarray of myocardial fibers
v LVH leads to a stiff LV that result in diastolic filling abnormalities
v Obstruction in LV outflow
v 50 % genetically inherited
ASSESSMENT
• Dyspnea
• Angina
• Fatigue, syncope, palpitations
• Mild cardiomegaly
• Ventricular dysrhythmias
• Sudden death common
• Heart failure
RESTRICTIVE CARDIOMYOPATHY
v Restriction or filling of the rigid ventricular walls
v The cause is unknown (ie, idiopathic) in most cases.
v Can be caused by endocrinal or myocardial disease and produce a clinical picture similar to constrictive pericarditis
v Fibrosed walls cannot expand or contract
v Chamber is also narrowed
ASSESSMENT
• Dyspnea & fatigue
• HF (Right side)
• Mild to moderate cardiomegaly
• Heart block
SHOCK
v Inadequate organ perfusion to meet the tissue's oxygenation demand.
v Hypoperfusion can be present in the absence of significant hypotension
v 3 Types of Shock
o Hypovolemic
o Cardiogenic
o Distributive – systemic vasodilation leading to decreased blood pressure and insufficient tissue perfusion
§ Neurogenic
§ Anaphylactic
§ Septic

TYPES OF SHOCK
HYPOVOLEMIC
v Occurs when there is a loss of fluid (blood, plasma) resulting in inadequate tissue perfusion; caused by:
ü Hemorrhage/Excessive bleeding
ü Excessive diarrhea or vomiting
ü Dehydration
ü Fluid loss from fistulas or burns
ü Massive third spacing/edema
TREATMENT
• Primary problem/underlying cause must be treated
• Whole blood, plasma (fluid and blood) Replacement and electrolytes
MANAGEMENT:
Major goals in the treatment of hypovolemic shock are to restore intravascular volume to reverse the sequence of events
leading to inadequate tissue perfusion, to redistribute fluid volume, and to correct the underlying cause of the fluid loss as
quickly as possible
CARDIOGENIC
v Occurs when pump failure causes inadequate tissue perfusion; caused by
ü Congestive heart failure
ü Myocardial infarction
ü Cardiac tamponade
MANAGEMENT
• The goals of medical management in cardiogenic shock are to limit further myocardial damage and preserve the
healthy myocardium and to improve the cardiac function by increasing cardiac contractility, decreasing ventricular
afterload, or both.
NEUROGENIC
v Neurogenic shock develops as a result of the loss of autonomic nervous system function below the level of the
lesion in the spinal cord which caused rapid vasodilation and subsequent pooling of blood within the peripheral
vessels
MANAGEMENT
• Treatment of neurogenic shock involves restoring sympathetic tone, either through the stabilization of a spinal cord
injury or, by positioning the patient properly.
• It is important to elevate and maintain the head of the bed at least 30 degrees to prevent neurogenic shock when a
patient receives spinal or epidural anesthesia. Elevation of the head helps prevent the spread of the anesthetic agent
up the spinal cord.
ANAPHYLACTIC
❖ Caused by an allergic/anaphylactic reaction that causes a release of histamine and subsequent systemic vasodilation
MANAGEMENT:
• Treatment of anaphylactic shock requires removing the causative antigen (eg, discontinuing an antibiotic
agent), administering medications that restore vascular tone, and providing emergency support of basic life
functions.
• Epinephrine is given for its vasoconstrictive action (emergency drug).
• Diphenhydramine (Benadryl) is administered to reverse the effects of histamine, thereby reducing capillary
permeability.
SEPTIC
v Similar to anaphylaxis; the body's reaction to bacterial toxins (generally gram-negative infections) results in the
leakage of plasma into tissues
MANAGEMENT
• Current treatment of sepsis and septic shock involves identification and elimination of the cause of infection.
TYPE MECHANISM
Hypovolemic Loss of blood or plasma
Cardiogenic Decreased pumping capability/contractility of heart
Distributive Systemic vasodilation
- Anaphylactic due to severe allergic reaction
- Septic due to severe infection
- Neurogenic due to loss of SNS and vasomotor tone
HYPERTENSION
v Hypertension is defined as a systolic blood pressure greater than 140 mm Hg and a diastolic pressure greater than 90
mmHg
TYPES OF HYPERTENSION
ESSENTIAL HYPERTENSION
• No known direct cause
• Risk factor
ü Age > 60 yrs
ü Family history of hypertension
ü Excessive caloric consumption
ü Physical inactivity
ü Excessive alcohol intake
ü Hyperlipidemia
ü High salt intake or caffeine; reduced intake of potassium, calcium, or magnesium
ü Smoking
SECONDARY HYPERTENSION
• Disease
ü Renal vascular & parenchymal disease
ü Primary aldosterone
ü Pheochromocytoma
ü Cushing's disease
ü Coarctation of aorta
ü Brain tumors
ü Encephalitis
• For patients with uncomplicated hypertension and no specific indications for another medication, the recommended
initial medications include diuretics, beta blockers and angiotensin-converting enzyme (ACE)
BETA-BLOCKERS
• First line drug therapy
• Reduce BP by decreasing CO
• Decrease sympathetic stimulation
• Inhibit release of renin from the kidneys
ANGIOTENSIN -CONVERTING ENZYME (ACE) INHIBITORS

• Lower BP by reducing peripheral vascular resistance w/o reflex increase in CO, HR or contractility.
ü Captopril (Capoten)
ü Enalapril (Vasotec)
ü Lisinopril (Zestril)
• Decrease secretion of aldosterone
CENTRAL ALPHA ANTAGONIST

• Acts on CNS preventing reuptake of norepinephrine resulting in lower peripheral Vascular resistance & BP
ü Clonidine (Catapres)
ü Does not decrease renal blood flow

CALCIUM-CHANNEL BLOCKER
• Verapamil (Isoptin
• Amlodipine
• Diltiazem
• Nicardipine
DIURETICS (WATER PILL)

• Thiazide
ü Chlorothiazide (Diuril)
ü Hydrochlorothiazide (Hydrodiuril)
• Loop
ü Furosemide (Lasix)
ü Bumetanide (Bumex)
• Potassium - sparing
ü Spironolactone (Aldactone)
• The objective of nursing care for patients with hypertension focuses on lowering and controlling the blood pressure
without adverse effects and without undue cost through:
ü Adhere to the treatment regimen
ü Implementing necessary lifestyle changes
ü Taking medications as prescribed
ü Scheduling regular follow-up appointments
THROMBOANGIITIS OBLITERANS/ BUERGER'S DISEASE

v Buerger's disease is characterized by recurring inflammation of the intermediate and small arteries and veins of the
lower and upper extremities
• Factors
ü Men between 20-35 years of age
ü Heavy smoking and chewing tobacco
• Foot cramps, especially of the arch (instep claudication), after exercise
• Pain is relieved by rest
• Intense rubor (reddish-blue discoloration) of the foot and absence of the pedal pulse
MEDICAL MANAGEMENT
• The main objectives are to improve circulation to the extremities, prevent the progression of the disease
• Vasodilators are rarely prescribed
RAYNAUD'S PHENOMENON
v Raynaud's phenomenon is a form of intermittent arteriolar vasoconstriction that results in coldness, pain, and pallor
of the fingertips or toes.
Factors:
• Raynaud's phenomenon is most common in women between 16 and 40 years of age, and it occurs more frequently in
cold climate
• The characteristic sequence of color change of Raynaud's phenomenon is described as white, blue, and red.
• Numbness, tingling, and burning pain occur as the color changes.
• The manifestations tend to be bilateral and symmetric and may involve toes and fingers.
MEDICAL MANAGEMENT
• Avoiding the particular stimuli (E.g. cold, tobacco) that provoke vasoconstriction is a primary factor in controlling
Raynaud's phenomenon.
• Calcium channel blockers (Nifedipine [Procardia], amlodipine [Norvasc])
• Sympathectomy (interrupting the sympathetic nerves by removing the sympathetic ganglia or dividing their branches)
may help some patients.
NURSING MANAGEMENT
• Exposure to cold must be minimize
• Sweater should be available when entering air-conditioned rooms
ü Avoid smoking and all sources of nicotine like nicotine gum or patches.
VENOUS THROMBOEMBOLISM
v Deep vein thrombosis (DVT)
• Virchow's triad
ü Vessel wall injury
ü Venous stasis (stasis of blood)
ü Altered blood coagulation
• Risk Factors for Venous stasis

ü Bed rest or immobilization
ü Obesity
ü History of varicosities
ü Spinal cord injury
ü Age (greater than 65 years)
ASSESSMENT
• Obstruction of the deep veins comes edema and swelling of the extremity because the outflow of venous blood is
inhibited
• Limb pain, a feeling of heaviness, functional impairment, ankle engorgement, and edema
PREVENTION
• Preventive measures include the application of graduated compression stockings
• In surgical patients is administration of subcutaneous unfractionated or low molecular- weight heparin (LMWH).
• Lifestyle changes as appropriate, which may include weight loss, smoking cessation, and regular exercise
MEDICAL MANAGEMENT
Anticoagulant therapy
• (Administration of a medication to delay the clotting time of blood, prevent the formation of a thrombus in
postoperative patients, and forestall the extension of a thrombus after it has formed)
• Oral Anticoagulant Warfarin (Coumadin)
Thrombolytic
• Alteplase (Activase, t-PA)
• Urokinase (Abbokinase)
• Streptokinase (Streptase)
NURSING MANAGEMENT
• If the patient is receiving anticoagulant therapy, the nurse must frequently monitor the aPTT, prothrombin time (PT)
and INR
• Elevation of the affected extremity, graduated compression stockings, and analgesic agents for pain relief are
adjuncts the therapy. They help improve circulation and increase comfort.
• Warm, moist- packs applied to the affected extremity reduce the discomfort associated with DVT
• The patient is encouraged to walk once anticoagulation therapy has been initiated. The nurse should instruct the
patient that walking is better than standing or sitting for long periods
NURSING ALERT
• For ambulatory patients, graduated compression stockings are removed at night and reapplied before the legs are
lowered from the bed to the floor in the morning.
ANEURYSMS
v An aneurysm is a localized sac or dilation formed at a weak point in the wall of the artery.

CAUSES
• Congenital: Primary connective disorders (Marfan's syndrome)
• Mechanical (hemodynamic): Poststenotic and arteriovenous fistula and amputation related
• Traumatic (pseudoaneurysms): Penetrating arterial injuries, blunt arterial (pseudoaneurysms)
• Infectious (mycotic): Bacterial, fungal, spirochetal infections
• Pregnancy-related degenerative:
• Nonspecific, inflammatory variant
• Anastomotic (postarteriotomy) and graft aneurysms: Infection, arterial wall failure, suture failure, graft failure
TYPES
v Normal artery.
v False aneurysm—actually a pulsating hematoma. The clot and connective tissue are outside the arterial wall,
v True aneurysm. One, two, or all three layers of the artery may be involved.
v Fusiform aneurysm—symmetric, spindle shaped expansion of entire circumference of involved vessel.
v Saccular aneurysm—a bulbous protrusion of one side of the arterial wall.
v Dissecting aneurysm—this usually is a hematoma that splits the layers of the arterial wall.
MEDICAL MANAGEMENT
• Antihypertensive agents, including:
ü Diuretics,
ü Beta blockers,
ü Ace inhibitors,
ü Angiotensin II receptor antagonists, calcium channel blockers
These drugs are frequently prescribed to maintain the patient's blood pressure within acceptable limits to prevent rupture
of the aneurysms
SURGICAL MANAGEMENT
• Resection of the vessel and sewing a bypass graft in place
• Endovascular grafting, which involves the transluminal placement and attachment of a sutureless aortic graft
prosthesis across an aneurysm

RESPIRATORY SYSTEM
ANATOMY
v Comprised of the upper airway and lower airway structures.
v Upper respiratory system
v Filters, moistens and warms air during inspiration.
• Nose
ü Serves as a passageway for air to pass to and from the lungs. It filters impurities and humidifies and
warms the air as it is inhaled
• Paranasal Sinuses
ü Prominent function of the sinuses is to serve as a resonating chamber in speech
• Pharynx
• Throat, is a tube-like structure that connects the nasal and oral cavities to the larynx
• Larynx
ü Voice organ, is a cartilaginous epithelium lined structure that connects the pharynx and the trachea.
ü The major function is for vocalization
• Trachea (Windpipe)
ü Serves as the passage between the larynx and the bronchi
v Lower respiratory system
v Enables the exchange of gases to regulate serum PaO2, PaCO2 and pH.
v Lungs
ü Paired elastic structures enclosed in the thoracic cage, which is an airtight chamber with distensible walls
• Pleura
ü Serous membrane that lined the lungs and wall of the thorax
• Bronchi and Bronchioles
• Alveoli
ü Basic gas-exchange unit of the respiratory system is the alveoli.
ü Alveolar stretch receptors respond to inspiration by sending signals to inhibit inspiratory neurons in the brain
stem to prevent lung over distention.
ü During expiration stretch receptors stop sending signals to inspiratory neurons and inspiratory is ready to start
again.
ü Oxygen and carbon dioxide are exchanged across the alveolar capillary membrane by process of diffusion.
ü Neural control of respiration is located in the medulla. The respiratory center in the medulla is stimulated by the
concentration of carbon dioxide in the blood.
ü Chemoreceptors, a secondary feedback system, located in the carotid arteries and aortic arch respond to
hypoxemia. These chemoreceptors also stimulate the medulla.
DISORDERS OF THE UPPER RESPIRATORY SYSTEM
RHINITIS
v A group of disorders characterized by inflammation and irritation of the mucous membranes of the nose
v Allergic rhinitis
• Further classified as seasonal rhinitis (occurs during pollen seasons) or perennial rhinitis (occurs
throughout the year)
• Commonly associated with exposure to airborne particles such as dust, dander, or plant pollens in people
who are allergic to these substances
ü Rhinorrhea (excessive nasal drainage, runny nose)
ü Nasal congestion
ü Sneezing
ü Pruritus of the nose, roof of the mouth, throat, eyes, and ears
• Management
ü Antihistamines
ü Corticosteroid nasal sprays
ü Desensitizing immunizations
• Nursing Intervention
ü Instruct the patient with allergic rhinitis to avoid or reduce exposure to allergens and irritants
ü Instructs the patient in correct administration of nasal medications
ü To achieve maximal relief, the patient is instructed to blow the nose before applying any medication into the
nasal cavity
VIRAL RHINITIS (COMMON COLD)

• Most frequent viral infection in the general population caused by coronavirus
• Highly contagious because virus is shed for about 2 days before the symptoms appear and during the first part of
the symptomatic phase
• Clinical Manifestation
ü Low-grade fever
ü Nasal congestion
ü Rhinorrhea and nasal discharge
ü Halitosis, sneezing
ü Tearing watery eyes
ü “Scratchy” or sore throat
ü General malaise, chills
ü Headache and muscle aches
• Management
ü Symptomatic therapy
ü Adequate fluid intake and rest
ü Prevention of chilling
ü Warm salt-water gargles to soothe the sore throat
ü NSAIDs to relieve aches and pains
ü Antihistamines are used to relieve sneezing, rhinorrhea, and nasal congestion
ü Inhalation of steam or heated, humidified air
ACUTE PHARYNGITIS
v A sudden painful inflammation of the pharynx, the back portion of the throat that includes the posterior third of the
tongue, soft palate, and tonsils
v Commonly referred to as a sore throat
• Fiery-red pharyngeal membrane and tonsils
• Swollen lymphoid follicles
• Enlarged and tender cervical lymph nodes
• Fever
• Malaise
• Sore throat
v Pharmacologic Therapy
• Penicillin is the treatment of choice
• Cephalosporins
• Macrolides
• Gargles with benzocaine may relieve symptoms
• Liquid or soft diet is provided during the acute stage
• Cool beverages, warm liquids, and flavored frozen desserts such as Popsicles are often soothing
• Warm saline gargles or throat irrigations
• Ice collar can relieve severe sore throats
• CBR during febrile stage
• Instruct the patient about preventive measures
CHRONIC PHARYNGITS
v Chronic pharyngitis is a persistent inflammation of the pharynx. It is common in adults, who work in dusty
surroundings, use their voice to excess, suffer from chronic cough, or habitually use alcohol and tobacco.
v Three types of chronic pharyngitis
• Hypertrophic – characterized by general thickening and congestion of the pharyngeal mucous membrane
• Atrophic – late stage of the first type (the membrane is thin, whitish, glistening, and at times winkled)

• Chronic Granular (“clergyman’s sore throat”) – characterized by numerous swollen lymph follicles on the
pharyngeal wall
• Constant sense of irritation or fullness in the throat
• Mucus that collects in the throat
• Difficulty swallowing
v Management
• Nasal sprays or medications containing ephedrine sulfate or phenylephrine hydrochloride
• Antihistamine decongestant medications
• Acetaminophen
• Instruct the patient to avoid contact with others until the fever subsides to prevent the spread of infection
• Avoidance of alcohol, tobacco, secondhand smoke, and exposure to cold or to environmental or occupational
pollutants
TONSILITIS AND ADENOIDITIS

• The tonsils are composed of lymphatic tissue and are situated on each side of the oropharynx
• The adenoids or pharyngeal tonsils consist of lymphatic tissue near the center of the posterior wall of the
nasopharynx
• Acute inflammation/infection that is usually caused by GABHS (group A beta-hemolytic streptococcus)
• Sore throat, fever, snoring and difficulty swallowing
• Enlarged adenoids may cause mouth-breathing, earache, draining ears, frequent head colds, bronchitis, foul-
smelling breath, voice impairment, and noisy respiration
v Management
• Penicillin (first-line therapy) or cephalosporins
• Tonsillectomy or adenoidectomy is indicated if the patient has had repeated episodes of tonsillitis despite
antibiotic therapy
v Nursing interventions (post-op)
• In the immediate postoperative period, the most comfortable position is prone, with the patient’s head turned
to the side to allow drainage from the mouth and pharynx
• Apply ice collar to the neck
• Assess for post op bleeding such as frequent swallowing
• Instruct the patient to refrain from coughing and too much talking
• Ice chips may be given to the patient
• Alkaline mouthwashes and warm saline solutions are useful in coping with the thick mucus and halitosis that
may be present after surgery
• Milk and milk products (ice cream and yogurt) may be restricted
• Provide soft, adequate diet
• Instruct the patient to avoid vigorous tooth brushing or gargling
• Encourage the use of a cool-mist vaporizer or humidifier in the home
• Instruct patient to avoid smoking and heavy lifting or exertion for 10 days
PERITONSILLAR ABSCESS (QUINSY)

v Most common major suppurative complication of sore throat/tonsillitis. This collection of purulent exudate between
the tonsillar capsule and the surrounding tissues, including the soft palate, may develop after an acute tonsillar
infection that progress to a local cellulitis and abscess
• Severe sore throat, fever trismus (inability to open the mouth), and drooling.
• Severe pain, raspy voice
• Odynophagia (a severe sensation of burning, squeezing pain while swallowing)
• Dysphagia (difficulty swallowing)
• Otalgia (pain in the ear), tender and enlarged cervical lymph nodes
• Airway obstruction may occur
Management
• Antimicrobial agents (Penicillin)
• Corticosteroid therapy
• Needle aspirations are performed to decompress the abscess
• Assist in performing intubation, cricothyroidotomy, or tracheotomy to treat airway obstruction
• Assist in needle aspiration when indicated
• Gentle gargling after the procedure with a cool normal saline gargle may relieve discomfort
• Provide cool liquids
• Instruct the patient to refrain from or cease smoking
• It is also important to reinforce the need for good oral hygiene
LARYNGITIS
v An inflammation of the larynx, often occurs as a result of voice abuse or exposure to dust, chemicals, smoke and
other pollutans
v Most common cause is virus, bacterial invasion may be secondary
v Clinical manifestations
• Hoarseness of voice – initial sign
• Aphonia (complete loss of voice)
• Severe cough
• Throat feels worse in the morning and improves when the patient is in a warmer climate
v Management
• Instruct the patient to rest the voice and avoid irritants (including smoking)
• Inhaling cool steam or an aerosol is provided
• Administer antibacterial therapy as ordered
• Topical corticosteroids may be given by inhalation
• Increased oral fluid intake
CANCER OF THE LARYNX

v Etiology
• Most tumors of the larynx are squamous cell carcinoma
• Men > women, age 60-70
• Cigarette smoking and alcohol consumption are associated with laryngeal cancer
• Hoarseness of voice for more than 2 weeks
• Persistent cough and sore throat
• Dyspnea
• Dysphagia
• Pain radiating to ear and burning sensation in the throat
• Weight loss
• Enlarged cervical lymph nodes
• Unilateral nasal obstruction
• Virtual endoscopy
• Optical imaging
• CT scan MRI
• Direct laryngoscopic examination
v Management
• Radiation therapy
• Chemotherapy
• Surgery:
ü Partial Laryngectomy – A portion of the larynx is removed, along with one vocal cord and the tumor
Complication: change in voice quality or hoarseness of voice
ü Total Laryngectomy – Laryngeal structures are removed, including the hyoid bone, epiglottis, cricoid
cartilage, and two or three rings of the trachea
Complication: permanent loss of voice, salivary leak, wound infection, stomal stenosis and dysphagia
v Nursing interventions
• Arrange for clients with larnygectomies to meet with members of support groups
• Establish a method for communication before surgery
• Maintain airway; have suction equipment at bedside
• Observe for signs of hemorrhage or infection
• Teach about tracheostomy and stoma care
• Assist with period of grieving
DISORDERS OF THE LOWER RESPIRATORY SYSTEM
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

v Refers to a disease characterized by airflow limitation that is not fully reversible. The airflow limitations is generally
progressive and is normally associated with an inflammatory response of the lungs due to irritants, COPD includes
chronic bronchitis and pulmonary emphysema
v Diagnostic Criteria: Cough of 3 months for 2 consecutive years
v Chronic Bronchitis
• Chronic inflammation of the lower respiratory tract characterized by excessive mucous secretion, cough, and
dyspnea associated with recurring infections of the lower respiratory tract characterized by three primary
symptoms: chronic cough, sputum production, and dyspnea on exertion
ü Blue bloater
ü Usually insidious, developing over a period of years
ü Presence of a productive cough lasting at least 3 months a year for 2 successive years
ü Production of thick, gelatinous sputum; greater amounts produced during superimposed infections
ü Wheezing and dyspnea as disease progresses
v Emphysema
• Complex lung disease characterized by destruction of the alveoli, enlargement of distal airspaces, and a
breakdown of alveolar walls. There is a slowly progressive deterioration of lung function for many years
before the development of illness
• 2 types:
ü Panlobular Emphysema – destruction of respiratory bronchiole, alveolar duct and alveolus
Ø All air spaces within the lobule are essentially enlarged, but there is little inflammatory disease
Ø Hyperinflated (hyperexpanded) chest, marked dyspnea on exertion, and weight loss typically occur
Ø Negative pressure is required during inspiration to move air into and out of the lungs
Ø Expiration becomes active and requires muscular effort
ü Centrilobular (Centroacinar) Emphysema – pathologic changes take place mainly in the center of the
secondary lobule, preserving the peripheral portions of the acinus
Ø There is a derangement of ventilation-perfusion rations, producing chronic hypoxemia, hypercapnia,
polycythemia, and episodes of right-sided heart failure
Ø Leads to central cyanosis and respiratory failure, and patient also develops peripheral edma
ü Pink puffer
ü Dyspnea, decreased exercise tolerance
ü Cough may be minimal, except with respiratory infection
ü Sputum expectoration
ü Barrel chest – Increased anteroposterior diameter of chest due to air trapping with diaphragmatic
flattening
v Diagnostic Procedure for COPD
• Spirometry - used to evaluate airflow obstruction
• ABG levels – decreased Pao2, pH, and increased CO2
• Chest X-ray – in late stages, hyperinflation, flattened diaphragm, increased retrosternal space, decreased
vascular markings, possible bullae
• Alpha-1-antitrypsin assay useful in identifying genetically determined deficiency in emphysema
v Medical Management for COPD
• Smoking cessation
• Bronchodilators to relieve bronchospasm
• Inhaled and systemic corticosteroids
• Alpha 1-antitrypsin augmentation therapy
• Antibiotic agents, Mucolytic agents Antitussive agents, vasodilators and narcotics

v Surgical Management
• Bullectomy – surgical removal of enlarged airspaces that do not contribute to ventilation but occupy space in
the thorax
• Lung Volume Reduction Surgery – removal of a portion of the diseased lung parenchyma
v Nursing Interventions For COPD
• Pulmonary rehabilitation to reduce symptoms, improve quality of life and increased physical and emotional
participation in everyday activities
• Pursed-lip breathing helps slow expiration, prevents collapse of small airways, and helps the patient control
the rate and depth of respiration
• Instruct the patient to coordinate diaphragmatic breathing with activities such as walking, bathing, bending, or
climbing stairs
• Provide small frequent meals and offer liquid nutritional supplements to improve caloric intake and counteract
weight loss
• Administer low flow of oxygen (1-2L/min)
• Administer bronchodilator as prescribed
• Adequately hydrate the patient
• Instruct the patient to avoid bronchial irritants
• If indicated, perform CPT int the morning and at night as prescribed
• Encourage alternating activity with rest periods
• Teach relaxation technique or provide a relaxation tape for patient
• Enroll patient in pulmonary rehabilitation program where available
• Monitor respiratory status, including rate and pattern of respirations, breath sounds, and signs and symptoms of
acute respiratory distress
BRONCHIAL ASTHMA
v Chronic inflammatory disease of the airways that causes airway hyperresponsiveness, mucosal edema, and mucus
production is reversible and diffuse airway inflammation that leads to airway narrowing
• Three most common symptoms of asthma:
ü Cough
ü Dyspnea
ü Wheezing
• Chest tightness, diaphoresis, tachycardia, and a widened pulse pressure, hypoxemia and central cyanosis
• There are two general classes of asthma medications:
ü Quick relief medications for immediate treatment of asthma symptoms and exacerbations
Ø Short-acting beta2-adrenergic agonists (albuterol [Proventil Ventolin], levalbuterol [Xopenex], and
pirbuterol [Maxair])
ü Long acting medications to achieve and maintain control of persistent asthma
Ø Corticosteroids
Ø Long-acting beta2-adrenegic agonists
Ø Leukotriene modifiers (inhibitors)
Ø Antileukotrienes, Montelukast (Singulair), zafirlukast (Accolate), and zileuton (Zyflo)
• Assesses the patient’s respiratory status by monitoring the severity of symptoms, breath sounds peak flow, pulse
oximetry, and vital signs
• Administer medications as prescribed and monitor the patient’s responses to those medications
• Administer fluids if the patient is dehydrated emphasize adherence to prescribed therapy, preventive measures,
and the need to keep follow-up appointments with health care providers
BRONCHIECTASIS
v A chronic, irreversible dilation of the bronchi and bronchioles
v Etiology
• Airway obstruction
• Diffuse airway injury
• Pulmonary infections and obstruction of the bronchus or complications of long-term pulmonary infections
• Generic disorders such as cystic fibrosis
• Abnormal host defense (eg, ciliary dyskinesia or humoral immunodeficiency)
• Idiopathic causes
• CT scan – reveals bronchial dilation
• Chronic cough with copious amount of purulent sputum
• Hemoptysis
• Clubbing of the fingers
• Repeated episodes of pulmonary infection
v Management
• Chest physiotherapy
• Bronchoscopy to remove mucopurulent sputum
• Antimicrobial therapy based on result of culture and sensitivity of the sputum
• Influenza and pneumococcal vaccines
• Bronchodilators
• Surgical interventions for patients who continue to expectorate large amount of sputum and hemoptysis
despite adherence to treatment regimen
v Nursing intervention
• Assess the patient in alleviating the symptoms and in clearing pulmonary secretions
• Encourage the patient in smoking cessation
• Educate the patient and his family in performing postural drainage
• Instruct the patient to avoid exposure to people with upper respiratory or other infection
• Assess nutritional status and ensure adequate diet
OCCUPATIONAL LUNG DISEASES

v Asbestosis is diffuse interstitial fibrosis of the lung caused by inhalation of asbestos dust and particles.
• Found in workers involved in manufacture, cutting and demolition of asbestos-containing materials
v Silicosis is a chronic pulmonary fibrosis caused by inhalation of silica dust
• Exposure to silica dust is encountered in almost any form of mining because the earth’s crust is composed of
silica and silicates (gold, coal, tin, copper mining); also stone cutting, quarrying, manufacture of abrasives,
ceramics, pottery, and foundry work
v Sarcoidosis
• Granulomatous disease in which clumps of inflammatory epithelial cells occur in many organs, primarily in lungs.
• Lymph node enlargement seen on chest X-ray
• Chronic cough; productive in silicosis
• Dyspnea on exertion; progressive and irreversible in asbestosis
• Susceptibility to lower respiratory tract infections
• Bibasal crackles in asbestosis
v Management
• There is no specific treatment; exposure is eliminated, and the patient is treated symptomatically
• Give prophylactic isoniazid (INH) to patient with positive tuberculin test, because silicosis is associated with high
risk of TB
• Persuade people who have been exposed to asbestos fiber to stop smoking to decrease risk of lung cancer
• Keep asbestos worker under cancer surveillance; watch for changing cough, hemoptysis, weight loss, melena
• Bronchodilators may be of some benefit if any degree of airway obstruction is present
• Administer oxygen therapy as required
• Administer or teach self-administration of bronchodilators as ordered
• Encourage smoking cessation
• Advise patient on pacing activities to prevent fatigue
• Provide information to healthy workers on prevention of occupational lung disease

PENETRATING TRAUMA
v Pneumothorax
• Pneumothorax occurs when the parietal or visceral pleura is breached, and the pleural space is exposed to
positive atmospheric pressure
v Simple/Spontaneous Pneumothorax
• Occurs when air enters the pleural space through a breach of either the parietal or visceral pleura. Most
commonly, this occurs as air enters the pleural space through the rupture of a bleb or a bronchopleural fistula
v Traumatic Pneumothorax
• A traumatic pneumothorax occurs when air escapes from a laceration in the lung itself and enters the pleural
space or from a wound in the chest wall, it may result from blunt trauma (eg, rib fractures), penetrating chest or
abdominal trauma (eg, stab wounds or gunshot wounds), or diaphragmatic fear
v Open Pneumothorax
• One form of traumatic pneumothorax. It occurs when a wound in the chest wall is large enough to allow air to
pass freely in and out of the thoracic cavity with each attempted respiration
v Tension Pneumothorax
• Occurs when air is drawn into the pleural space from a lacerated lung or through a small opening or wound in the
chest wall. It may be a complication of other types of pneumothorax. The air that enters the chest cavity with
each inspiration is trapped. this causes the lung to collapse and the heart, the great vessels, and the trachea to
shift toward the unaffected side of the chest (mediastinal shift)
• Hyperresonance; diminisher breath sounds
o Reduced mobility of affected half of thorax
• Tracheal deviation away from affected side in tension pneumothorax
o Clinical picture of open or tension pneumothorax is one of air hunger, agitation, hypotension, cyanosis
and profuse diaphoresis
• Mild to moderate dyspnea and chest discomfort may be present with spontaneous pneumothorax
v Management
Spontaneous Pneumothorax
• Treatment is generally nonoperative if pneumothorax is not too extensive.
ü Observe and allow for spontaneous resolution for less than 50% pneumothorax in otherwise healthy person.
ü Needle aspiration or chest tube drainage may be necessary to achieve re-expansion of collapsed lung if
greater than 50% pneumothorax
• Surgical intervention by pleurodesis or thoracotomy with resection of apical blebs is advised for patients with
recurrent spontaneous pneumothorax
Tension Pneumothorax
• Immediate decompression to prevent cardiovascular collapse by thoracentesis or chest tube insertion to let air
escape
• Chest tube drainage with underwater-seal suction to allow for full lung expansion and healing
Open Pneumothorax
• Close the chest wound immediately to restore adequate ventilation and respiration
ü Patient is instructed to inhale and exhale gently against a closed glottis (Valsalva maneuver) as a pressure
dressing (petroleum gauze secured with elastic adhesive) is applied. This maneuver helps to expand
collapsed lung
• Chest tube is inserted and water-seal drainage set up to permit evacuation of fluid/air and produce re-expansion
of the lung
• Surgical intervention may be necessary to repair trauma
v Nursing Intervention
• Apply petroleum gauze to sucking chest wound
• Assist with emergency thoracentesis or thoracostomy
• Position patient upright if condition permits to allow greater chest tubes
• Maintain patency of chest tubes
• Assist patient to splint chest while turning or coughing and administer pain medications as needed
• Monitor oximetry and ABG levels to determine oxygenation
• Provide oxygen as needed

PLEURAL CONDITIONS
PLEURAL EFFUSION
v Collection of fluid (transudate or exudate) in the pleural space
v Maybe a complication of heart failure, pulmonary infection or nephrotic syndrome
v Usually caused by underlying disease
• Dyspnea
• Difficulty lying on flat
• Coughing/fever
• Chills
• Pleuritic chest pain
• CT scan
• Lateral Decubitus X-ray
v Management
• Treatment of underlying disease
• Thoracentesis or chest tube drainage is performed
• Surgical pleurectomy for pleural effusion caused by malignancy
• Pleuroperitoneal shunt – fluids from the pleural space is drain into the peritoneum
• Assist in thoracentesis
• Record the amount of fluid aspirated and send it to the laboratory
• Administer medications as ordered such as analgesics and antibiotics
• Assist the patient in a comfortable position
HEMOTHORAX
v Blood in pleural space as a result of penetrating or blunt chest trauma
v Accompanies a high percentage of chest injuries
v Can result in hidden blood loss
v Patient may be asymptomatic, dyspneic, apprehensive, or in shock
v Management
• Assist with thoracentesis to aspirate blood from pleural space
• Assist with chest tube insertion and set up drainage system for complete and continuous removal of blood and air
ü Auscultate lungs and monitor for relief of dyspnea
ü Monitor amount of blood loss in drainage
v Replace volume with I.V. fluids or blood products
PLEURISY (PLEURITIS)
v Inflammation of both layers of the pleurae (parietal and visceral)
v May develop in conjunction with pneumonia or an upper respiratory tract infection, TB or collagen disease
v When the inflamed pleural membranes rub together during respiration (intensified on inspiration), the result is
severe, sharp, knifelike pain
• Pleuritic pain during deep breath, coughing or sneezing
• Pain is limited in distribution rather than diffuse
• Pleural friction rub can be heard with stethoscope
• Chest X-ray
• Sputum Analysis
• Thoracentesis
• Pleural Biopsy
v Management
• Treatment of underlying condition causing pleurisy
• Topical applications of heat or cold
• Indomethacin for pain relief
• Intercostal Nerve Block if pain is severe

• Instruct the patient in heat/cold application for pain relief
• Instruct the patient to turn onto the affected side to splint the chest wall and reduce the stretching of the
pleauare
• Teach the patient to use hands or pillow to splint the ribcage while coughing
EMPYEMA THORACIS
v Accumulation of purulent fluid in the pleural space
v Occur as complication of bacterial pneumonia, lung abscess or chest trauma
v Patient is acutely ill and has signs and symptoms similar to acute respiratory infection
v Diagnosis is established by chest CT
v Main objective is to drain the fluid in the pleural cavity
v Thoracentesis is done if fluid is not too thick
v Tube Thoracostomy is done to patients with loculated or complicated pleural effusions
v Open chest drainage via thoracotomy is done to remove thickened pleura, pus and debris
v Nursing intervention: provide care specific to the method of drainage of the pleural fluid
INFECTIOUS DISEASES OF THE LOWER RESPIRATORY TRACT
PNEUMONIA
v Inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria, fungi and
viruses
v Community-Acquired Pneumonia
• Occurs either in the community setting or within the first 48 hours after hospitalization or institutionalization
v Hospital-Acquired Pneumonia
• Also known as nosocomial pneumonia, is defined as the onset of pneumonia symptoms more than 48 hours
after admission in patients with no evidence of infection at the time of admission
v Aspiration Pneumonia
• Refers to the entry pulmonary consequences resulting from entry of endogenous or exogenous substances into
the lower airway
v Clinical Manifestation
• Sudden onset, rapidly rising fever of 38.3°C to 40.5°C
• Cough productive of purulent sputum
• Pleuritic chest pain aggravated by deep respiration/coughing
• Dyspnea, tachypnea accompanied by respiratory grunting, nasal flaring use of accessory muscles of respiration
fatigue
• Rapid, bounding pulse
• Orthopnea
• Rusty, blood-tinged sputum
• Poor appetite, diaphoresis
• Chest X-ray shows presence/extent of pulmonary disease typically consolidation.
• Gram stain and culture and sensitivity test of sputum may indicate offending organism
• Blood culture detects bacteremia (bloodstream invasion) occurring with bacterial pneumonia
v Management
• Administration of the appropriate antibiotic as determined by the results of a Gram stain
ü S. pneumonia – macrolide antibiotic (azithromycin, clarithromycin, or erythromycin)
ü Pseudomonas infection – anti pneumococcal, antipseudomonal beta-lactam
• Treatment of viral pneumonia is primarily supportive
• Oxygen therapy if patient has inadequate gas exchange
v Complications
• Shock and respiratory failure
• Pleural Effusion
• Encourage coughing and deep breathing after chest physiotherapy, splinting the chest if necessary
• Maintain semi-Fowler’s position
• Promote hydration (2-3 L/day) to liquefy secretions
• Teach effective coughing techniques to minimize energy expenditure; plan rest periods
• Suction if necessary
• Instruct client to cover nose and mouth when coughing
• Teach the need to continue entire course of antimicrobial therapy which is usually seven to ten days
• Teach the patient about proper administration of antibiotics and potential side effects
• Teach that findings are expected to be less within 48 to 72 hours of initial therapy
• Nutritionally enriched drinks or shakes maybe helpful in maintaining nutrition
PULMONARY TUBERCULOSIS
v Tuberculosis (TB) is an infectious disease that primarily affects the lung parenchyma. It also may be transmitted to
other parts of the body, including the meninges, kidneys, bones and lymph nodes
v The primary infectious agent, M, tuberculosis, is an acid-fast aerobic rod that grows slowly and is sensitive to heat
and ultraviolet light spreads from person to person by airborne transmission
• Fatigue, anorexia, weight loss, low-grade fever, night sweats
• Some patients have acute febrile illness, chills, and flu-like symptoms
• Cough (insidious onset) progressing in frequency and producing mucoid or mucopurulent sputum
• Hemoptysis, chest pain, dyspnea (indicates extensive involvement)
v Diagnostic Evaluation
• Sputum smear/Sputum culture confirms a diagnosis of TB
• Chest X-ray to determine presence and extent of disease
• Tuberculin skin test (purified protein derivative [PPD] or Mantoux test)
v Classification
• Data from the history, physical examination, TB test, chest x-ray, and microbiologic studies are used to classify
TB into one of five classes. A classification scheme provides public health officials with a systematic way to
monitor epidemiology and treatment of the disease
ü Class 0: no exposure; no infection
ü Class 1: exposure; no evidence of infection
ü Class 2: latent infection; no disease (eg, positive PPD reaction but no clinical evidence of active TB)
ü Class 3: disease; clinically active
ü Class 4: disease; not clinically active
ü Class 5: suspected disease; diagnosis pending
v Management
• Pulmonary TB is treated primarily with antituberculosis agents for 6 to 12 months
• The initial phase consists of a multiple-medication regime of INH, rifampin, pyrazinamide, and ethambutol and is
administered daily for 8 weeks
• Continuation phase of treatment include INH and rifampicin and lasts for an additional 4 or 7 months
• Vitamin B (pyridoxine) is usually administered with INH to prevent IHN-associated peripheral neuropathy
FIRST-LINE ANTITUBERCULOSIS MEDICATIONS

Commonly Adult Daily Dosage Most Common Side Effects
Used Agents
Isoniazid (INH) 5 mg/kg (300 mg maximum Peripheral neuritis, hepatic enzyme elevation, hepatitis,
daily) hypersensitivity
Rifampicin 10 mg/kg (600 mg maximum Hepatitis, febrile reaction, purpura (rare), nausea, vomiting
daily)
Pyrazinamide 15-30 mg/kg (2.0 g maximum Hyperuricemia, hepatotoxicity, skin rash, arthralgias, GI
daily) distress

Ethambutol 15-25 mg/kg (no maximum Optic neuritis (may lead to blindness; very rare at 15 mg/kg),
(Myambutol) daily dose, but base on lean skin rash
body)
• Instructs the patient to increase fluid intake and about correct positioning to facilitate airway drainage
• Discuss the medications schedule and side effects of the drugs
• Instructs the patient to take the medication either on an empty stomach or at least 1 hour before meals
because food interferes with medication absorption
• Patients taking INH should avoid foods that contain tyramine and histamine because it may result in
headache, flushing, hypotension, lightheadedness, palpitations, and diaphoresis
• Monitors for side effects of anti-TB drugs
• Encourage rest and avoidance of exertion
• Provide nutritional plan that allows for small, frequent meals
• Instruct the patient about important hygiene measures, including mouth care, covering the mouth and nose
when coughing and sneezing, proper disposal of tissues, and hand washing
ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)

v Severe form of acute lung injury. This clinical syndrome is characterized by a sudden and progressive pulmonary
edema, increasing bilateral infiltrates on chest x-ray, hypoxemia unresponsive to oxygen supplementation regardless
of the amount of Positive End-Expiratory Pressure (PEE) and the absence of an elevated left atrial pressure
v Patients often demonstrate reduced lung compliance
• Typically develops over 4 to 48 hours
• Severe dyspnea, severe hypoxemia
• Arterial hypoxemia that does not respond to supplemental oxygen
• Chest x-ray are similar to those seen with cardiogenic pulmonary edema
• Increased alveolar dead space
• Severe crackles and rhonchi heard on auscultation
• Labored breathing and tachypnea
v DIAGNOSTICS
• Clinical presentation and history of findings
• Hypoxemia on ABG despite increasing inspired oxygen level
• Chest x-ray shows bilateral infiltrates
• Plasma Brain Natriuretic Peptide (BNP)
• Echocardiography
• Pulmonary Artery Catheterization
v Management
• Treatment of the underlying condition
• Optimize oxygenation
• Intubation and mechanical ventilation
• Sedation may be required
• Paralytic agents may be necessary
• Antibiotics, as indicated
• PEEP usually improves oxygenation
• Supportive drugs includes surfactant replacement therapy, pulmonary antihypertensive agents and antisepsis
agent
• Requires close monitoring in the intensive care unit
• Assess the patient’s status frequently to evaluate the effectiveness of the treatment
• Turn the patient frequently to improve ventilation and perfusion in the lungs and enhance drainage secretions
• Res is essential for patient to limit oxygen consumption and reduce oxygen needs
• Adequate nutritional support is vital, 35 to 45 kcal/kg/day is required to meet caloric requirements
• Identify problems with ventilation that may cause anxiety reaction to the patient

PULMONARY EMBOLISM
v Refers to the obstruction of the pulmonary artery or one of its branches by a thrombus (or thrombi) that originates
somewhere in the venous system in the right side of the heart
v Often associated with trauma, surgery (orthopedic, major abdominal, pelvic, gynecologic, pregnancy, heart failure,
age older than 50 years, hypercoagulable states, and prolonged immobility
• Dyspnea is the most frequent symptom
• Chest pain (sudden and pleuritic), may be substernal and any mimic angina pectoris or a myocardial
infarction.
• Petechiae over the chest
• Anxiety, fever, tachycardia and apprehension
• Cough, diaphoresis, hemoptysis, and syncope. The most frequent sign is tachypnea
• Chest x-ray – shows infiltrates, atelectasis, elevation of the diaphragm on the affected side
• ECG – shows sinus tachycardia, PR-interval depression and nonspecific T-wave changes
• Arterial blood gas analysis – shows hypoxemia and hypocapnia
• Ventilation-perfusion (V/Q.) scan
• Pulmonary angiography is considered the best method to diagnose PE
• Spiral computed CT scan of the lung
v Management
• Treatment goal is to dissolve the existing emboli
• Improve respiratory and vascular status, anticoagulation therapy, thrombolytic therapy, and surgical
intervention
• Stabilize the cardiopulmonary system
• Nasal oxygen is administered immediately to relieve hypoxemia, respiratory distress, and central cyanosis
• Intravenous infusion lines are inserted to establish routes for medications or fluids that will be needed
• Hypotension is treated by a slow infusion of dobutamine (Dobutrex), which has a dilating effect on the
pulmonary vessels and bronchi, or dopamine (Intropin)
• Small doses of IV morphine or sedatives are administered to relieve patient anxiety, to alleviate chest
discomfort, to improve tolerance of the endotracheal tube, and to ease adaptation to the mechanical
ventilator
• Anticoagulant therapy (heparin, warfarin sodium
• Coumadin has traditionally been the primary method for managing PE
• Thrombolytic therapy (urokinase, streptokinase, alteplase) is used in treating PE, particularly in patients who
are severely compromised
• Surgical embolectomy is performed if the patient has massive PE.
• Monitor oxygen therapy and assess the patient for hypoxia
• Watch patient for signs of discomfort and pain
• Assess patient for bleeding related to anticoagulant or thrombolytic therapy
• Advise patient of the possible need to continue taking anticoagulant therapy
• Monitor for potential complication of cardiogenic shock or right ventricular failure
• Encourage ambulation and active/passive leg exercises to prevent venous stasis
• Advise the patient not to sit or lie in bed for prolonged periods, not to cross the legs, and not to wear
constrictive clothing

GASTROINTESTINAL SYSTEM
DEFINITION
v 23-26 foot long pathway that the:
• Mouth
• Esophagus
• Stomach
• Small intestines
• Large intestines
• Rectum
• Anus
ESOPHAGUS
v Located in the mediastinum, anterior to the spine and posterior to the trachea
v Approximately 25cm in length
v Tube connecting the mouth to the stomach
STOMACH
v Distensible pouch into which the food bolus passes to be ingested by gastric enzymes
v Hollow muscular organ with a capacity of approximately 1500mL
v Stores food during eating
SMALL INTESTINE
v Longest segment of the GI tract where the process of absorption of nutrients takes place
v Consisting of three parts:
• Duodenum
• Jejunum
• Ileum
LARGE INTESTINE
v The portion of the GI tract into which waste material from the small intestine passes as absorption continues and
elimination begins
v Consists of several parts:
• Ascending colon
• Transverse colon
• Descending colon
• Sigmoid colon
• Rectum
FUNCTIONS OF THE DIGESTIVE SYSTEM
Digestion
v Occurs when digestive enzymes and secretions mix with ingested food and when proteins, fats and sugars are
broken down into their component smaller molecules.
Absorption
v Occurs when small molecules, vitamins, and minerals pass through the walls of the small and large intestine and
into the bloodstream
Elimination
v Occurs after digestion and absorption, when waste products are evacuated from the body
v Chewing and swallowing
• 1st process of digestion
• Approximately 1.5 L of saliva is secreted daily from the parotid, the submaxillary, and the sublingual glands
• Salivary amylase
ü Is an enzyme that begins the digestion of starches
• Swallowing begins as a voluntary act that is regulated by the swallowing center in the medulla oblongata of
the central nervous system.
v Gastric Function
• Secretes highly acidic fluid in response to the presence of anticipated ingestion of food (hydrochloric acid)
• Intrinsic Factor
ü Secreted by the gastric mucosa, combines w/ dietary vitamin B12
• Pepsin
ü An important enzyme for protein digestion.

ü End-product of the conversion of pepsinogen from the chief cells.
• Food remains in the stomach for variable length of time, from 30 minutes to several hours, depending on
the:
ü Volume
ü Osmotic pressure
ü Chemical composition of the gastric contents.
v Small Intestine Function
• Secretions contain digestive enzymes:
ü Amylase
Ø Aids in digesting starch
ü Lipase
Ø Aids in digesting fats
ü Trypsin
Ø Aids in digestion of protein
ü Bile
Ø Secreted by the liver and stored in the gallbladder
Ø Aids in emulsifying ingested fats
Ø Making them easier to digest and absorb.
• Intestinal secretions total approximately 1L/day of pancreatic juice, 0.5 L/day of bile, and 3 L/day of secretions
from the glands of small intestine.
• Two types of contractions occur regularly in the small intestines:
ü Segmentation contractions
Ø Produce mixing waves that move the intestinal contents back and forth in a churning motion.
ü Intestinal peristalsis
Ø Propels the contents of the small intestine toward the colon
v Colonic Function
• Bacteria assist in completing the breakdown of waste material, especially of undigested or unabsorbed pro
and bile salts.
• The slow, weak peristaltic activity along the tract allows for efficient reabsorption of water and electrolytes,
which is the primary purpose of the colon.
• Intermittent, strong peristaltic waves propel the contents and eventually reach the rectum, usually in about
12 hours
v Physical examination:
• Inspection
• Auscultation
• Percussion
• Palpation
v Order of Palpation
• Right Lower Quadrant
• Right Upper Quadrant
• Left Upper Quadrant
• Left Lower Quadrant
v Right Hypochondriac
• Right lobe of the liver
• Gallbladder
• Part of the duodenum
• Hepatic flexure of colon
• Upper half of the right kidney
• Suprarenal gland
v Epigastric
• Aorta
• Pyloric end of stomach
• Pancreas
• Part of live
v Left hypochondriac
• Stomach
• Spleen
• Tail of pancreas
• Splenic flexure of the colon
• Upper half of the left kidney
• Suprarenal gland
v Right Lumbar
• Ascending colon
• Lower half of right kidney
• Part of duodenum and jejunum
v Umbilical
• Omentum
• Mesentery
• Lower part of duodenum
• Part of jejunum and ileum
v Right Inguinal
• Cecum
• Appendix
• Lower end of the ileum
• Right ureter
• Right spermatic cord
• Right ovary
v Hypogastric
• Ileum
• Bladder (if enlarged)
• Uterus (if enlarged)
v Left Inguinal
• Sigmoid colon
• Left ureter
• Left spermatic cord
• Left ovary
Diagnostic Studies
UPPER GI SERIES
v Delineates the entire GI tract after the introduction of a contrast agent (Barium swallow)
v Enables the examiner to detect or exclude anatomic or functional derangement of the upper GI organs or
sphincters.
v Also aids in the diagnosis of ulcers, varices, tumors, regional enteritis, and malabsorption syndromes
• Clear liquid diet with NPO from midnight the night before the study.
• Smoking, chewing gum, and mints can stimulate gastric motility, so the nurse advises against these practices
• Increase fluid intake to facilitate evacuation of stool and the radiopaque liquid
• Typically, oral medications are withheld on the morning of the study and resumed that evening, but each
patient's medication regimen is evaluated on an individual basis
LOWER GI SERIES
v Visualization of the lower GI tract
v With introduction of barium enema
v The procedure usually takes about 15 to 30 minutes, during which time x-ray images are obtained
v The patient must be assessed for allergy to iodine or contrast agent.
• Emptying and cleansing the lower bowel prior to the procedure
• Low residue diet 1 to 2 days before the test
• Clear liquid diet, NPO after midnight; and cleansing enemas until returns are clear the following morning.
• Laxative is given before and after the procedure.
• Increased fluid intake after the procedure.
• Evaluation of bowel movement for evacuation of barium

ESOPHAGO-GASTRO-DUODENOSCOPY (EGD)
v Direct visualization
• Esophageal
• Gastric
• Duodenal mucosa through a lighted endoscope
v After the patient is sedated, the endoscope is lubricated with a water-soluble lubricant and passed smoothly and
slowly along the back of the mouth and down into the esophagus
v The procedure usually takes about 30 minutes.
v The patient may experience:
• Nausea
• Gagging
• Choking
v Use of topical anesthetic agents and moderate sedation makes it important to monitor and maintain the patient's
oral airway during and after the procedure.
v Precautions must be taken to protect the scope, because the fiberoptic bundles can be broken if the scope is bent
at an acute angle.
v The patient wears a mouth guard to keep from biting the scope.
v Nursing Interventions:
• The patient should be NPO for 8 hours prior to the examination.
• Before the introduction of the endoscope, the patient is given a local anesthetic gargle or spray.
• Midazolam (Versed), a sedative that provides moderate sedation and relieves anxiety during the
procedure
• Atropine may be administered to reduce secretions, and glucagon may be administered to relax smooth
muscle.
• The patient is positioned in the left lateral position to facilitate clearance of pulmonary secretions and
provide smooth entry of the scope.
• After gastroscopy, assessment includes
ü Level of consciousness
ü Vital signs
ü Oxygen saturation
ü Pain level
• Monitor for signs of perforation
ü Pain
ü Bleeding
ü Unusual difficulty swallowing
ü Rapidly elevated temperature
• After the patient's gag reflex has returned, lozenges, saline gargle, and oral analgesic agents may be
offered to relieve minor throat discomfort
• Patients who were sedated for the procedure must remain in bed until fully alert
Endoscopic Retrograde Cholangio-pancreatography (ERCP)

v Visualization of the common bile duct, the Pancreatic, hepatic ducts through the Ampulla of Vater in the
duodenum
v Uses the endoscope in combination with X-ray techniques to view the ductal structures of the biliary tracts.
COLONOSCOPY
v Direct visual inspection of the large intestine (anus, rectum, sigmoid, transverse, descending and ascending
colon)
v Therapeutically, the procedure can be used to remove all visible polyps with a special snare and cautery through
the colonoscope.
LAPAROSCOPY
v Direct visualization of the organs and structures within the abdomen, permitting visualization and identification of
any growths, anomalies, and inflammatory processes.
v A pneumoperitoneum (injecting carbon dioxide into the peritoneal cavity to separate the intestines from the pelvic
organs) is created
v Biopsy samples can be taken from the structures and organs as necessary
v Laparoscopy usually requires general anesthesia and sometimes requires that the stomach and bowel be
decompressed
ESOPHAGEAL DISORDERS
GASTROESOPHAGEAL REFLUX DISEASE (GERD)

v Excessive back-flow of gastric and duodenal contents into the esophagus due to incompetent lower esophageal
sphincter
v Clinical Manifestation:
• Burning sensation in the esophagus (Pyrosis)
• Dyspepsia (Indigestion)
• Dysphagia
• Hypersalivation
• Esophagitis
Note: The symptoms may mimic those of a heart attack. The patient's history aids in obtaining an accurate diagnosis.
v Diagnostic Procedures:
ü Endoscopy or barium swallow Ambulatory 12 to 36 hour esophageal pH monitoring
ü Bilirubin Monitoring (Bilitec)
v Pharmacologic Management:
ü Antacids- neutralize acid
v H2 receptor antagonist
ü Decreases amount of HCI produced by stomach by blocking action of histamine on histamine receptors of
parietal cells in the stomach
• Proton Pump Inhibitors
ü Decreases gastric acid secretion by slowing the ATPase pump on the surface of the parietal cells
ü More potent than H2 receptor antagonists
• Prokinetic agents
ü Enhancing colonic transit by increasing propulsive motor activity
ü Teaching the patient to avoid actions that decrease lower esophageal sphincter pressure or cause esophageal
irritation
ü Low fat diet
ü Maintain normal body weight
ü Avoid caffeine, tobacco, beer, milk, and carbonated drinks, spicy foods
ü Avoid eating/drinking 2hours before bedtime.
ü Avoid tight fitting clothes
ü Elevate head of bed on 6 to 8 inches.
ü Avoid lying after meals
v Surgical Management:
ü Nissen Fundoplication
ü Wrapping of a portion of the gastric fundus around the sphincter area of the esophagus.
BARRETT'S ESOPHAGUS
ü A condition in which the lining of the esophageal mucosa is altered.
ü Associated with GERD
ü Reflux causes changes in the lining of the lower esophagus.
ü The cells that are laid to cover the exposed area are no longer squamous in origin
ü Precursor to esophageal cancer
ü Burning sensation in the esophagus (Pyrosis)
ü Dyspepsia (Indigestion)
ü Dysphagia
ü Hypersalivation
ü Esophagitis

v Diagnostic Procedure:
ü Esophagogastroduodenoscopy (EGD)
ü Biopsy
v Management:
• Photodynamic therapy
ü Laser thermal ablation; destroy the metaplastic cells
• Esophagectomy
ü Total resection of the esophagus with removal of the tumor plus a wide tumor-free margin of the
esophagus and the lymph nodes the area.
HIATAL HERNIA
v The opening in the diaphragm through which the esophagus passes becomes enlarged and part of the
upper stomach tends to Move up into the lower portion of the thorax.
v Types:
• Sliding
ü Upper stomach and the gastroesophageal junction are slide displaced upward and out of the thorax.
• Paraesophageal
ü All or part of the stomach pushes through the diaphragm beside the esophagus
• Heartburn
• Regurgitation
• Dysphagia
• Sense of fullness after eating or chest pain
• Xray studies
• Barium swallow
• Fluoroscopy
v Management:
• Same pharmacological management with GERD
• Small frequent feedings
• Patient is advised not to recline for 1 hour after eating
• Elevate head of bed
• Surgery is indicated in about 15% of patients.
v Surgical management:
• Nissen Fundoplication
GASTRITIS
v Inflammation of the gastric mucosa
Causes:
• Repeated exposure to irritating agents (e.g. highly seasoned foods)
• Overuse of aspirin and other non-steroidal anti-inflammatory drugs Excessive alcohol intake
• Bile reflux
• Radiation therapy
• Ingestion of strong acid or alkali
• Bacteria (helicobacter pylori)
DUODENAL ULCER GASTRIC ULCER

INCIDENCE -usually 50 and over
-Age 30-60 -15% of peptic ulcers
-80% of peptic ulcers
SIGNS, SYMPTOMS, AND CLINICAL FINDINGS
Hypersecretion of HCI Normal to hyposecretion of HCI
May have weight gain Weight loss may occur
Pain occurs 2-3 hrs after meal Pain occurs ½ -1 hr after meals
Vomiting uncommon Vomiting common
Hemorrhage less likely than gastric ulcer Hemorrhage more likely to occur

Melena more common than hematemesis Hematemesis more common than melena
Relieved by eating Aggravated by eating
MALIGNANCY POSSIBILITY -occasionally
-rare
RISK FACTORS -H. pylori
-alcohol -gastritis
-smoking -alcohol
-stress -use of NSAID’s
-H. pylori -stress
• Abdominal discomfort
• Headache
• Lassitude
• N/V and hiccupping
• Heartburn after eating
• Intolerance to spicy or fatty foods
• Vitamin deficiency (Vit. B12)
• Belching
v Assessment and Diagnostic:
• Achlorhydria or hypochlorhydria (Absence or low levels of HCI)
• Can be determined by an upper GI series or endoscopy
• Tissue specimen (Biopsy)
v Medical Management:
• H2 blockers
• Antibiotics (Amoxicillin, Clarithromycin)
• Proton Pump Inhibitors
• Gastrojejunostomy
ü Anastomosis of jejunum to stomach to detour around the pylorus.
• Avoidance to gastric irritating agents
ü Alcohol
ü Spicy
ü Fatty foods
ü Aspirin
ü NSAID's until symptoms subside.
• Discourage caffeinated beverages.
• Be alert for indicator of hemorrhagic gastritis (hematemesis, tachycardia, hypotension.)
• Notify the physician if signs of hemorrhagic gastritis are present.
PEPTIC ULCER DISEASE

v Excavation that forms in the mucosa wall of
v The stomach, in the pylorus, or in the duodenum.
v Causes:
• Gram-negative bacteria (H. Pylori)
• Excessive secretion of HCL in the
• Stomach due to ingestion of caffeinated beverages, spicy foods, smoking, and alcohol
Zollinger-Ellison Syndrome
• Consists of severe peptic ulcers, extreme gastric hyperacidity, and gastrin-secreting benign or malignant tumors.
Medical Management:
• H2 Blockers (Ranitidine, Cimetidine)
• Antibiotics
• Proton Pump Inhibitors (Omeprazole)
• Antacid
• Cytoprotectants

üCreates a viscous substance in the presence of gastric acid that forms a protective barrier, binding to the
surface of the ulcer, and prevents digestion by pepsin
ü Misoprostol, Sucralfate
• Vagotomy and Pyloroplasty
ü Transecting nerves that stimulate acid secretion and opening the Pylorus
• Billroth I (Gastroduodenostomy)
ü Removal of the lower portion of the antrum of the stomach (which contains the cells that secrete gastrin)
as well as a small portion of the duodenum segment.
ü Upper portion of stomach anastomosed to duodenum.
• Billroth II (Gastrojejunostomy)
ü Removal of lower portion (antrum) of stomach with anastomosis to jejunum. A duodenal stump remains
and is oversewn.
• Stress reduction and rest
• Dietary modification
ü Avoidance to the food and beverages that irritate the gastric mucosa (alcohol, coffee, milk spicy foods, soft
drinks, tea, NSAID's, Aspirin)
DUMPING SYNDROME
v It is partially the result of rapid gastric emptying, which prevents adequate mixing with pancreatic and biliary
secretions.
v It is an unpleasant set of and GI symptoms that sometimes occur in patients who have had gastric surgery or a
form of vagotomy.
v Clinical Manifestations:
• Symptoms occurring 30 minutes after eating
• Nausea and vomiting
• Feelings of abdominal fullness and
• Abdominal cramping
• Diarrhea
• Palpitations and tachycardia
• Perspiration
• Weakness and dizziness
• Borborygmi Sound
• Steatorrhea- "fats in the stool"
v Management:
• Lie down after meals
• Avoid sugar, salt, and milk
• Take anti-spasmodic medications as prescribed to delay gastric emptying
• Fluid intake with meals is discouraged, instead fluids may be consumed up to 1 hour before or 1 hour after
mealtime.
• Meals should contain more dry items than liquid items.
• The patient can eat fat as tolerated but should keep carbohydrate intake low and avoid concentrated sources of
carbohydrate
INTESTINAL AND RECTAL DISORDERS

DIVERTICULAR DISEASE
• A sac-like herniation of the lining that of the bowel that extends through a defect in the muscle layer
• Most commonly occur in the sigmoid colon.
v Diverticulosis
o Multiple diverticula are present w/o inflammation or symptoms
v Diverticulitis
o Diverticulosis with inflammation
o Results when food and bacteria retained in a diverticulum produce infection.
• Bowel irregularity with intervals of diarrhea
• Nausea and anorexia
• Bloating or abdominal distention
• Narrow stools
• Increased constipation or at times intestinal obstruction
• Signs and symptoms of infection
• Colonoscopy
• Barium enema
• CT Scan (test of choice for diverticulitis, and can also reveal fiber abscesses)
• Abdominal x-rays
v Management:
• Antibiotics, analgesics and anticholinergics to reduce bowel spasms as prescribed
• An opioid (eg, Meperidine [Demerol]) is prescribed for pain relief.
• Morphine is contraindicated because it can increase intraluminal pressure in the colon, exacerbating symptoms.
• Instruct the client to refrain from lifting, straining, coughing, or bending to avoid increased intra-abdominal
pressure
• Diet:
ü For diverticulosis, soft, high fiber foods are indicated for diverticulosis.
ü For diverticulitis, a low fiber diet may be necessary until signs of infection decrease.
ü Monitor for perforation, hemorrhage, fistulas, and abscesses
ü Avoid gas forming foods
v Surgical Interventions:
• Colon resection with primary anastomosis
• Temporary or permanent colostomy may be required for increased bowel inflammation
INFLAMMATORY BOWEL DISEASES

CROHN'S DISEASE (REGIONAL ENTERITIS)
v Description:
• Subacute and chronic inflammation of the GI tract wall that extends through all layers, (transmural lesion)
• Most common in ileum and colon but can occur anywhere along the GI tract.
• Leads to thickening and scarring, a narrowed lumen, fistulas, ulcerations, and abscesses
• (Classic cobblestone appearance)
• Fever and leukocytosis
• Cramp-like and colicky pain after meals
• Diarrhea (Semi solid), which may contain mucus or pus
• Abdominal Distention
• Anorexia, nausea, and vomiting
• Weight loss
• Anemia
• Dehydration
• Electrolyte imbalances
ULCERATIVE COLITIS
v Recurrent ulcerative and inflammatory disease of the mucosal and submucosal layers of the colon and rectum
Risk Factors:
• Prevalence is highest in Caucasians and Jewish
• NSAIDs exacerbate IBD
• Anorexia
• Weight loss
• Diarrhea (10 to 20 liquid stools per day)
• Malaise
• Left lower quadrant abdominal
• Tenderness and cramping
• Rectal Bleeding
• Dehydration and electrolyte imbalances
• Anemia and hypocalcemia
• Vitamin K deficiency
Diagnostic Procedures:
• Colonoscopy
• Sigmoidoscopy
• Barium Enema
• CBC
• Abdominal X-ray
• Stool Examination
Management for Inflammatory Bowel Diseases:
• Pharmacologic Therapy
(Priority: Relieve inflammation.)
ü Salicylate Compounds
Ø Effective for mild or moderate inflammation and are used to prevent or reduce recurrences in long-term
maintenance regimens
ü Corticosteroids
Ø Are used to treat severe and fulminant disease and can be administered orally in outpatient treatment or
parenterally in hospitalized patients
ü Immunosuppressants
Ø Have been used to alter the immune response. The exact mechanism of action of these medications in
treating IBD is unknown
ü Anti—diarrheal drugs
Ø Are used to minimize peristalsis to rest the inflamed bowel. They are continued until the patient's stools
approach normal frequency and consistency.
• NPO status and administer fluids and electrolytes for acute episodes
• Diet
ü Low residue
ü High protein
ü High calorie diet
ü Supplemental vitamin therapy
ü Iron replacement.
• IV or via parenteral nutrition as prescribed
• Monitor for bowel perforation, peritonitis, and hemorrhage
• Avoid gas-forming food
v Surgical Interventions:
• Proctocolectomy with permanent ileostomy
ü An ileostomy, the surgical creation of an opening into the ileum or small intestine (usually by means
of an ileal stoma on the abdominal wall), is commonly performed after a total colectomy (ie, excision
of the entire colon).
• Continent Ileostomy (Kock ileostomy)
ü Creation of a continent ileal reservoir (ie, Kock pouch) by diverting a portion of the distal ileum to the
abdominal wall and creating a stoma
• Restorative Proctocolectomy
ü Surgical procedure of choice in cases where the rectum can be preserved in that it eliminates the
need for a permanent ileostomy. It establishes an ileal reservoir that functions as a "new" rectum,
and anal sphincter control of elimination is retained
• Ileoanal Anastomosis (Ileorectostomy)
ü Involves connecting the ileum to the anal pouch (made from a small intestine segment), and the
surgeon connects the pouch to the anus in conjunction with removing the colon and the rectal
mucosa
APPENDICITIS
v Inflammation of the appendix
v Appendix
• Small, fingerlike appendage about 10 cm (4 in) long that is attached to the cecum just below the ileocecal
valve.
v Risk factors:
• Between the ages of 10 and 30 years
v Causes:
• Kinked or occluded by a fecalith
• Tumor
• Foreign body
• Vague epigastric or periumbilical pain
• Right lower quadrant pain (ie, parietal pain that is sharp, discrete, and well localized)
• Low-grade fever
• Nausea and Vomiting
• Loss of appetite
• Rebound tenderness (ie, production or intensification of pain when pressure is released)
• Rovsing's sign may be elicited by palpating the left lower quadrant; this paradoxically causes pain to be felt
in the right lower quadrant
• Complete blood cell count- Increase WBC
• Abdominal x-ray films
• Ultrasound studies
• CT scans- right lower quadrant density
• Pregnancy test- to rule out ectopic pregnancy
v Complications:
• Perforation of the appendix
• Peritonitis
• Abscess formation (collection of purulent material)
• Portal pylephlebitis- septic thrombosis of the portal vein caused by vegetative emboli that arise from septic
intestines
v Pharmacologic Management
• IV fluids are administered
• Antibiotic therapy to prevent infection
• Morphine sulfate: prescribed to relieve pain.
• Appendectomy (ie, surgical removal of the appendix) is performed as soon as possible to decrease the risk of
perforation
ü Low abdominal incision (laparotomy)
ü Laparoscopy
• Perforation- place a drain in the abscess
• Post-operatively, the nurse places patient in a high- Fowler's position.
ü Reduces the tension on the incision and abdominal organs, helping to reduce pain.
• Discharge teachings:
ü Have the surgeon remove the sutures between the 5th and 7th days after surgery.
ü Incision care
ü Heavy lifting is to be avoided postoperatively
ü Normal activity can usually be resumed within 2 to 4 weeks.
HEMORRHOIDS
v Dilated portions of veins in the anal canal.
v Causes:
• 50 years of age
• Shearing of the mucosa during defecation
• Increased pressure in the hemorrhoidal tissue due to pregnancy
v Types:
• Internal hemorrhoids
ü Above the internal sphincter
• External hemorrhoids
ü Appearing outside the external sphincter
v Clinical manifestations:
• Itching
• Pain
• Bright red bleeding
• External hemorrhoids severe pain from the inflammation and edema caused by thrombosis
• Internal hemorrhoids are not usually painful until they bleed or prolapse when they become enlarged.
v Pharmacologic Management:
• Hydrophilic bulk-forming agents (Psyllium)
• Analgesic ointments and suppositories
• Astringents (eg, witch hazel)
v Non-Surgical & Surgical Management:
• Infrared photocoagulation
• Bipolar diathermy
• Laser therapy
• Injection of sclerosing agents
• Rubber-band ligation procedure
• Cryosurgical hemorrhoidectomy
• Hemorrhoidectomy
• Good personal hygiene
• Avoiding excessive straining during defecation
• High-residue diet that contains fruit and bran
• Increase fluid intake
• Warm compresses/Sitz baths
• Bed rest
HEPATOBILIARY SYSTEM
v Liver
• Largest gland of the body
• Divided into four lobes
ü Left
ü Right
ü Caudate
ü Quadrate
• Contains several cell types, including hepatocytes and Kupffer's cells
• Regulating blood glucose level by
• Making glycogen, which is stored in hepatocytes
• Converting ammonia produced from gluconeogeneticby-products and bacteria to urea
v Gall Bladder
• Pear-shaped organ attached to the liver under the right lobe.
• Normally holds 30-50m1 of bile and can hold up to 70 ml when fully distended
v Pancreas
• A slender, fish-shaped organ, that lies horizontally in the abdomen behind the stomach and extends roughly
from the duodenum to the spleen
• Endocrine and exocrine functions Has pancreatic juice:
ü Amylase
ü Lipase
ü Trypsin
DISORDERS OF THE LIVER, GALLBLADDER, AND PANCREAS

HEPATITIS
• Inflammatory disorder of the liver parenchyma
• Occurring in Hepatitis A, B, C, D, E, and toxic or drug-induced hepatitis
• Hepatocellular damage results from the body's immune response to the virus or toxin and is characterized by
diffuse inflammatory infiltration with local necrosis
• Pre-Icteric Stage
ü Earliest symptoms are not specific
ü Flu-like symptoms
ü Malaise
ü Fatigue
ü Headache
ü Myalgias
ü Anorexia
ü Nausea & vomiting
ü Diarrhea
• Icteric Stage
ü Few days to weeks after pre-icteric stage
ü Jaundice
ü Dark-colored urine
ü Light-colored stool
ü Steatorrhea
ü Enlarged liver
Viral hepatitis Mode of transmission Incubation Outcome
Hepatitis A Fecal-oral route In: 15-50 days Usually mild with recovery
Hepatitis B Parenterally; perinatal: In: 28-160 days May be severe

sexual
Hepatitis C Blood transfusion: sexual In: 15-160 days Frequent occurrence of chronic hepatic cancer carrier
transmission state and chronic liver disease.
Hepatitis D Same as HBV In: 21-140 days Similar to HBV but greater likelihood of carrier state
Hepatitis E Fecal-oral route In: 15 to 65 days Similar to HAV except very severe in pregnant women
• Post- Icteric Stage
ü Convalescent stage lasting a few weeks
ü Fatigue decreases
ü Appetite returns
• Liver function test results are elevated
• Serum bilirubin level is increased
• Urinalysis reveals increased bilirubin levels
v Management:
• Administer prescribed medications, which may include:
ü Immunoglobulins
ü Immunizations
ü Antiviral
• Prevent transmission of infection
• Promote adequate rest without complications
• Encourage proper nutrition
LIVER CIRRHOSIS
v Chronic liver disease marked by diffuse destruction and fibrotic regeneration of hepatic cells
v Classifications:
• Laennec’s Cirrhosis
ü Commonly caused by alcoholism and
ü Chronic nutritional deficiencies
• Biliary cirrhosis
ü Caused by bile duct disorders that suppress bile flow
• Post- hepatic cirrhosis
ü Caused by various types of hepatitis
• Enlarged, firm liver
• Chronic dyspepsia
• Constipation or diarrhea
•Gradual weight loss
•Ascites
•Splenomegaly
•Spider telangiectasis
•Caput Medusae
ü Dilated abdominal blood vessels
• Portal Hypertension
• Mental deterioration
v Laboratory and Diagnostic Findings:
• Liver biopsy
• Liver Scan
• Liver function test (ALT, AST)
• Serum protein levels
• Prothrombin time
v Management:
• Administer diuretics to decrease ascites.
• Promote adequate nutrition (Vitamins and nutritional supplements promote healing of damaged liver cells.)
• Prevent threats to skin integrity
• Minimize risk of bleeding
ü Antacid/ H2 antagonist to minimize possibility of GI bleeding
• Limit visitors, and orient the client to date, time, and place
• Avoid drinking alcoholic beverages Institute safety measures, such as raising side rails and assisting with
ambulation
• Diet:
ü Early Phase: High protein diet- to promote healing of the liver
ü Late Phase: Low protein diet- to decrease ammonia levels in the
PORTAL HYPERTENSION
v Elevated pressure in the portal vein associated with increased resistance to blood flow through the portal venous
system
v Obstruction of portal venous flow through the liver lead to:
• Formation of esophageal, and hemorrhoidal varicosities due to
ü Increased venous pressure
ü Accumulation of fluid in the abdominal cavity
• Ascites
• Rapid weight gain
• Shortness of breathing
• Fluid wave on abdominal percussion
• Liver dullness
• Dilated abdominal vessels radiating from umbilicus (caput medusa)
• Enlarged, palpable spleen
• Fluid and electrolyte imbalance
v Management:
• Bed rest
• Administering medications which may include diuretics
• Measure & record abdominal girth & body weight daily
• Promote measures to prevent or reduce edema
• Assist the health care provider with paracentesis
• Monitor serum ammonia and electrolyte levels.
ESOPHAGEAL VARICES
v Hemorrhagic process involving dilated, tortuous veins in the submucosa of the lower esophagus
v Caused by portal hypertension
• Hematemesis and melena
• Massive hemorrhage occurs
• Signs of hepatic encephalopathy
• Dilated abdominal veins
• Ascites
• History of Alcohol Abuse
v Diagnostics:
• Endoscopy
• Lab. Tests: ALT, AST,Bilirubin (increased)
• Portal Hypertension Measurements
v Management:
• Assess for ecchymosis, epistaxis, petechiae, and bleeding gums
• Monitor level of consciousness, vital signs, and urinary output to evaluate fluid balance
• Monitor the client during blood transfusion
• Provide nursing care for the client undergoing prescribed tamponade to control bleeding balloon
ü Sengstaken-Blakemore Tube
ü Four openings:
Ø Gastric aspirations
Ø Esophageal aspiration
Ø Gastric balloon inflation
Ø Esophageal balloon inflation
ü Instrument at the bedside- Scissors (Cut the tube in case of respiratory distress.)
ü The patient being treated with balloon tamponade must remain under close observation in the ICU because
of the risk of serious take complications. Precautions must be taken to ensure that the patient not pull on or
inadvertently displace the tube.
• Vasopressin- initial mode of therapy
• Sclerotherapy
ü After treatment for acute hemorrhage, the patient must be observed for bleeding, perforation of the
esophagus, aspiration pneumonia, and esophageal stricture
• Variceal Band Ligation
ü A modified endoscope loaded with an elastic rubber band is passed through a band directly onto the varix (or
varices) to be banded.
ü Complications:
Ø Superficial ulceration
Ø Dysphagia
Ø Transient chest discomfort
Ø Esophageal strictures
HEPATIC ENCEPHALOPATHY
v Neurologic syndrome that develops as a complication of liver disease
v It may be acute and self –limiting and progressing or chronic
v Incidence is similar to cirrhosis
Due to:
• Severe liver damage
• Hepatocellular failure
v Increased serum ammonia levels from:
• GI bleeding
• High-protein diet
• Bacterial growth in the intestine Uremia
v Pathophysiology:
Hepatic Insufficiency
↓
Inability to detoxify toxic by-products of metabolism (ammonia)
↓
Ammonia enters the brain
↓
Excites peripheral benzodiazepine-type receptors on astrocyte

cells
↓
Stimulates GABA
↓
Depression of Central Nervous System
↓
Encephalopathy
• Neurological dysfunction progressing from minor mental aberrations and motor disturbances to coma
• Flapping tremors/Liver flap (Asterixis)
ü The patient is asked to hold the arm out with the hand held upward (dorsiflexed). Within a few seconds,
the hand falls forward involuntarily and then quickly returns to the dorsiflexed position.
• Fetor hepaticus
ü A sweet, slightly fecal odor to the breath that is presumed to be of intestinal origin,
• Constructional Apraxia
ü Deterioration of handwriting and inability to draw a simple star figure occurs with progressive hepatic
encephalopathy.
• Serum ammonia level is elevated
• Serum bilirubin level is elevated
• Prothrombin time is prolonged
v Management:
• Administer prescribed medications which may include laxatives (Lactulose)
ü Ammonia is kept in the ionized state, resulting in a decrease in colon pH
ü Evacuation of the bowel takes place, which decreases the ammonia absorbed from the colon
ü The fecal flora are changed to organisms that do not produce ammonia from urea
• Administer antibiotics (Neomycin)
ü Reduce levels of ammonia-forming bacteria in the colon
• Closely monitor neurologic status for any changes
• Evaluate serum ammonia values daily
• Monitor for signs of impending coma.
• Reduce or eliminate the client's dietary protein intake if you detect evidence of impending coma.
• Monitor the client closely, and administer a conservative dose of prescribed sedative or analgesic medication,
because liver damage alters drug metabolism.
GALL BLADDER DISORDERS

v Risk Factors:
• Obesity
• Women especially who have had
• Multiple pregnancies or who are of Native American or U.S. Southwestern Hispanic Ethnicity
• Frequent changes on weight
• Rapid weight loss
• High dose estrogen
• Ileal resection or disease
• Cystic Fibrosis
• Diabetes mellitus
v Cholelithiasis
• Formation of calculi in the gallbladder
• Causes:
ü Result from changes in bile components or bile stasis, which may be associated with such factors as
infection, cirrhosis, and pancreatitis
v Cholecystitis
• Acute or chronic inflammation of the gallbladder
• Causes
ü Obstruction of the cystic duct by impacted gallstone
ü Tissue damage due to trauma, massive burns, or surgery
ü Gram-negative septicemia
ü Overuse of opioid analgesics
• Cholelithiasis
ü Episodic, cramping pain in the RUQ of the abdomen or the epigastrium, possibly radiating to the back
near the right scapular tip
ü Fat intolerance
ü Fever and leukocytosis
ü Jaundice
ü Epigastric distress
v Cholecystitis
ü Biliary colic
ü Tenderness and rigidity in the RUQ elicited on palpation
ü Murphy's sign- Pain on taking a deep breath when the examiner's fingers are on the approximate location
of the gallbladder.
ü Fever
ü Fat intolerance
ü Heart burn
ü Flatulence
ü Vitamin deficiency
v Diagnostic Tests:
• Abdominal X-ray
• Ultrasonography- diagnostic procedure
• of choice
• Cholescintigraphy- radioactive agent is administered intravenously
• Cholecystography- iodide containing contrast agent is administered before xray
• Endoscopic Retrograde
• Cholangiopancreatography (ERCP)
ü Permits direct visualization of structures that previously could be seen only during laparotomy
ü A fiberoptic duodenoscope, with side-viewing apparatus is inserted into the duodenum. The ampulla of
Vater is catheterized, and the biliary tree is injected with contrast agent
v Management:
• Pharmacologic Management
ü Ursodeoxycholic acid (UDCA [URSO, Actigall]) - dissolve small radiolucent gall stone
ü Administer prescribed medication, which may include analgesic {morphine sulfate} and antacids
• Nutritional therapy
ü Low-fat liquids
ü High in protein and carbohydrates
• Non-surgical Approach
ü Intra-corporeal Lithotripsy
Ø Stones in the gallbladder or common bile duct may be fragmented by means of laser pulse technology
ü Extracorporeal Shockwave Lithotripsy
Ø Non-invasive procedure; uses repeated shock waves directed at the gallstones in the gallbladder or common
bile duct to fragment the stones.
• Surgical Approach
ü Laparoscopic Cholecystectomy
Ø Performed through a small incision or puncture made through the abdominal wall at the umbilicus
ü Cholecystectomy
Ø Gall bladder is removed through an abdominal incision after the cystic duct and artery are ligated.
Ø A drain is placed close to the gall bladder if there is a bile leak, removed after 24 hours
Ø Bile duct injury-serious complication
ü Choledochostomy
Ø Making an incision in the common bile duct for removal of stones.
• Maintaining skin integrity and Promoting Biliary Drainage
ü If bile is not draining properly, an obstruction is probably causing the bile to be forced back into the liver or
bloodstream
ü To prevent loss of bile, the physician may want the drainage tube or collection receptacle elevated above the
level of the abdomen
ü Every 24 hours, the nurse measures the bile collected and records the amount, color and character of
drainage.
ü After several days of drainage, the tube may be clamped for 1 hour before and after each meal to deliver bile
to the duodenum to aid in digestion
ü Within 7 to 14 days, the drainage tube is removed.
ACUTE PANCREATITIS
v Self- digestion of the pancreas by its own proteolytic enzymes, principally trypsin
v Inflammation of the pancreas ranging from a relative mild, self-limiting disorder to rapidly fatal, acute
hemorrhagic pancreatitis
v Cause
ü Alcoholism
ü Cholecystitis
ü Surgery involving or near the pancreas
• Abdominal Tenderness with back pain
• GI problems, such as nausea, vomiting, diarrhea, and steatorrhea
• Fever
• Jaundice
• Mental confusion
• Flank or umbilical bruising
• Hypotension
• Signs of hypovolemia
• Internal bleeding:
ü Cullen's sign- bluish discoloration around the umbilicus
ü Turner's sign- discoloration lateral of the trunk or posteriorly
v Diagnostic Tests:
• Elevated amylase
• Lipase
• Increase WBC Levels
• Hypocalcemia
v Management:
• Administer prescribed medications, which include opioid or non-opioid analgesics histamine receptor antagonist
proton pump inhibitors
• Drug of Choice for pain: Morphine sulfate
• The client should avoid oral intake to inhibit pancreatic stimulation and secretion of pancreatic enzymes
• Maintain fluid and electrolyte balance
• Promote adequate nutrition
CHRONIC PANCREATITIS
v Progressive pancreatic inflammation resulting in permanent structural damage to pancreatic tissue
v Results from repeated episodes of acute pancreatitis
v More than half of chronic pancreatitis cases are associated with alcoholism
v Long term alcohol consumption causes hypersecretion of protein in pancreatic secretions, resulting in protein
plugs and calculi within the pancreatic ducts.
• Recurring attacks of severe upper abdominal and back pain
• Weight loss
• Steatorrhea
ü Stools become frequent, frothy, and foul-smelling because of impaired fat digestion, which results in stools
with a high fat content
• Anorexia
v Assessment and Diagnostics:
• Serum lipase and amylase elevated
• WBC elevated
• Endoscopic retrograde
• Cholangiopancreatography
ü Detects pancreatic calcification
• Glucose tolerance test values are abnormal
v Management:
• Administer prescribed medications, which include pancreatic enzymes,
• Non-opioid pain medications, antacids, histamine receptor antagonist, and proton-pump inhibitors
• Provide symptomatic treatment focusing on relieving pain, promoting comfort, and treating new attacks
• Emphasize the importance of avoiding alcohol, caffeine, and foods that tend to cause abdominal
discomfort
• Manage any endocrine insufficiency such as Diabetes Mellitus, by initiating dietary and insulin or oral
hypoglycemic therapy.
• Pancreatic jejunostomy (Roux-en-Y)
ü Joining of the pancreatic duct to the jejunum.
ü Allows drainage of the pancreatic duct to the jejunum.
• A Whipple resection (pancreaticoduodenectomy)
ü Can be carried out to relieve the pain of chronic pancreatitis
PERITONITIS
v Inflammation of the peritoneum, the serous membrane lining the abdominal cavity and covering the viscera.
v Cause:
• Bacterial infection
• Injury or trauma
• Inflammation that extends from an organ outside the peritoneal area
• Appendicitis
• Perforated ulcer
• Diverticulitis
• Bowel perforation
• Abdominal surgical procedures
• Peritoneal dialysis
• Diffuse pain, becomes constant localized and more intense on the site of maximal peritoneal irritation
• Muscles become rigid and tender
• Rebound tenderness
• Paralytic ileus
• Anorexia
• Pyrexia
• Increased pulse rate
v Diagnostic Findings:
• Increase WBC
• Altered levels of Potassium, Sodium and Chloride
• Abdominal Xray- distended bowel loops
v Management:
• Fluid, colloid, replacement
• Analgesics are prescribed for pain
• Antiemetics
• Intestinal intubation and suction
ü Relieves abdominal distention and promotes intestinal function
• Oxygen therapy by nasal cannula or mask
• Antibiotic therapy
•Removing the infected area
- Excision (ie, appendix)
- Resection (ie, intestine)
• Correcting the cause
- Repair (ie, perforation)
- Drainage (ie, abscess).
• Positioning the patient for comfort are helpful in decreasing pain
• Patient is placed on the side with knees flexed- decreases tension on the abdominal organs
• Drains are frequently inserted during the surgical procedure.
• Prevent dislodging of the drain

ENDOCRINE SYSTEM
MAJOR COMPONENTS
• Glands- secrete their products directly into the chemical substances secreted by the endocrine glands.
• Hormones- chemical substances secreted by the endocrine glands.
• Target cells/ receptor
FUNCTIONS OF HORMONES
• Regulates and integrates body’s metabolic activities.
• Functions together with the nervous system.
ENDOCRINE GLANDS
HYPOTHALAMUS
• Produce and secrete pro- hormones (hormones that stimulate or inhibit production/ release of pituitary
hormones.)
Hormones:
• Releasing and inhibiting hormones
o Corticotropin- releasing hormone (CRH)
o Thyrotropin- releasing hormone (TRH)
o Growth hormone- releasing hormone (GHRH)
o Gonadotropin- releasing hormone (GnRH)
• Action: Controls the release of pituitary hormones.
PITUITARY GLAND
v Hypophysis
o Commonly referred to as the master gland because of the influence it has on secretion of hormones by other
endocrine glands.
v Anterior Pituitary
• Somatostatin/ Growth hormone (GH)
o Inhibits growth hormone and thyroid- stimulating hormone.
o Stimulates growth of bone and muscle, promotes protein synthesis and fat metabolism, decreases
carbohydrate metabolism.
• Adrenocorticotropic hormone (ACTH)
o Stimulates synthesis and secretion of adrenal cortical hormones.
• Thyroid-stimulating hormone (TSH)
o Stimulates synthesis and secretion of thyroid hormones.
• Follicle- stimulating hormone (FSH)/ Sertoli cell-stimulating hormone (males)
o Female: stimulates growth of ovarian follicle, ovulation.
o Male: stimulates sperm production
• Luteinizing hormone (LH) / Leydig cell-stimulating hormone (males)
o Female: stimulates development of corpus luteum, release of oocyte, production of estrogen and
progesterone.
o Male: stimulates secretion of testosterone, development of interstitial tissue of testes
• Prolactin
o Prepares female breast for breastfeeding.
• Melanocyte- stimulating hormone
v Posterior Pituitary
• Antidiuretic Hormone (ADH)/ Vasopressin
o Increases water reabsorption by kidney
• Oxytocin
o Stimulates contraction of pregnant uterus, milk ejection from breasts after child birth

ADRENAL CORTEX
v The outer portion of the adrenal gland; stimulated by ACTH to produce corticosteriods.
v Hormones:
• Mineralocorticoids (aldosterone)
o Increase sodium absorption, potassium loss by kidney.

• Glucocorticoids (cortisol)
o Affect metabolism of all nutrients; regulates blood glucose levels, affects growth, has anti- inflammatory
action, and decreases effects of stress
• Adrenal androgens
o Have minimal intrinsic androgenic activity; they are converted to testosterone and dihydrotestosterone in the
periphery
ADRENAL MEDULLA
v The center of the adrenal gland that reacts to autonomic nervous system signals to release catecholamines.
v Hormones:
• Epinephrine/Adrenaline
o Serve as neurotransmitters for the sympathetic nervous system.
o Prepares the body for the fight or flight response by converting glycogen, stored in the liver, to glucose and
increasing cardiac output.
• Norepinephrine/Noradrenaline
o Serve as neurotransmitters for the sympathetic nervous system.
o Produces effect similar to epinephrine and produces extensive vasoconstriction
THYROID GLAND
v Butterfly- shaped organ located in the lower neck, anterior to the trachea.
• Thyroid hormones: triiodothyronine (T3), Thyroxine (T4)
o Increase the metabolic rate; increase protein and bone turnover.
o Regulate cellular metabolic activity.
o T3 is produced predominantly from peripheral conversion of T4.
o T3- Metabolism
o T4- Heat
• Calcitonin
o Lower blood calcium and phosphate levels.
o Secreted in response to high blood calcium levels.
o Inhibits bone resorption.
PARATHYROID GLANDS
v Small glands, usually four, surround the posterior thyroid tissue; they are often difficult to locate and may be
removed accidentally during thyroid or other neck surgeries.
v Hormones:
• Parathormone (PTH, parathyroid hormone)
o Regulates serum calcium.
o Raise blood calcium levels by increasing calcium resorption from kidney, intestines and bones.
PANCREATIC ISLET CELLS

v A slender, elongated organ lying horizontally in the posterior abdomen behind the stomach which function as an
exocrine and an endocrine gland.
v Hormones:
• Glucagon (alpha cells)
o Increases blood glucose concentration by stimulation of glycogenolysis and gluconeogenesis.
o Glycogenolysis- breakdown of stored glucose.
o Gluconeogenesis- production of new glucose from amino acids and other substances.
• Insulin (beta cells)
• Lower blood glucose by facilitating glucose transport across cell membranes of muscle, liver, and adipose
tissue
• Somatostatin (delta cells)
o Delays intestinal absorption of glucose.

KIDNEY
v Paired organs located on either side of the vertebral column. They are between the 12th thoracic and 3rd lumbar
vertebrae in the posterior abdomen behind the peritoneum.
• 1,25- Dihydroxy vitamin D

o Stimulates calcium absorption from the intestine.
• Renin
o Activates renin- angiotensin-aldosterone system.
• Erythropoietin
o Increases red blood cell production
TESTES
• Male gonads
• Two almond-shaped organs suspended inside the scrotum; primary function is for reproduction.
• Steroid Hormone:
• Androgen (Testosterone)
o Affect development of male sex organs and secondary sex characteristics; aid in sperm production.
OVARIES
v Female gonads
v Two almond-shaped organs located at the anterior pelvis; primary function is for reproduction.
v Steroid Hormones:
• Estrogen
Ø Affect development of female sex organs and secondary sex characteristics
• Progesterone
o Regulates the endometrium of the uterus
o Maintains pregnancy
DISORDERS OF ANTERIOR PITUITARY GLAND
GIGANTISM
v Description:
• Oversecretion of GH results in gigantism in children; a person may be 7 or even 8 feet tall.
• Noticed at puberty.
• Epiphyseal plate still open.
• Enlargement of bones of head, hands & feet.
v Causes:
• Tumor of somatotrophs (signs of increased ICP)
v Diagnostic Tests:
• CT and MRI.
• Serum levels of pituitary hormones.
• More than 7 feet tall.
• Weak and lethargic.
• Severe headaches.
• Visual disturbance.
• Diplopia.
• Loss of color discrimination.
• Decalcification of the skeleton.
v Management:
• Pharmacological Management
o Bromocriptine (Parlodel)
ü A dopamine antagonist
o Octreotide (Sandostatin)
Ø A synthetic analogue of GH
• Surgical Management
o Hypophysectomy.
• Stereotactic Radiation Therapy
o Requires use of a neurosurgery- type stereotactic frame, may be used to deliver external beam radiation
therapy precisely to the pituitary tumor with minimal effect on normal tissue.
ü Record height and head circumference.
ü Provide nursing care when receiving radiation therapy, perioperative care.
ü Prepare the client for surgical removal of a pituitary tumor.
ü Assist child in interacting normally with peers.
ACROMEGALY
v Description: An excess of Growth hormone in adults, results in bone and soft tissue deformities and enlargement of
the viscera without an increase in height.
ü Closed epiphyseal plate.
v Diagnostic Tests:
• CT and MRI.
• Serum levels of pituitary hormones.
• Transverse enlargement of bones
• Broad skull
• Protruding jaw
• Prognathism
• Broadening of hands and feet
• Thickening heel pads
• Lips become heavier
• Enlarged tongue
• Soft tissue enlargement ( brain, heart, internal organs)
• Coarse features
v Management:
ü Bromocriptine (Parlodel) - a dopamine antagonist.
ü Ocreotide (Sandostatin) - a synthetic analogue of GH
ü Hypophysectomy
• Stereotactic Radiation Therapy
• Nursing Management
ü Prepare the client for pituitary irradiation and hypophysectomy if indicated.
ü Monitor post- surgical clients for signs of complications:
• Hemorrhage
• Transient diabetes insipidus
• Rhinorrhea, which may indicate cerebrospinal leak.
• Thyroid insufficiency
• Infection, particularly meningitis (marked by fever, nuchal rigidity, headache)
• Visual disturbances, decreased visual field
ü Monitor for hyperglycemia, cardiovascular and neurologic problems.
v What is Hypophysectomy?
ü Partial / complete removal of pituitary gland.
ü Approaches may include transfrontal, subcranial, oronasal transphenoidal.
• Nursing care:
ü Insulin therapy
ü Medication to treat peptic ulcer
ü Blood glucose monitoring
ü Assessment of stools for blood
ü Deep breathing is taught before the surgery
ü Head of bed is raised for at least 2 weeks to decrease pressure on the sella turcica and to promote drainage
ü Observe for post-nasal drip and check for glucose
ü Patient is cautioned against engaging in activities that increases ICP
ü Measure I & O, daily weight
ü Warm saline mouth rinses
DWARFISM
v Description: Generalized limited growth resulting from insufficient secretion of growth hormone during childhood.
v Diagnostics Tests:
• X-ray
• Computed tomography and MRI
• Blood sample
• Overweight for height
• Underdeveloped jaw
• Abnormal teeth position
• High voice
• Delayed puberty
v Management:
ü Somatrem (Protropin)
ü Somatropin (Humatrope)
• Nursing Interventions
ü Provide psychologic support and acceptance for alteration of body image.
ü Assist in ambulation; avoid high impact activities.
HYPERPROLACTINEMIA
v Female:
• Prolactin-secreting tumors
• Amenorrhea
• Galactorrhea
v Male:
• Gynecomastia
• Decreased sex drive
• Impotence
DISORDERS OF POSTERIOR PITUITARY GLAND
SYNDROME OF INAPPROPRIATE ANTI-DIURETIC HORMONE (SIADH)
v Description: Excessive ADH secretion from the pituitary gland even in the face of subnormal serum osmolality.
Patients cannot excrete dilute urine, retain fluids, and develop a sodium deficiency known as dilutional hyponatremia.
v Causes:
• Bronchogenic carcinoma
• Severe pneumonia
• Pneumothorax
• Malignant tumors
• Head injury
• Brain surgery or tumor
• Infection
• Some medications
v Diagnostic Tests:
• Decreased serum osmolality (<280mOsm/kg)
• Elevated ADH level (NV: 0-4.7pG/mL)
• Plasma osmolality and serum sodium levels are decreased
• Urinalysis detects elevated urine sodium and osmolality
• Serum ADH level is elevated.

• Decreased urine output
• Weight gain
• Altered mental status headache, confusion, lethargy, seizures, and coma in severe hyponatremia
• Delayed deep tendon reflex
v Management: (Eliminating the underlying cause)

• Pharmacological management:
ü Diuretics- Furosemide (Lasix)
ü Demeclocycline- drugs that render the kidneys less sensitive to ADH
• Nursing Management:
ü Monitor fluid intake and output, daily weight, urine and blood chemistries and neurologic status
ü Provide supportive measures and explanations of procedures and treatments to assist patient to deal with
this disorder
ü Restrict fluid intake as indicated
ü Regularly assess mental status
DIABETES INSIPIDUS (DI)

v Disorder of the posterior lobe of the pituitary gland that is characterized by a deficiency of ADH (vasopressin )
v Causes:
• Head trauma
• Brain tumor
• Surgical ablation/ irradiation of the pituitary gland
• Infections of the central nervous system (meningitis, encephalitis, tuberculosis)
• Tumor (eg. Metastatic disease, lymphoma of the breast or lungs)
• Failure of the renal tubules to respond to ADH, nephrogenic (hypokalemia, hypercalcemia, lithium, demeclocycline
[Declomycin]).
• Excessive thirst (2 to 20L of fluid intake daily)
• Dilute urine with a specific gravity of 1.001 to 1.005
• Dehydration
• Nocturia
• Weight loss
• Tachycardia
• Hypotension
• Weakness
v Diagnostic Tests:
• Plasma osmolality and serum sodium levels are elevated.
• Water (fluid) deprivation test- demonstrate inability of the kidneys to concentrate urine despite increased
plasma osmolality and low plasma vasopressin level.
• Vasopressin test- demonstrates that the kidneys can concentrate urine after administration of ADH, this
differentiates central from nephrogenic diabetes insipidus.
v Management:
ü Desmopressin (DDAVP)- intranasal synthetic vasopressin, could also be administered intramuscularly
ü Thiazide diuretics, mild salt depletion and prostaglandin inhibitor for nephrogenic DI
ü Replace fluids as indicated
ü Encourage the client to drink fluids in response to thirst
ü Teach the patient about follow- up care and emergency measures
ü Demonstrate correct medication administration
ü Advise wearing a medical identification bracelet.

DISORDERS OF THE THYROID GLAND
GOITER
v Description: Thyroid tumors or enlargement sufficient to visible swelling in the neck.
v Classifications:
• Toxic Goiter- accompanied by hyperthyroidism.
• Non- Toxic Goiter- associated with a euthyroid state.
v Types of Goiter
• Endemic (Iodine-Deficient) Goiter
ü Most common type
ü Caused by iodine deficiency
ü Simple/ colloid goiter
ü Usually no symptoms only swelling; tracheal compression when excessive.
Treatment:
Ø Supplementary iodine
Ø Iodized salt
Ø SSKI
• Nodular Goiter
ü Areas of hyperplasia (overgrowth)
ü Slowly increase in size
ü Can cause local pressure symptoms in the thorax
ü Some are malignant or with hyperthyroid state
• Thyroid Cancer
ü External radiation of the neck, or chest in infancy and childhood increases the risk of thyroid carcinoma.
HYPERTHYROIDISM
v Other terms: Grave’s disease/ Basedow’s/ Parry’s disease.
v Description: Results from an excessive output of thyroid hormones caused by abnormal stimulation of the thyroid
gland by circulating immunoglobulins.
v Diffuse toxic non-nodular goiter
v Autoimmune disease
• Thyrotoxicosis
ü Nervousness
ü Irritable and apprehensive
ü Palpitations
ü Tachycardia
ü Heat intolerance
ü Diaphoresis
ü Flush skin, warm, soft and moist
ü Tremors
• Exophthalmos
ü Bulging eyes, which produces a startled facial expression
ü von Graefe’s sign: eyelid lag when looking downwards
ü Dalyrimple’s sign: upper eyelid retraction
• Goiter
ü Swelling of the thyroid gland
ü Increased appetite
ü Progressive weight loss
ü Amenorrhea
ü Osteoporosis
ü Myocardial hypertrophy
v Diagnostic tests:
• Thrill at the anterior neck
• Bruit at the anterior neck

• Decrease Thyroid stimulating hormone.
• Increase in free T4
• Increase in radioactive iodine uptake
v Management:
Pharmacological Management:
1. Radioactive Iodine Therapy
ü Action: Destroy the overactive thyroid cells
ü Health teaching:
Ø Observe for thyroid storm.
Ø Propranolol may be given to control symptoms.
Ø Contraindicated during pregnancy because it crosses the placenta and while breastfeeding.
2. Antithyroid Medications
ü Action: Block the utilization of iodine by interfering with the iodination of tyrosine and the coupling of
iodotyrosines in the synthesis of thyroid hormone.
ü Propylthiouracil (PTU)
ü Methimazole (Tapazole)
ü Health teaching:
Ø With any sign of infection, especially pharyngitis and fever or the occurrence of mouth ulcers, the patient
is advised to stop the medication, notify the physician immediately, and undergo hematologic studies.
Ø Agranulocytosis is the most toxic side effects.
Ø Methimazole is the treatment of choice during pregnancy.
3. Adjunctive Therapy
ü Action: Iodine or iodide compounds decrease the release of thyroid hormones from the thyroid gland and
reduce the vascularity and size of the thyroid.
ü Potassium iodide (KI),
ü Lugol’s solution
ü Saturated solution of potassium iodide (SSKI)
ü Health Teaching:
Ø Iodine compounds are more palatable in milk or fruit juice.
Ø Administer through a straw to prevent staining of the teeth
Ø Beta- adrenergic blocking agents are important in controlling the sympathetic nervous system effects of
hyperthyroidism.
• Surgical Management:
ü Subtotal Thyroidectomy
Ø The surgical removal of about five sixths of the thyroid.
Ø Health teaching: Before surgery, PTU is administered until signs of hyperthyroidism have disappeared
Ø A beta- adrenergic blocking agent (eg. Propranolol) may be used to reduce the heart rate and other signs
and symptoms of hyperthyroidism
Ø Iodine (Lugol’s solution or KI) may be prescribed in an effort to reduce blood loss
Ø Medications that may prolong clotting (eg. Aspirin) are stopped several week
Ø Patients receiving iodine medication must be monitored for evidence of iodine toxicity (iodism), which
requires immediate withdrawal of medication
ü Symptoms of Iodism
Ø Swelling of the buccal mucosa
Ø Excessive Salivation
Ø Coryza
Ø Skin eruptions
ü Improving nutritional status
Ø Discourage highly seasoned foods and stimulants to reduce diarrhea
Ø High calorie, high protein foods are encouraged
Ø Weight and dietary intake are recorded
ü Enhancing coping measures
Ø Use calm, unhurried approach
Ø The environment is kept quiet and uncluttered

ü Improving Self- Esteem
Ø Eye care and protection drops or ointment
Ø The patients should also be discouraged from smoking.
ü Maintaining Normal Body Temperature
Ø Maintain the environment at a cool, comfortable temperature
Ø Cool baths and cool or cold fluids are encouraged
HYPOTHYROIDISM
v Description: State of insufficient serum thyroid hormone.
v Cause: Autoimmune thyroiditis
v Myxedema
• Refers to the accumulation of mucopolysaccharides in subcutaneous and other interstitial tissues
• Mucinous (mucus-filled) edema
• Extreme symptoms of severe hypothyroidism
• Hair loss
• Brittle nails
• Dry skin
• Numbness and tingling of the fingers
• Hoarseness of voice
• Amenorrhea, anovulation
• Loss of libido
• Subnormal body temperature
• Bradycardia
• Weight gain
• Thickened skin
• Masklike and expressionless face
• Cold intolerance
• Slow Speech
• Enlarged tongue
• Deafness
• Personality and cognitive changes
• Myxedema Coma
ü Sign of depression, diminished cognitive status, lethargy and somnolence, depressed respiratory drive,
narcosis and coma
v Management:
ü Synthetic levothyroxine (Synthroid or Levothroid)
• Prevention of Cardiac Dysfunction
ü Patients may have elevated serum cholesterol, atherosclerosis, and coronary artery disease
ü Angina or dysrhythmias can occur. The nurse must monitor for myocardial ischemia or infarction.
• Prevention of Medication Interactions
ü Thyroid hormones may increase blood glucose levels
ü Bone loss and osteoporosis may also occur with thyroid therapy.
• Supportive Therapy
ü Arterial blood gases
ü In all patients with hypothyroidism, the effects of analgesic agents, sedatives, and anesthetic agents are
prolonged
ü Fatigue
Ø Space activities to promote rest and exercise as tolerated
Ø Assist with self-care activities when patient is fatigued
Ø Provide stimulation through conversation and non- stressful activities
ü Cold intolerance
Ø Provide extra layer of clothing or extra blanket
Ø Protect from exposure to cold and drafts.

ü Constipation
Ø Encourage increased fluid intake within limits of fluid restriction.
Ø Provide foods high in fiber.
Ø Encourage increased mobility within patient’s exercise
Ø Encourage patient to use laxatives and enemas sparingly.
DISORDERS OF PARATHYROID GLANDS

HYPERPARATHYROIDISM
v Description: Overproduction of parathormone by the parathyroid glands, is characterized by bone decalcification
and the development of renal calculi (kidney stones) containing calcium.
• Apathy
• Fatigue
• Muscle Weakness
• Nausea
• Vomiting
• Constipation
• Hypertension
• Cardiac Dysrhythmias
• Hypercalcemia
• Renal stones
• Skeletal Pain and Tenderness
• Pathologic fractures
• Shortening of body stature
v Diagnostic tests:
• Elevated serum calcium
• Elevated concentration of Parathormone
• X-ray bone changes
• Double- antibody parathyroid hormone test
• Ultrasound
• MRI
• Thallium Scan
• Fine- needle biopsy
v Complications:
• Hypercalcemic crisis
ü Result in neurologic cardiovascular and renal symptoms that can be life threatening.
v Management:
• Pharmacological Management:
ü Antacids for peptic ulcer
ü Stool softener for constipation after surgery
ü Phosphate therapy
ü Cytotoxic agents
ü Calcitonin
ü Bisphosphonates
ü Parathyroidectomy
v Criteria:
1. Younger than 50 years of age.
2. Unable or unlikely to participate in follow-up care.
3. Serum calcium level more than 1.0. Mg/dl (0.25 mmol/L) above normal reference range.
4. Urinary calcium level greater than 400 Mg/ day.
5. 30% or greater decrease in renal function.
6. Complaints of primary hyperparathyroidism

• Hydration Therapy
ü Daily fluid intake of 2000 mL or more
ü Cranberry juice
ü Thiazide diuretics are avoided
• Mobility
ü Walking
ü Rocking chair
• Diet
ü Avoid a diet with restricted or excess calcium
• Pre- operative care:
ü Prepare the client
ü Force fluids to prevent dehydration
ü Reduce added calcium
ü Strain the urine for calculi
ü Post-operative care:
ü Assess for renal calculi, report hematuria or flank pain
ü Protect the client
ü Assist with ADL
ü Encourage weight bearing
ü Provide relief of constipation
ü Monitor nutritional status
HYPOPARATHYROIDISM
v Description: Inadequate secretion of parathormone after interruption of the blood supply or surgical removal of
parathyroid gland tissue during thyroidectomy, or radical neck dissection.
v Deficiency of parathormone results in:
• Increased blood phosphate (hyperphosphatemia)
• Decreased blood calcium (hypocalcemia) levels.
• Tetany
• Numbness, tingling and cramps in the extremities
• Stiffness in the hands and feet.
• Bronchospasm
• Laryngospasm
• Carpopedal spasm/Positive Trousseau’s sign
• Positive Chvostek’s sign
• Dysphagia
• Photophobia
• Cardiac dysrhythmia
• Seizures
• Anxiety
• Irritability
v Diagnostic Tests:
• Serum calcium 5 to 6 Mg/ dL or lower
• Serum phosphate levels are increased
• X-ray calcification
v Management:
• IV Calcium gluconate- after thyroidectomy if tetany occurs.
• Parenteral Parathormone- monitor for allergic reaction.
• Oral tablets of calcium salt
• Aluminum hydroxide gel
• Aluminum carbonate- after meals to bind with phosphate and promote its excretion through the GI tract.

• Vitamin D- enhanced absorption of Calcium.
• Care of postoperative patients who have undergo thyroidectomy, parathyroidectomy or radical neck
dissection.
• Calcium gluconate at bedside.
• Be alert for possible laryngeal spasm, keep a tracheostomy set available.
• Institute seizure precaution.
• Minimize environmental stimuli. Environment free of noise, drafts, bright lights, or sudden movement
• Encourage a diet high in calcium and low in phosphorus. Milk, milk products and egg yolks must be
avoided because they are high in phosphorus.
DISORDERS OF ADRENAL GLANDS

PHEOCHROMOCYTOMA
v Description: Tumor that is usually benign and originates from the chromaffin cells of the adrenal medulla.
v It is one form of hypertension that is usually cured by surgery; however, without detection and treatment, it
is usually fatal.
• Vertigo
• Blurring of Vision
• Diaphoresis
• Air hunger
• Palpitations
• Tachycardia
• Tremors
• Flushing
• Anxiety
• Nausea and Vomiting
• Five H’s
ü Hypertension
ü Hyperhidrosis
ü Hypermetabolism
ü Hyperglycemia
ü Headache
• Vanillylmandelic acid (VMA) test

ü A 24- hour specimen of urine is collected.
ü A number of medications and foods, such as coffee and tea (including decaffeinated varieties),
bananas, chocolate, vanilla, and aspirin, may alter the results of this test.
• Total plasma catecholamine (epinephrine and norepinephrine)

ü Measured at supine and at rest for 30 minutes.
ü Values of epinephrine greater than 400 pg/ mL (2180 pmol/ L ) or norepinephrine values greater
than 2000 pg/ Ml (11,800 pmol/ L ) are considered diagnostic of pheochromocytoma.
• Clonidine suppression test

ü May be performed if the results of plasma and urine tests of catecholamines are inconclusive.
• CT, MRI, and Ultrasonography
v Management:
• Pharmacological Management: Antihypertensive:
ü Alpha- adrenergic blocking agents (eg, phentolamine [Regitine])
ü Smooth muscle relaxants (eg, sodium nitroprusside [Nipride])
ü Phenoxybenzamine (Dibenzyline), a long-acting alpha adrenergic blocker,

ü Calcium channel blockers such as nifedipine (Procardia)
ü Beta- adrenergic blocking agents such as propranolol (Inderal)
• Surgical Management: Adrenalectomy

ü The patient needs to be well hydrated before, during, and after surgery to prevent hypotension.
ü Corticosteroid replacement is required if bilateral adrenalectomy has been necessary.
ü Hypotension and hypoglycemia may occur in the postoperative period because of the sudden
withdrawal of excessive amounts of catecholamines.
ü Advise bed rest, with head of bed elevated to promote orthostatic decrease in blood pressure.
ü Monitor ECG changes, arterial pressures, fluids and electrolyte balance and blood glucose levels.
ü Encourage patient to schedule follow-up appointments to observe for return of normal blood pressure
ü Give instructions regarding long term steroid therapy, including the risk of skipping doses or stopping
medication abruptly.
ADDISON’S DISEASE
v Descriptive: Adrenocortical insufficiency, occurs when adrenal cortex function is inadequate to meet the
patient’s need for cortical hormones.
v Autoimmune or idiopathic atrophy of the adrenal glands is responsible for the vast majority of cases.
• Muscle weakness
• Anorexia
• Fatigue
• Emaciation
• Dark pigmentation
• Hypotension
• Low blood glucose
• Low serum sodium
• High serum potassium
• Addisonian Crisis- characterized by cyanosis and the classic signs of circulatory shock (pallor,
apprehension, rapid, and weak pulse, rapid respirations and low blood pressure)
v Diagnostic Tests:
• Early morning serum cortisol less than 165nmol/ L and plasma ACTH more than 22.0 pmol/ L
• Decreased levels of blood glucose (Hypoglycemia)
• Decreased level of serum sodium (Hyponatremia)
• Increase in serum potassium (Hyperkalemia)
• Increased white blood cell count (Leukocytosis)
v Management:
ü Hydrocortisone (Solu- Cortef) is administered by IV, followed by 5% dextrose in normal saline-
immediate treatment for crisis.
ü Vasopressor amines may be required if hypotension persists.
ü Antibiotics may be administered if infection has precipitated adrenal crisis
ü During stressful procedures or significant illnesses, additional supplementary therapy with
glucocorticoids is required to prevent Addisonian crisis.
ü Select foods high in sodium during GI disturbances and in very hot weather.
ü Administer hormone replacement as prescribed.
ü Modify the dosage during illness and other stressful situations.

ü Monitor for signs and symptoms indicative of Addisonian crisis, which can include shock;
hypotension; rapid, weak
ü Avoid unnecessary activity and stress that could precipitate another hypotensive episode.
ü Instruct the patient to inform other health care providers, such as dentists, about the use of
corticosteroids.
ü Wear a medical alert bracelet; and to carry information at all times about the need for corticosteroid
CUSHINGS DISEASE
v Description: Excessive, rather than deficient, adrenocortical activity caused by use of corticosteroid
medications.
v Is infrequently the result of excessive corticosteroid production secondary to hyperplasia of the adrenal
cortex, tumor of the pituitary gland.
• Buffalo Hump
• Central obesity, thin extremities
• Skin is thin, fragile, and easily traumatized
• Ecchymosis
• Weakness
• Hypertension
• Moon faced appearance
• Acne
• Weight gain
• Slow healing
• Virilization
• Hirsutism
• Breast atrophy
• Loss of libido
v Diagnostic Tests and Findings:

• Dexamethasone suppression test
ü Increase in serum sodium
ü Increase blood glucose levels
ü Decrease in serum potassium,
ü Reduction in the number of blood eosinophils,
ü Disappearance of lymphoid tissue
ü Plasma and urinary cortisol levels increased
v Management:
ü Adrenal enzyme inhibitors
Ø Metyrapone [Metopirone]
Ø Aminoglutethimide [Cytadren]
Ø Mitotane [Lysodren]
Ø Ketoconazole [Nizoral])
ü Hydrocortisone may be given after adrenalectomy
ü Transsphenoidal hypophysectomy
ü Bilateral Adrenalectomy
Ø Lifetime replacement of adrenal cortex hormones is necessary.
• Radiation of the pituitary gland

Nursing Management:
ü Establishing a protective environment
ü Recommend foods high in protein, calcium and vitamin D to minimize muscle wasting

ü Space rest periods throughout the day
ü Meticulous skin care
ü Low carbohydrate, low sodium diet
DISORDER OF THE PANCREATIC ISLETS
DIABETES MELLITUS
v Group of metabolic diseases characterized by increased levels of glucose in the blood (hyperglycemia) resulting
from defects in insulin secretion, insulin action, or both.
v Risk Factors:
• Family history of diabetes
• Obesity
• Race (African Americans, Hispanic Americans, Native Americans, Asian Americans, Pacific Islanders)
• Age > 45 yrs. Old
• Hypertension
• HDL cholesterol level <35 mg/dl and triglyceride level >250 mg/dl
v Classification of DM:
• Type 1 diabetes
• Type 2 diabetes
• Gestational diabetes
• Diabetes mellitus associated with other conditions or syndromes
v Diagnostic tests and findings:
• Fasting plasma glucose
• Random plasma glucose
• Oral Glucose Tolerance Test (OGTT)
v Criteria of the diagnosis of Diabetes Mellitus:

1. Symptoms of diabetes plus casual plasma glucose concentration equal to or greater than 200 mg/dl
(11.1mmol/L). Casual is defined as any time of day without regard to time since last meal. The classic symptoms of
diabetes include polyuria, polydipsia, and unexplained weight loss.
Or
2. Fasting plasma glucose greater than or equal to 126 mg/dl (7.0 mmol /L). Fasting is defined as no caloric intake
for at least 8 hours
or
3. Two-hour postprandial glucose equal to or greater than 200 mg/dL (11.1 mmol/L) during an oral glucose tolerance
test. The test should be performed as described by the World Health Organization, using a glucose load containing
the equivalent of 75 g anhydrous glucose dissolved win water.
TYPE 1 DIABETES MELLITUS

v Description:
• Characterized by destruction of the pancreatic beta cells.
• Abnormal response in which antibodies are directed against normal tissues of the body, responding to these
tissues as if they were foreign.

• Destruction of the beta cells results in decreased insulin production, unchecked glucose production by the
liver, and fasting hyperglycemia.
• Glucose derived from food cannot be stored in the liver but instead remains in the bloodstream and
contributes to postprandial (after meals) hyperglycemia
• If the concentration of glucose in the blood exceeds the renal threshold for glucose, usually 180 to 200 mg/dl
(9.9 to 11.1 mmol/L), the kidneys may not reabsorb all of the filtered glucose; the glucose then appears in the
urine (glycosuria).
• When excess glucose is excreted in the urine, it is accompanied by excessive loss of fluids and electrolytes.
This is called osmotic diuresis.
• Fat breakdown occurs, resulting in an increase production of ketone bodies, which are the byproducts of fat
breakdown.
• Ketone bodies are acids that disturb the acid-base balance of the body when they accumulate in excessive
amounts. The result is diabetic ketoacidosis (DKA).
TYPE 2 DIABETES MELLITUS

v Description:
• The two main problems:
ü Increased Insulin resistance
ü Decreased Insulin sensitivity
ü Impaired insulin secretion.
• Idiopathic
• This is called metabolic syndrome, which includes hypertension, hypercholesterolemia, and abdominal
obesity.
• Despite the impaired insulin secretion that is characteristic of type 2 diabetes, there is enough insulin present
to prevent the breakdown of fat and the accompany production of ketone.
v Management:
v Nutritional Therapy
• To promote a 1-to-2-pound weight loss per week,
• 500 to 1000 calories are subtracted from the daily total.
• The caloric distribution currently recommended is higher in carbohydrates than in fat and protein.
• Foods high in carbohydrates, such as sucrose are not totally eliminated from the diet but should be eaten in
moderation because they are typically high in fat and lack vitamins, minerals, and fiber.
• Additional recommendations include limiting total intake of dietary cholesterol to less than 300 mg/day.
• Increase fiber in the diet may improve blood glucose levels, decrease the need the exogenous insulin, and
lower total cholesterol and low-density lipoprotein levels in the blood
• Alcohol is absorbed before other nutrients and does not require insulin for absorption. Large amounts can be
converted to fats, increasing the risk for DKA
• It is important that patients read the labels of “health foods” especially snacks because they often contain
carbohydrates and saturated fats, which may be contraindicated in people with elevated blood lipid levels
v Exercise
• Exercise lower blood glucose levels by increasing the uptake of glucose by body muscles and by improving
insulin utilization
• Exercise at the same time (preferable when blood glucose levels are at their peak) and in the same amount
each day.
• Regular daily exercise
• Walking is a safe and beneficial.
• Eat 15-g carbohydrate snack before engaging in moderate exercise to prevent unexpected hypoglycemia.
• Use proper footwear. Avoid exercise in extreme heat or cold. Inspect feet daily after exercise. Avoid exercise
during periods of poor metabolic control
v Self- Monitoring of Blood Glucose

• This allows for detection and prevention of hypoglycemia and hyperglycemia and plays a crucial role in
normalizing blood glucose levels,
v Glycated hemoglobin (also referred to as glycosylated hemoglobin, HgbA1C, or A1C)
• is a blood test that reflects average blood glucose levels over a period of approximately 2 to 3 months.
v Testing for Ketone
ü Ketone in the urine signal that there is adeficiency of deficiency of insulin and control of type 1 diabetes is
deteriorating. The risk of DKA is high.
ü Insulin Therapy
ü In type 1 diabetes, exogenous insulin must be administered for life because the body loses the ability to
produce insulin.
TIME COURSE AGENT ONSET PEAK DURATION INDICATION

Rapid-acting Lispro (Humalog) 10-15 min 1h 2-4 h Used for rapid reduction of
glucose
Aspart (Novolog) 5-15 min 40-50 min 2-4 h Level, to treat postprandial
Glulisine (Apidra) 5-15 min 30-60 min 2h Hyperglycemia, and/or to
prevent noctumal hypoglycemia
Short-acting Regular (Humalog R, ½-1 h 2-3 h 4-6 h Usually administered 20-30 min
Novolin R, Iletin II before a meal; may be taken
Regular alone or in combination with
longer-acting insulin
Can be incorporated to an IV
infusion
Intermediate NPH (neutral 2-4 h 4-12 h 16-20 h Usually taken after food
- acting protamine Hagedorn)
(Humulin N, Iletin II 3-4 h 4-12 h 16-20 h
Lente, Iletin II NPH)
Novolin L [Lente],
Novolin N [NPH]
Long-acting Glargine (Lantus) 1h Continuous 24 h Used for basal dose
Determir (Levemir) (no peak)
ü Human insulin preparations have a shorter duration of action than insulin from animal sources because
the presence of animal protein triggers an immune response that results an in the binding of animal
insulin.
ü Short-acting insulins are called regular insulin (marked R on the bottle). Regular insulin is a clear
solution and is usually administered 20 to 30 minutes before a meal. Regular insulin is the only insulin
approved for IV use.
ü Intermediate-acting insulins are called NPH insulin (neutral protamine Hagedorn) or lente insulin.
Intermediate-acting insulins.
ü “Peakless” basal or very long-acting insulins that’s is, the insulin is absorbed very slowly over 24
hours and can be given once a day.
• Complications of Insulin Therapy

ü Local Allergic Reactions.
Ø Redness, swelling, tenderness, and induration or 2- to 4-cm wheal) may appear at the injection
site 1 to 2 hours after the insulin administration.
ü Systematic Allergic Reactions.
Ø When they do occur, there is an immediate local skin reaction that gradually spreads into
generalized urticaria (hives).
Ø These rare reactions are occasionally associated with generalized edema or anaphylaxis.
ü Insulin Lipodystrophy
Ø Lipodystrophy refers to a localized reaction, in the form of either lipoatrophy of
lipohypertrophy, occurring at the site of insulin injections.
Ø Lipoatrophy is loss of subcutaneous fat; it appears as slight dimpling or more serious pitting of
subcutaneous fat
ü Resistance to Injected Insulin
Ø Most patients have some degree of insulin resistance at one time or another. The most common
being obesity, which can be overcome by weight loss
ü Morning hyperglycemia
Ø An elevated blood glucose level on arising in the morning is caused by an insufficient level of
insulin, which may be caused by several factors: the dawn phenomenon, the Somogyi effect, or
insulin waning

• Oral antidiabetic agents
ü Sulfonylureas
Ø Stimulate beta cell of the pancreas to secrete insulin; may improve binding between insulin and
insulin receptors of increase the number of insulin receptors or increase the number of insulin
receptors
ü Biguanide
Ø Inhibits production of glucose by the liver
Ø Increase body tissues sensitivity to insulin
Ø Decrease hepatic synthesis of cholesterol
Ø The only biguanide in the market: Metformin
ü Alpha-glucosidase inhibitors
Ø Delay absorption of complex carbohydrates in the intestine and slow entry of glucose into
systemic circulation.
ü Non-sulfonylureas Secretagogues (Meglitinides and phenylalanine derivatives)
Ø Stimulate pancreas to secrete insulin
ü Thiazolidinediones (Glitazone)
Ø Sensitized body tissue to insulin; stimulate receptor sites to lower blood glucose and improve
action of insulin
ü Dipeptide-pepidase-4 (DDP-4) Inhibitors
Ø Increase and prolongs the action of incretin, a hormone that increases insulin release and
decreases glucagon levels, with the result of improved glucose control
CAUSE OF MORNING HYPERGLYCEMIA
Characteristic Treatment
Insulin Waning Increase evening (predinner or bedtime) dose
Progressive rise in blood glucose from bedtime of intermediate acting or long-acting insulin, or
to morning institute a dose of insulin before the evening
meal if one is not already part of the treatment
regimen.
Dawn Phenomenon Change time of injection of evening
Relatively normal blood glucose until about 3 intermediate-acting insulin from dinnertime to
am, when the level begins to rise bedtime.
Somogyi Effect Decrease evening (predinner or bedtime) dose
Normal or elevated blood glucose at bedtime, a of intermediate acting insulin, or increase
decrease at 2-3 am to hypoglycemic levels, and bedtime snack.
a subsequent increase caused by the
production of counterregulatory hormones
ü Storing Insulin
Ø Vials not in use, including spare vials. should be refrigerated.
Ø Insulin should not be allowed to freeze and should not be kept in direct sunlight
Ø The insulin vial in use should be kept at room temperature to reduce local irritation at the
injection site
Ø The patient should be instructed to always have a spare vial of the type or types of insulin he or
she uses.
Ø Cloudy insulins should be thoroughly mixed by gently inverting the vial or rolling it between the
hands before drawing the solution into a syringe or a pen
Ø Bottles of intermediate-acting insulin should also be inspected for flocculation, which is a
frosted, whitish coating
ü Mixing Insulins.
Ø Longer-acting insulin must be mixed thoroughly before drawing into the syringe.
Ø Regular insulin should be drawn up first.
ü Withdrawing Insulin
Ø Inject air into the bottle of insulin equivalent to the number of units of insulin to be withdrawn
ü Selecting and Rotating the Injection Site.
Ø The four main areas for injection are the abdomen, upper arms (posterior surface) thighs
(anterior surface), and hips.

Ø The speed of absorption is greatest in the abdomen and decreases progressively in the arm,
thigh, and hip, respectively.
Ø Systematic rotation of injection sites within an anatomic area is recommended to prevent
localized changes in fatty tissue (lipodystrophy).
Ø Administer each injection 0.5 to 1 inch away from the previous injection. Another approach
to rotation
Ø Patient should try not to use the same site more than once in 2 to 3 weeks.
Ø Insulin should not be injected into the limb that will be exercised because this will cause the
drug to be absorbed faster, which may result in hypoglycemia.
ü Preparing the Skin.

Ø They should be cautioned to allow the skin to dry after cleansing with alcohol.
Ø The alcohol may be carried into the tissues, resulting in a localized reddened area and a burning
sensation.
ü Inserting the Needle.

Ø For a normal or overweight person, a 90- degree angle is the best insertion angle.
Ø Aspiration is generally not recommended with self-injection of insulin.
ü Disposing of Syringes and Needles.

Ø Used sharps should be placed in a puncture-resistant container.
COMPLICATIONS OF DIABETES MELLITUS

HYPOGLYCEMIA
v Occurs when the blood glucose falls to less than 50 to 60 mg/dL (2.7 to 3.3 mmol/L), because of too much insulin or
oral hypoglycemic agents, too little food, or excessive physical activity.
• Mild hypoglycemia
ü Sweating
ü Tremor
ü Tachycardia
ü Palpitation
ü Nervousness
ü Hunger.
• Moderate hypoglycemia
ü Inability to concentrate
ü Headache
ü Lightheadedness
ü Confusion
ü Memory lapses
ü Numbness of the lips and tongue
ü Slurred speech
ü Impaired coordination
ü Emotional changes
ü Irrational or combative behavior
ü Double vision
ü Drowsiness.
• Severe hypoglycemia
ü Patient needs the assistance of another person for treatment of hypoglycemia.
ü Disoriented behavior
ü Seizures
ü Difficulty arousing from sleep
ü Loss of consciousness.

v Emergency measures:
• Injection of glucagon 1mg (subcutaneously or intramuscularly.)
• A concentrated source of carbohydrate followed by a snack should be given to the patient on awakening
• In hospitals and emergency departments, for patients who are unconscious or cannot swallow, 25 to 50 mL of
50% dextrose in water (D5OW) may be administered IV.
• Assuring patency of the IV line because (D5OW) is very irritating to veins.
• Taking additional food when physical activity is increased
• Routine blood glucose tests are performed
• Wear an identification bracelet or tag stating that they have diabetes.
• Learn to carry some form of simple sugar with them at all times
• Refrain from eating high-calorie, high-fat dessert foods (eg, cookies, cakes, doughnuts, ice cream).
DIABETES KETOACIDOSIS
v Caused by an absence or markedly inadequate amount of insulin. This deficit in available insulin results in disorders in
the metabolism of carbohydrate, protein, and fat. The three main clinical features of DKA are:
• Hyperglycemia
• Dehydration and electrolyte loss
• Acidosis
v Pathophysiology:
• Polyuria
• Polydipsia
• Blurred vision
• Weakness
• Headache
• Weak and rapid pulse
• Anorexia
• Abdominal pain
• Acetone breath
• Kussmaul’s respiration – rapid, deep breathing
v Diagnostic Tests and Findings:

• Blood glucose levels may vary between 300 and 800 mg/dL
• Serum bicarbonate (0 to 15 mEq/L)
• Low pH (6.8 to 7.3)
• A low partial pressure of carbon dioxide
• (PCO2; 10 to 30 mm Hg)
• Increased levels of creatinine

• Increased blood urea nitrogen (BUN)
• Increased hematocrit
v Management:
• Rehydration
ü 0.9% Sodium chloride (normal saline solution) 0.65 to 1 Uh for2-3 hours
ü Half strength normal saline (0.45%)- hypernatremia
ü Monitoring fluid volume status
ü Vital signs
ü Lung assessment
ü Intake and output
ü Plasma expanders-severe hypotension
ü Monitor for signs of overload
• Restoring Electrolytes
ü Serum potassium level must be monitored frequently.
ü As much as 40 mEq/h may be needed for several hours.
ü Frequent (every 2 to 4 hours initially) ECGs and laboratory. measurements of potassium are necessary.
ü Because a patient's serum potassium level may drop quickly as a result of rehydration and insulin treatment,
potassium replacement must begin once potassium levels drop to normal.
• Reversing Acidosis
ü Insulin is usually infused intravenously at a slow, continuous rate
ü Bicarbonate infusion to correct severe acidosis is avoided during treatment of DKA because it precipitates
further, sudden decreases in serum potassium levels.
ü When mixing the insulin drip, it is important to flush the insulin solution through the entire IV infusion set
and to discard the first 50 mL of fluid.
ü Insulin molecules adhere to the inner surface of IV infusion sets; therefore, the initial fluid may contain a
decreased concentration of insulin.
HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC SYNDROME (HHNS)

v Serious condition in which hyperosmolarity and hyperglycemia predominate, with alterations of the sensorium (sense
of awareness)
v Ketosis is usually minimal or absent
v Persistent hyperglycemia causes osmotic diuresis, which results in losses of water and electrolytes
• Hypotension
• Profound dehydration (dry mucous membranes, poor skin turgor)
• Tachycardia
• Alteration in sensorium
• Seizures
• Hemiparesis
v Diagnostic tests and Findings:
• Blood glucose- 600 to 1200mg/dL
• Osmolality exceeds 350 mOsm/kg
v Management
• Fluid replacement
• Correction of electrolyte imbalances
• Insulin administration
• Fluid treatment is started with 0.9% or 0.45%NS
• Central venous or hemodynamic pressure monitoring
• Potassium is added to IV fluids
• Insulin plays a less important role in the treatment of HHNS because it is not needed for reversal of acidosis

Characteristic DKA HHNS

Patients most commonly Can occur in type 1 or type 2 diabetes; More common in type 2 diabetes,
affected more common in type 1 diabetes. especially elderly patients with type 2
diabetes
Precipitating event Omission of insulin; physiologic stress PHYSIOLOGIC STRESS (infection surgery,
(infection, surgery, CVA,MI CVA, MI)
Onset Rapid (<24h) Slower (over several days)
Blood glucose levels Usually >250 mg/dL (>3.9mmol/L) Usually >600 mg/dL (>33.3 mmol/L
Arterial pH level 7.3 Normal
Serum and urine ketones Present Absent
Serum osmolality 300-350 mOsm/L >350 mOsm/L
Plasma bicarbonate level <15 mEg/L Normal
BUN and creatinine levels Elevated Elevated
Mortality rate <5% 10-40%

GENITOURINARY SYSTEM
KIDNEY
Characteristics:
• Bean-shaped paired organs
• 150 grams
• Right kidney slightly lower than the left
• Receive 20% of cardiac output (at rest)
• Receive 2-4% cardiac output (under stress)
Location:
• Posterior abdominal wall, retroperitoneal
• T12-L3 (iliac crest)
Functions:
• Urine formation
• Excretion of waste products
• Regulation of electrolytes
• Regulation of acid-base balance
• Control of water balance
• Control of blood pressure
• Renal clearance
• Regulation of red blood cell production
• Synthesis of vitamin D to active form
• Secretion prostaglandins
• Regulates calcium and phosphorus balance
v Renal circulation
Renal Artery (hilum) branches into afferent arterioles
(Glomerular Capillary beds)
Efferent Arterioles
Renal Vein
NEPHRON
v Anatomic & functional unit of the kidney
v 1 million per kidney
v Process:
l Urine is formed in the nephrons in a three-step process:
ü Filtration – transfer of water and waste from blood to glomerulus
ü Reabsorption – water and necessary ions are transferred back into the blood
ü Excretion – excess substances and wastes are removed and transferred into urine
l Water, electrolytes, and other substances, such as glucose and creatinine, are filtered by the glomerulus;
varying amounts of these substances are reabsorption in the renal tubule or excreted in the urine.
Parts
l Glomerulus
ü Urine filtration (water & solutes except blood, albumin & fibrinogen)
ü Is a unique network of capillaries suspended between the afferent and afferent blood vessels.
l Bowman’s capsule (Glomerular capsule)
ü Collects the filtrate
ü Epithelial structures that encloses the glomerulus
l Proximal convoluted tubules (PCT)
ü Reabsorption (peritubular capillaries)
ü Glucose (active transport)
ü Sodium (active transport)

ü Chloride & Bicarbonate (diffusion)
ü 80% of water (osmosis)
l Loop of Henle
ü Reabsorption
Ø Water (osmosis)
Ø Chloride (active transport)
Ø Sodium (diffusion)
l Distal convoluted tubule (DCT)
ü Reabsorption
Ø Sodium (active transport aldosterone)
Ø Water (osmosis-ADH)
Ø Secretion (active transport)
Ø Hydrogen
Ø Potassium
Ø Ammonia
l Collecting tubules
ü Final osmotic reabsorption of water (ADH)
URETERS
v 10 -12 inches (25-30 cm)
v Expands as it enters the kidney to form the renal pelvis (subdivided into calyces each containing renal papillae)
v Collects urine secreted by the kidney & propels it to the bladder by peristaltic wave
URINARY BLADDER
v Hollow, spherical, collapsible bag of smooth muscle
v Behind the symphysis pubis
v Reservoir for urine
v Capacity of the adult bladder 300-500 mL
v Influenced by Automatic Nervous System
URETHRA
l Musculo-membranous tube lined with mucosa opening to urinary meatus
v Female
l Behind the symphysis pubis
l Anterior to the vagina
l 3-5 cm
l Passageway for expulsion of urine
v Male
l Extends through the prostate gland and semen
URINE VOLUME CONTROL

v Glomerular filtration rate (GFR)
v Constant (125 ml/min)
v Renin-Angiotensin-Aldosterone-System
v Specialized juxtaglomerular cells called densa cells secrete the hormone renin.
v Renin converts angiotensinogen to angiotensin I.
v By Angiotensin-converting enzyme (ACE) in lungs, Angiotensin I is converted to Angiotensin II the most
powerful vasoconstrictor.
v Angiotensin II causes the blood pressure to increase.
v The adrenal cortex secretes Aldosterone in response to poor perfusion or increasing serum osmolality.
v Aldosterone causes sodium retention and potassium excretion.
v “Where sodium goes, water follows.”
v The result is an increase in Blood volume and Blood pressure.
v Antidiuretic hormone (ADH)
v Plasma/Urine osmolarity

NORMAL URINE VALUES
Color: amber/straw (light yellow)
Odor: aromatic
Consistency: clear or slightly turbid
pH: 4.5-8
Specific gravity: 1.010-1.020
WBC/RBC: (-)
Albumin: (-)
E coli: (-)
Mucus thread: few
Amorphous urate: (-)
DISORDERS OF THE GENITO-URINARY TRACT
CYSTITIS
v Infection of urinary bladder
v Usually caused by an ascending bacterial infection (E.coli)
v Most common route is transurethral
v Female (shorter urethra, childbirth, anatomic proximity of urethra to rectum)
v Male (due to epididymitis, prostatitis, renal calculi)
v Predisposing factors:
l Microbial invasion - E.coli
l High risk - women
l Obstruction
l Urinary retention
l Increase estrogen levels
l Sexual intercourse
l Pain- flank area
l Hematuria
l Nocturia
l Dysuria
l Pyuria
l Fever
l Urgency
l Chills
l Suprapubic pain
l Urinary frequency
v Diagnostic Tests:
l Urine culture & sensitivity (+) to E.coli
v Management
l Pharmacologic Management
ü Antibiotics
Ø Co-trimoxazole - drug of choice
ü Antispasmodics
ü Analgesic
l Nursing Management
ü Force fluid / hydration
ü Diet
Ø Cranberry/orange juice
Ø Avoid urinary tract irritants
Ø (coffee, tea, alcohol)
ü Warm sitz bath
ü Empty bladder after sexual intercourse
ü Good hygiene
ü Encourage frequent voiding

URETHRITIS
v Inflammation of the urethra
v Causative agents: E. coli, staphylococcus, streptococci, Pseudomonas
v Although inflammatory symptoms are similar to gonorrheal urethritis, sexual contract is not the cause
v May cause prostatitis & epididymitis
v Sign and symptoms:
l Burning on urination
l Purulent urethral discharge appear 3-14 days
v Treatment:
l Tetracycline or doxycycline
NEPHROLITHIASIS/UROLITHIASIS
l Formation of stones at urinary tract
l Types of Stones: Acidic and Alkaline
Acidic Stones Cause/Diet

Calcium oxalate Cabbage, beans, spinach, cranberry, nuts, tea, chocolate
Uric Acid Anchovies, organ meat, whole grain, nuts, sardines
Cystine Meat, milk, eggs, cheese
Alkaline Stones
Calcium Phosphate Dairy products, meat, immobility, obesity, hyperparathyroidism
Struvite Urea-splitting bacteria
v Predisposing Factor:
l Diet- increase Ca & oxalate
l Hereditary- gout
l Obesity
l Sedentary lifestyle
l Hyperparathyroidism
l Males (3x) more common
l Catheterization, infection, urinary stasis
l Dehydration
v Signs and Symptoms
l Nephrolithiasis
ü Intense, deep ache in costovertebral region
ü Hematuria
ü Pyuria
ü Acute pain, nausea, vomiting, costovertebral area tenderness (renal colic)
ü Abdominal discomfort
ü Diarrhea
l Ureterolithiasis
ü Acute, excruciating, colicky, wavelike pain, radiating down the thigh to the genitalia
ü Frequent desire to void, but little urine passed
ü Hematuria
l Urolithiasis
ü Hematuria
ü Symptoms of irritation
ü Urinary retention
ü Possible sepsis
v Diagnostic Test:
l Intravenous Pyelogram
l Kidney Ureter Bladder x-ray
l Cystoscopic exam
l Stone analysis
l Urinalysis
l Ultrasound

v Management
l Pharmacologic Management:
ü Narcotic analgesic
ü Antispasmodics
ü Allopurinol (uric acid)
ü Diuretics
ü Antibiotics
l Surgical management
ü Nephrolithotomy- renal stone
ü Pyelolithotomy- renal pelvis stone
ü Ureterolithotomy- ureteral stone
ü Cystolithotomy- bladder stone
l Nursing Management
ü I&O
ü Stain urine using gauze pad & save solid materials for analysis
ü Exercise
ü Warm sitz bath - for comfort
ü Alternate warm compress at flank area
ü Diet:
Ø Force fluid (3L/day) to help client pass stone
Ø Acidic stones: Alkaline-ash diet
Ø Fruits and Vegetables
Ø Milk
Ø Alkaline stones: Acid-ash diet
Ø Cranberry
Ø Prune
Ø Plum
Ø Meat and poultry
Ø Calcium stone (low calcium, diet; acid-ash diet; decrease dietary protein and sodium intake)
Ø Uric Acid (low purine foods; alkaline-ash diet)
Ø Cystine stone (low methionine; alkaline-ash diet)
Ø Phosphate stone (aluminum hydroxide gel, low in phosphorus)
BENIGN PROSTATIC HYPERPLASIA

v Slow enlargement of prostate gland in men >40 yrs old
v Constriction of urethra & subsequent interference in urination
v Unknown cause
v Predisposing factors:
• Aging process
• Hormonal imbalance (estrogen, androgen)
• Frequency
• Nocturia
• Hesitancy
• Residual Urine
• Decrease in force of urine steam
v Diagnostic Tests:
• Digital rectal exam (DRE)
• Cystoscopy
• Renal biopsy
• Prostatic massage
• Relief of obstruction by insertion of indwelling catheter
v Management:
• Pharmacologic Management:
ü Terazosin (Hytrin)
Ø A1 - adrenergic receptor blocker
Ø Relaxes bladder sphincter
ü Finasteride (Proscar)

Ø Inhibits 5- alpha reductase (blocks uptake & & utilization of androgens by the prostate)
Ø Reduction of glandular hyperplasia
Ø Atrophy of prostate gland
• Balloon Dilation
ü To relax smooth muscle of the bladder neck and prostate
• Immediate Catheterization
ü If patient cannot void
• Watchful waiting
ü To monitor disease progression
ü TURP (Transurethral Resection of the Prostate)
Ø No incision
Ø Prostate resected through urethra
Ø Continuous bladder irrigation (cystoclysis)
Ø No incontinence
Ø No impotence
ü Suprapubic prostatectomy
Ø Incision over lower abdomen & bladder
Ø With cystostomy tube & 2 - way foley catheter
Ø No incontinence
Ø No impotence
ü Retropubic prostatectomy
Ø Low abdominal incision
Ø No incontinence
Ø No impotence
ü Perineal prostatectomy
Ø Impotence
Ø Incontinence or rectal injury my be a complication
• Post-operative Nursing Care:
ü Increase fluid intake
ü Maintain patency of the catheter
Ø If drainage is reddish, increase flow rate
ü Practice asepsis
ü Us a sterile NSS to prevent water intoxication
ü Prevent thrombophlebitis
ü Monitor for hemorrhage
ü After removal of catheter observed for urinary retention/dribbling
ü Kegel’s exercise
ü Avoid anti-cholinergics
ü Antihistamines
ü Upon discharge avoid the following:
Ø Vigorous exercise
Ø Heavy lifting
Ø Sexual intercourse 3 weeks after discharge
Ø Driving 2 weeks after discharge
Ø Straining w/defecation
Ø Prolonged sitting or standing
Ø Crossing the legs
Ø Long trips

PYELONEPHRITIS
v Infection of kidney
v Bacteria (most common) fungal, viral
v 2 TYPES
• Acute
ü Bacterial contamination from urethra by instrumentation (iatrogenic) or hematogenous spread
ü E. Coli/streptococcus
• Chronic
ü Idiopathic; obstruction or reflex (stone, tumor, or neurogenic bladder)
ü Progressive scarring of the kidney resulting in weight loss, hypertension and renal failure
Acute Chronic
Fever Fatigue
Urgency Headache
Chills Poor appetite
Hematuria Polyuria
Nocturia Excessive thirst
Pyuria Weight loss
Flank pain
Urinary frequency
Costovertebral
Tenderness
Dysuria
malaise
v Diagnosis Tests:
l Urinalysis
l Urine culture & sensitivity
l Cystoscopy, IVP, ultrasound
l CT-scan
v Management:
l Pharmacologic management
ü Antibiotics
ü Antispasmodics
ü analgesics
l Nursing management
ü Complete bed rest
ü VS, I & O, weight
ü Diet
Ø Cranberry juice, orange juice
Ø Force fluids (3-4 L/day)
ü Empty the bladder regularly
ü Performing recommended perineal hygiene (wipe the perineum from front to back)
ACUTE GLOMERULONEPHRITIS (AGN)/ NEPHRITIC SYNDROME

v Inflammatory & degenerative disorder of the glomerulus
v Damage to both kidney from filtration of trapping of antibody-antigen complexes within the glomeruli resulting to
decrease glomerular filtration rate
v Types:
• Acute Post-Streptococcal
ü After 7 - 10 days after streptococcal throat infection
ü Immune reaction to the presence of an infectious organism (group A beta hemolytic streptococcus/GABHS)
• Chronic Glomerulonephritis
ü Hypertensive nephrosclerosis
ü Heat failure
ü Chronic renal failure

v Signs and Symptoms:
• Pathognomonic sign: Periorbital edema
• Flank pain, costovertebral tenderness
• Headache, visual disturbance
• Fever, malaise, weakness, fatigue
• Anorexia
• Dyspnea (salt & water retention)
• Tachycardia, hypertension
• Oliguria
v Assessment and Diagnostic Test:
• Urinalysis
ü Hematuria & proteinuria (MOST important indicator of glomerular injury)
ü Casts
• Elevated BUN & creatinine
• Positive antibody response test for streptococcus
• Elevated Erythropoietin Sedimentation Rate
• Hyponatremia, hypophosphatemia
• Hyperkalemia
v Management:
• Pharmacologic management
ü Diuretics
ü Antihypertensive
ü Corticosteroids
ü If residual streptococcal infection is suspected, penicillin is the agent of choice
• Nursing management
ü Monitor VS, I & O daily weight & urine specific gravity
ü Dietary restriction of sodium, fluid & protein
ü Carbohydrates are given liberally to provide energy and reduce the catabolism of protein.
ü Provide special skin care
ü Provide for complication (renal failure, cardiac failure, hypertensive encephalopathy)
ü Monitor urinalysis, BUN creatinine levels
ü Promote rest & regular activity when hematuria & proteinuria resolve
NEPHROTIC SYNDROME
v Renal pathology characterized by increased glomerular permeability and is manifested by massive proteinuria
v Pathophysiology:

• Pathognomonic sign: Anasarca (generalized edema)
• Edema (soft and pitting)
• Periorbital edema
• Dependent edema (sacrum, ankle, and hands)
• Ascites
• Irritability
• Headache
• Malaise
v Assessment and Diagnostic Findings:

• Proteinuria
• Increased WBC in urine
• Needed biopsy of the confirmatory exam
v Complications
• Infection
• Thromboembolism
• Pulmonary Emboli
• Acute Renal Failure
• Accelerate atherosclerosis
v Management:
ü Diuretics
ü ACE inhibitors
ü Lipid lowering Agents
ü Monitor VS, I & O daily weight & urine specific gravity
ü Dietary restriction of sodium, fluids & protein
ü Carbohydrates are given liberally to provide energy and reduce the catabolism of protein.
ü Provide special skin care
ü Observe for complication (renal failure, cardiac failure, hypertensive encephalopathy)
ü Monitor urinalysis, BUN & creatinine levels
ü Promote rest & regular activity when hematuria & proteinuria resolve
ACUTE RENAL FAILURE

v Acute tubular necrosis (ATN) renal parenchymal failure, Acute tubule-interstitial Nephritis
v Reversible condition characterized by:
• A sudden reduction or cessation of renal function
• Retention of waste products
• Increased UN & creatinine
v Causes of Acute Renal Failure

• Pre-renal
ü Hypoperfusion of kidney
ü Volume depletion
ü Impaired cardiac efficiency
ü Vasodilation
• Intra-renal
ü Actual damage to kidney tissue
ü Prolonged renal ischemia
ü Nephrotoxic agents
ü Infectious process
• Post renal
ü Obstruction to urine flow
ü Urinary tract obstruction
ü Calculi (stones), tumors
ü Benign prostatic hyperplasia
ü Blood clots
v Phases of Acute Renal Failure

• Onset
ü Benign with initial insult and ends when oliguria develops
ü Initial phase of injury 1-3 days
• Oliguric phase
ü The oliguria period is accompanied by an increase in the serum concentration of substances usually excreted
by the kidney
ü Urine output <400 cc/24 hrs for 3 days – 2 weeks
ü BUN, creatinine
ü Edema, hypertension
ü Hyperkalemia
ü Hyponatremia
ü Hyperphosphatemia
ü Metabolic Acidosis
• Diuretic phase
ü The diuresis period is marked by a gradual increase in urine output, which signals that glomerular filtration
has started to recover.
ü Urine output 3 – 5 L/day for 10 days
ü Elevated BUN & creatinine
ü Elevated BP
ü Hypokalemia
ü Last- 1 week
• Recovery phase
ü The recovery period signals the improvement of renal function and may take 3 to 12 months
ü Avoid nephrotoxic drugs
ü May lead to CRF
v Diagnostic and Laboratory Findings:

• Hyperkalemia
• Hyperphosphatemia
• Hypocalcemia
• Metabolic acidosis
• Azotemia
• Proteinuria
• Urinalysis (Cast, RBC, WBC)
v Sign and Symptoms:

• Irritability
• Headache
• Anorexia
• Tingling of extremities
• Lethargy that can progress to stupor & coma
• Sudden dramatic drop in urinary output
• Restlessness, twitching, convulsions
• Skin pallor, anemia & increased bleeding time
• Ammonia odor breath & perspiration
• Generalized edema
• Hypertension which can progress to pulmonary edema & CHF
v Management
(Correct underlying cause)
• Pharmacologic management
ü Volume expanders (Dopamine) to restore renal perfusion in hypertensive client
ü Loop diuretics
ü ACE inhibitors for hypertension
ü H2 blockers to prevent gastric ulcers
ü Kayexalate to reduce potassium
ü Sodium bicarbonate to treat acidosis
ü Diet
Ø Moderate protein restriction
Ø High carbohydrates & restricted potassium
ü Total parenteral nutrition
ü Monitor I & O
ü Observe for oliguria followed by polyuria
ü Weight patient daily & observe for edema
ü Monitor electrolyte imbalance (acidosis & hyperkalemia)
ü Assess for sign of overhydration (edema, crackles, headache, distended neck vein, hypertension)
ü Provide periods of undisturbed rest
ü Protect client from injury
ü Observed for early signs of complication
ü Provide skin care
ü Assist in peritoneal dialysis or hemodialysis
CHRONIC RENAL FAILURE

v Irreversible condition of progressive damage to the nephrons & glomerulus
v Retention of waste product (uremia)
v Most common cause:
• DM nephropathy-leading cause
• Hypertension
• Glomerulonephritis
• SLE
v Stages of Chronic Kidney Failure

• Stages are based on the glomerular filtration rate (GFR)
• The normal GFR-125 mL/min/1.73 m2
Stage 1
GFR:90 mL/min/1.73 m2
Kidney damage with normal or increased GFR
Stage 2
GFR:60-89 mL/min/1.73 m2
Mild increased in GFR
Stage 3
GFR:30-59 mL/min/1.73 m2
Moderate increased in GFR
Stage 4
GFR:15-29 mL/min/1.73 m2
Severe increased in GFR
Stage 5/ CKD V
GFR:15 mL/min/1.73 m2
Kidney failure (end-stage renal disease {ESRD})
v Stages of Chronic Renal Failure

• Diminished renal reserve volume
ü Asymptomatic
ü No accumulation of waste products
ü Healthier kidney compensation
• Renal insufficiency
ü Metabolic waste accumulation
ü Decrease GFR
ü Symptoms of renal failure
• End-stage renal disease (ESRD)
ü Excessive amounts of metabolic waste
ü Uremia
ü Life-threatening condition
• Gastrointestinal system
ü Nausea & vomiting
ü Stomatitis
ü Uremic breath/uremic fetor
ü Diarrhea/constipation
• Respiratory system
ü Kussmaul’s respiration
ü Deep, rapid respiration
ü Decrease cough reflex
• Fluid & electrolytes
ü Hyperkalemia
ü Dilutional hyponatremia
ü Hypermagnesemia
ü Hyperphosphatemia
• Integumentary system
ü Pruritus
ü Dry skin
ü Uremic frost
ü Edema
• Cardiovascular system
ü Hypertension due to activation of RAAS
ü Pericarditis due to irritation by uremic toxins
• Hematologic system
ü Anemia
ü Thrombocytopenia
• Musculoskeletal system
ü Muscles cramps
ü Loss of muscle strength
ü Renal osteodystrophy
ü Bone pain
ü Bone fractures
• Reproductive system
ü Amenorrhea
ü Testicular atrophy
ü Infertility
ü Decreased libido
• Neurologic system
ü Confusion
ü Disorientation
ü Seizures
ü Burning of soles of feet
ü Behavior changes
v Management
• Pharmacologic management:
ü Calcium and phosphorus binders
ü Antihypertensive and Cardiovascular Agents
ü Antiseizure agents
ü Erythropoietin

ü Nutrition Therapy
Ø Regulate protein intake
Ø Allow only protein with high biologic value (daily products, eggs, meat)
Ø Fluid intake to balance fluid losses
Ø Fluid allowance (500-600Ml) more than the previous days 24 hour urine output
Ø Some restriction of potassium
Ø Adequate caloric intake and vitamin supplement
ü Maintain fluid & electrolyte balance
Ø Monitor VS & I & O
Ø Weight the patient daily
Ø Assess presence & extent of edema
Ø Auscultate breath sounds
Ø Administer phosphate – binding agent (Amphojel)
ü Prevent infection & injury
Ø Meticulous skin care
Ø Encourage activity but avoid fatigue
Ø Protect from exposure to infectious agent
Ø Avoid aspirin
Ø Soft toothbrush
ü Promote comfort
Ø Analgesic as ordered
Ø Antipruritic
ü Assist with coping in lifestyle & self-concept
Ø Promote hope
Ø Provide opportunity to express feelings
Ø Identify available community
Ø Resources
Ø Prepare client for dialysis or Kidney Transplant
PERITOEAL DIALYSIS
v Principles:
• Dialyzing solution is introduced via a catheter inserted in the peritoneal cavity
• The peritoneal membrane is used as a dialyzing membrane to remove toxic substances metabolic waste & excess
fluid
• Patient can dialyze alone in any location
• Can be used in patients who are hemodynamically unstable
• The peritoneal membrane that covers the abdominal organs and lines the abdominal wall serves as the
semipermeable membrane
• Once the cavity, uremic toxins such as urea and creatinine begin to be cleared from the blood through diffusion
and osmosis.
v Nursing Care:
• Preparing the patient:
ü Consent (patient and the family)
ü Obtain Baseline vital signs
ü Explain the procedure
ü Empty the bladder and bowel to prevent puncture
ü Administer broad-spectrum antibiotic to prevent infection
ü Administer heparin to prevent fibrin formation
ü Warm the dialysate to dilate vessels of peritoneum.
• Note: Normal color of the drainage fluid is colorless.
§ Cloudy: infection, peritonitis.
§ Bloody: normal at first few exchanges
§ Yellowish: Punctured urinary bladder
ü Regulate fluid volume & drainage
ü Promote comfort
ü Prevent complications
o Leaks

o Obstruction
o Peritonitis
ü Drain exit site infection
ü Monitor urine/glucose levels
ü Teach client of dialysis & care of peritoneal catheter
HEMODIALYSIS
v Client is attached (via a surgically created AV fistula or Graft) to a machine that pumps blood along a semi-permeable
membrane, dialyzing solution is on the other side of the membrane, and osmosis, diffusion of waste, toxins, and fluid
from the client occurs
v Diffusion, osmosis and ultrafiltration are the principles in dialysis
v Hemodialysis Access
• AV Fistula
ü Commonly in the forearm anastomosis artery to vein either side to side or end to end
ü It takes at least 14 days to mature
ü Palpate for thrills, Auscultate for bruits
• AV Graft
ü Can be created by subcutaneously interposing a biologic, semibiologic, or synthetic graft material between an
artery and vein
ü A graft is created when the patient’s vessels are not suitable for fistula.
• Vascular access devices
ü Creation of a double-lumen large core catheter into the subclavian, internal jugular or femoral vein.
• Protecting vascular access
ü Evaluate venous access site for bruit or thrill
ü Absence means blockage or clotting
• Taking precautions During IV
ü The rate of the administration must be as slow as possible
• Monitoring symptoms of uremia
ü Deleting Cardiac and Respiratory Complications
Ø Assessment must be conducted frequently
ü Controlling electrolyte levels and diet
• Managing discomforts and pain
ü Antihistamine for pruritis
ü Use bath oils, superfatted soap, cream of lotion
ü Keep nails trimmed to avoid scratching and excoriation
ü Applying lotion to the skin instead of scratching also promotes comfort.
• Monitoring blood pressure
ü Antihypertensive agents must be withheld before dialysis to avoid hypertension due to the combined effect of
the dialysis and the medications.
• Preventing infection
ü Caring for the catheter site
Ø Performed during showering or bathing
Ø Exit site should not be submerged in bath water
Ø Liquid soap is recommended
Ø Make sure that the catheter remains secure to avoid tension and trauma.
v Vascular Access Complications:
• Poor blood flow
• Clotting
• Infection
• Pseudoaneurysm / aneurysm
• Ischemia of the hand
• May contribute to congestive heart failure
RENAL TRANSPLANT
v Kidney transplantation involves transplanting a kidney from a living donor or deceased donor to a recipient who are
longer has renal function
v Philippines’ Organ Donation Act of 1991
• Republic Act 7170
“Any individual, at least 18 years of age and of sound mind, may give by way of legacy, to take effect after his death, all
or part of his body for the purpose of medical or dental education, research advancement of medical or dental science,
therapy or transplant”.
“In all donations, the death of a person from whose body organ will be removed after his death for the purpose of
transplantation to a living person, shall be diagnosed separately by two (2) qualified physicians neither of whom shall be:
- A member of the team of medical practitioners who will affect the removal of the organ from the body
- Lead of hospital or designated officer authorizing the removal of the organ”
v Where do organs come from?
• Living related donors
• Living unrelated Donors
ü Emotionally related donors
ü Husband/wife
ü Best friend
• Decreased Donor
ü Acute head/neurological trauma
ü vehicular crash; gunshot wound
ü blunt head injuries
ü Cerebrovascular accidents
ü aneurysm
ü cerebral anorexia
ü drowning; Hanging
ü primary brain tumors
v Pre-operative Nursing Care
• Complete physical examination is performed
ü Tissue typing
ü Blood typing
ü Antibody screening
ü Psychosocial evaluation
• Patient teaching
ü Post-operative pulmonary hygiene
ü Pain management options
ü Dietary restrictions
ü Early ambulance
•No BLOOD TRANSFUSION for at least 2 weeks prior to transplantation

ü Commercially prepared erythropoietin used as substitute for management of anemia
v Post-operative Nursing Care
• Immunosuppressive agents are administered
• Assessing the patient for Transplant rejection
ü Oliguria
ü Edema
ü Fever
ü Increasing blood pressure weight gain
ü Swelling or tenderness over the transplanted kidney
ü Increase in serum creatinine level.
• Preventing Infection
ü Signs and symptoms:
Ø Shaking chill
Ø Fever
Ø Tachycardia
Ø Tachypnea
Ø Increase or decrease in WBC
ü Attention to hand hygiene
• Monitor Urinary Function
• Addressing psychological concerns
ü Assessment of the patient’s stress and coping.

•Monitoring and managing potential complications
ü Breathing exercises
ü Early ambulation
ü Care of the surgical incision
v Detecting Rejection
• Ultrasonography may be used to detect enlargement of the kidney
• Percutaneous renal biopsy (most reliable) and x-ray techniques are used to evaluate transplant rejection
v Renal Transplant Rejection
• Hyperacute
ü Within hours after surgery
ü Antibody-antigen reaction
ü No urine output
ü Blue, flaccid kidney
ü Transplanted kidney must be removed
ü Client resumes hemodialysis
• Acute
ü Days to month after surgery
ü Body mounts an immune system defense against donor kidney
ü Urine output drops sharply
ü Increased BUN and creatinine
ü Fever, graft tenderness, swelling
ü Increased dosage of immunosuppressant drugs
• Chronic
ü Months to years after surgery
ü Unclear cause
ü Gradual decline in kidney function
ü No specific treatment
FLUIDS, ELECTROLYTES AND ACID BASE

FLUIDS AND ELECTROLYTES
DEFINITION OF TERMS
FLUIDS AND ELECTROLYTES
v Comprisesapproximately 60% of body weight
BODY FLUIDS
v Necessary for chemical reactions and transport
v Contained in the body in several compartments separated by semi-permeable membranes.
v The major compartments are:
• Intracellular—the area inside the cell membrane, containing 65 percent of body fluids
• Extracellular—the area in the body that is outside the cell, containing 35 percent of body fluids
• Tissues or interstitial area—contains 25 percent of body fluids
v Blood plasma and lymph—represents 8 percent of body fluids
v Blood plasma is contained in the intravascular spaces
v Transcellular fluid—includes all other fluids and represents 2 percent of body fluids (e.g., eye humor, spinal fluid,
synovial fluid, and peritoneal, pericardial, pleural, and other fluids in the body)
ELECTROLYTES
v Charged molecules contributes to fluid concentration
v Allows fluid movement from one compartment to another
MAJOR ELECTROLYTES IN THE ICF

v Potassium and Phosphorus
MAJOR ELECTROLYTES IN THE ECF

v Sodium and Chloride

NORMAL LABORATORY VALUES FOR ELECTROLYTES
• Sodium — 135-145 mEq/L
• Potassium — 3.5-5.5 mEq/L
• Calcium - 4.5-5.5 mEq/L or 8.5-10 mg/dL
• Phosphorus — 1.7-2.6 mEq/L
• Chloride — 98-108 mEq/L
• Magnesium — 1.5-2.5 mEq/L
MOVEMENT OF FLUIDS AND ELECTROLYTES

v DIFFUSION — movement of SOLUTE; high to low concentration
v OSMOSIS — movement of SOLVENT; low to high concentration
v HOMEOSTASIS — balance of fluid in the body
FACTORS THAT AFFECT FLUID AND ELECTROLYTE BALANCE

v GENDER
1. MALES — 60%; FEMALES — 50%
• Males - more muscle (muscle is 80% water)
• Females - more adipose tissue (fat is only 15% water)
v AGE
1. INFANTS — 80%
2. ELDERLY — less muscle; thirst center diminished
• BOTH are at risk for fluid and electrolyte imbalance!
LABORATORY TESTS INDICATING FLUID IMBALANCE

v Urine Specific Gravity
• The normal range for specific gravity is 1.010-1.020.
• As fluid volume in the blood increases leads to a more dilute urine, which causes the specific gravity of the urine
to decrease (below 1.010).
• Conversely, as the fluid volume in the blood decreases, as occurs in dehydration, the water excreted in the
urinedecreases, making it more concentrated and causing the specific gravity of the urine to increase (above
1.020).
v Hematocrit
• Indirectly indicates fluid volume in the blood. The test measures the number of blood cells per volume of blood
• Increased fluid in the blood will dilute the blood cells and cause the hematocrit level to decrease. The normal
range of values for men is 39 to 49 percent and for women is 35 to 45 percent
• Consequently, too little fluid in the blood will cause hemoconcentration and result in a high hematocrit level.
v Serum Osmolality
• Measures the concentration of particles dissolved in blood.
• Sodium is a major contributor to osmolality in extracellular fluid.
• Generally ranges from 285 to 295 mOsm/kg of H2O or 285 to 295 mmol/kg (SI units).
• As fluid volume decreases, as in dehydration, serum osmolality increases. Conversely, as fluid volume increases,
as in fluid overload, serum osmolality decreases.
v Urine Osmolality
• Measures the concentration of particles dissolved in the urine. The test can show how well the kidneys are able to
clear metabolic waste and excess electrolytes and concentrate urine.
• In a random urine sample, the normal range is 50-1200 mOsm/kg of H2O or 50-1200 mmol/kg.
POTASSIUM
v Major cation INSIDE the cell.
v Critical to neuromuscular function because it plays an important role in action potentials, nerve
polarization/depolarization and excitability.
HYPOKALEMIA
v May be caused by the use of diuretic medications that result in the excretion of potassium in the urine and by the loss
of potassium through diarrhea or excessive sweating.
v Deficient dietary intake of potassium and magnesium (which causes potassium to move into the cells) could
contribute to the development of hypokalemia.
Symptoms the nurse may notice include:
• Irregular heart rhythm and cardiac dysrhythmia: hypokalemia (prominent U wave, flat T wave)
• General discomfort or irritability
• Muscle weakness
• Paralysis
• Hyperglycemia (check glucose levels; hypokalemia=decreased insulin release, decreased insulin sensitivity)
• Rhabdomyolysis (i.e., disintegration of muscle fibers with myoglobinuria owing to hypokalemia, which can reduce
blood flow to skeletal muscles)
• Renal impairment owing to prolonged hypokalemia with dilute urine (inability to concentrate urine), polyuria,
nocturia, and polydipsia
HYPERKALEMIA
• Results most commonly from decreased excretion of potassium owing to renal failure
• May result from excessive intake or overaggressive treatment of potassium deficit with potassium supplements.
• In addition, acidosis also can cause hyperkalemia by causing a shift of hydrogen ions into the cell and potassium
ions out of the cell and into the blood.
• Transfusion of hemolyzed blood also can result in high potassium levels.
• Leukemic patients may demonstrate hyperkalemia owing to leukocytosis that occurs with the condition.
• The nurse should assess the heart because potassium excess can cause heart rhythm (pulse) and ECG changes,
including
ü Ventricular fibrillation
ü Prolonged PR interval; peaked, narrow T waves;and shortened QT interval progressing to a
widened/prolonged QRS complex as potassium level rises
Signs and Symptoms
• Tingling in the extremities
• Weakness
• Constipation
• Lethargy
• Cardiac dysrhythmia
SODIUM
v Major cation in the extracellular fluid and spaces.
v Concentration of sodium across the cellular membrane plays an important part in neuromuscular cell activity.
Risk factors for sodium imbalance

• Recent trauma (surgery, or shock that might cause fluid loss (triggers the rennin— angiotensin—aldosterone
mechanism)
Drugs that may increase sodium levels, including some of the following:
• Anabolic steroids
• Antibiotics
• Clonidine
• Corticosteroids
• Cough medicines
• Laxatives
• Methyldopa
• Estrogens
• Carbenicillin
Drugs that may decrease sodium levels, including:
• Carbamazepine
• Diuretics
• Sodium-free IV fluids
• Sulfonylureas
• Angiotensin-converting enzyme (ACE) inhibitors
• Captopril
• Haloperidol
• Heparin
• Nonsteroidal anti-inflammatory drugs
• Tricyclic antidepressants
• Vasopressin

HYPONATREMIA
v Most often results from excessive fluid retention or infusion that dilutes the sodium in the blood.
v Patients with conditions that result in excessive retention of fluid, such as the syndrome of inappropriate
antidiuretic hormone (SIADH), also should be observed for a dilutional hyponatremia.
Assessment
• General fatigue
• Weakness
• Nausea
• Headache
• Confusion
• Seizure
• Coma
• Death
HYPERNATREMIA
v Results from excessive sodium intake or sodium retention with excessive loss of water owing to diarrhea, diuretic
medication use, vomiting, sweating, heavy respiration, or severe burns.
Symptoms the nurse may note:
• Signs of dehydration
• Dry skin and mucous membranes
• Slow skin turgor
• Complaints of thirst
• Neurologic changes, including
• Twitching
• Irritability
• Delirium
CHLORIDE
v Most of the chloride in the body comes from the salt (sodium chloride) ingested and absorbed in the intestines as
food is digested.
HYPOCHLOREMIA
v Often results from diarrhea, vomiting, gastric suctioning (resulting in loss of acid and metabolic
alkalosis),chronicrespiratory disease (causing respiratory acidosis), and any condition that causes a loss of sodium
owing to decreased reabsorption of sodium and chloride.
Symptoms the nurse might note in patients with hypochloremia include:
• Hyperexcitability of the muscles and nerves
• Shallow respirations
• Low blood pressure (hypotension)
• Tetany
HYPERCHLOREMIA
v Can result from dehydration and other conditions, including renal disease and excess parathyroid hormone (PTH).
v Also results from metabolic acidosis owing to the loss of base and respiratory alkalosis that occurs with
hyperventilation.
Symptoms the nurse might note in patients with hyperchloremia include:

• Lethargy
• Weakness
• Deep breathing
CALCIUM
v Mineral necessary for clotting (factor IV)
v Has a role in cardiac muscle contraction and excitability
o Skeletal muscle: Stimulant
o Smooth and cardiac muscle: Inhibitor

HYPOCALCEMIA
Low calcium levels can result from:
• Decreased parathyroid gland function (i.e., hypoparathyroidism)
• Decreased dietary intake of calcium
• Decreased levels of vitamin D
• Magnesium deficiency
• Elevated phosphorus
• Acute inflammation of the pancreas
• Chronic renal failure
• Calcium ions becoming bound to protein (alkalosis)
• Bone disease
• Malnutrition
• Alcoholism
The nurse may note the following signs of hypocalcemia:
• Nervousness
• Excitability
• Cramps
• Trousseau’s sign (carpopedal spasm)
• Chvostek’s sign
• Laryngospasm
• Tetany
• ECG: Prolonged QT interval
HYPERCALCEMIA
v Most commonly from increased parathyroid function often owing to a tumor or from cancer in the bones that releases
calcium into the bloodstream.
Additional causes of hypercalcemia include:
• Hyperthyroidism
• Bone breakage with inactivity
• Sarcoidosis
• Tuberculosis
• Vitamin D excess
• Kidney transplant
Symptoms the nurse might note in patients with hypercalcemia include:
• Anorexia
• Nausea
• Vomiting
• Muscle weakness
• Somnolence
• Coma
• ECG: Shortened QT interval
MAGNESIUM
v Found primarily in the intracellular environment and is bound to adenosine triphosphate (ATP).
v It is important in almost all the body's metabolic functions.
HYPOMAGNESEMIA
v May be noted in patients with conditions that cause excessive urinary loss of magnesium, including poorly
controlled diabetes and alcohol abuse,or in patients using drugs such as loop and thiazide diuretics (e.g., Lasix,
Bumex, Edecrin, and hydrochlorothiazide), Cisplatin (which is used widely to treat cancer), and the antibiotics
gentamicin, amphotericin, and cyclosporine.
v Result from conditions resulting in chronic malabsorption such as occurs with diarrhea and fat malabsorption
(which usually occurs after intestinal surgery or infection) or problems such as Crohn's disease, gluten-sensitive
enteropathy, and regional enteritis.
v The nurse may note many symptoms, including the following signs of hypomagnesemia:
• Neuromuscular weakness
• Irritability
• Convulsions
• Tetany (owing to low calcium metabolism)
• ECG changes
• Neurologic changes, including delirium
HYPERMAGNESEMIA
v May result from an excessive intake of magnesium, specifically found in antacids, as well as from renal failure
owing to decreased excretion of magnesium
v The nurse may note the following signs of hypermagnesemia:
• Mental status changes
• Nausea
• Diarrhea
• Appetite loss
• Muscle weakness
• Difficulty breathing
• Extremely low blood pressure
• Irregular heartbeat
PHOSPHATE
v Necessary to maintain acid base balance (through the buffer system)
v Phosphate levels represent the phosphorous that is inorganic, or not part of another organic compound.
v High Phosphate=Low Calcium; Low Phosphate=High Calcium
HYPOPHOSPHATEMIA
v May result from poor absorption such as occurs with ingestion of antacids that bind to phosphate. Phosphate may
be decreased withreducedrenalreabsorptionoften secondary to high levels of parathyroid hormone (PTH or in high
calcium levels and vitamin D deficiency.
v The nurse may note respiratory distress in patients with hypophosphatemia owing to weakness of respiratory
muscles, particularly the diaphragm, which may cause respiratory failure and difficulty in weaning the patient from
mechanical ventilation, and in patients with an increased tendency for hemoglobin to cling onto oxygen, resulting in
less oxygen availability to tissues. Cardiacmuscle weakness with low blood pressure and dysrhythmias also may be
noted, as well as neurologicsymptoms, includingdelirium, seizures, and peripheral neuropathy.
HYPERPHOSPHATEMIA
v Owing to the release of phosphate from the bones by tumors. Sarcoidosis; acromegaly owing to growth hormone
deficiency; renal failure; cell injury such as occurs in trauma, severe infection, rhabdomyolysis, and hemolytic
anemia; and conditions of hypoparathyroidism and hypocalcemia, vitamin D intoxication,hyperalimentation,
thyrotoxicosis, and acidosis may predispose a patient to hyperphosphatemia.
v The nurse may observe central nervous system (CNS) symptoms, including altered mental status with paresthesias,
delirium, convulsions, seizures, and coma, as well as muscle cramping, tetany, and hyperexcitability (Chvostek and
Trousseau signs). In addition, hypotension and heart failure, as well as a prolonged QT interval, may be noted.
Long-term hyperphosphatemia can result in vascular wall calcification and arteriosclerosis with increased blood
pressure and ventricular hypertrophy.
ARTERIAL BLOOD GASES

v NORMAL BLOOD PH: 7.35-7.45
v PCO2: 35-45 mmHg
v P02: 80-100 mmHg
v Bicarbonate: 22-26
Decreased Blood PH = acidosis
Increased Blood PH = alkalosis
Dehydration
• Fluid loss without electrolyte loss
Assessment
• Thirst
• Weight loss
• Elevated Temperature
• Dry mouth and throat
• Warm, flushed, dry skin
• Soft, sunken eyeballs

FLUID VOLUME DEFICIT (HYPOVOLEMIA)
v Description: Fluid volume deficit (FVD), or hypovolemia, occurs when loss of ECF volume exceeds the intake of
fluid ratio of serum electrolytes to water remains the same
v Causes:
• Vomiting
• Diarrhea
• GI suctioning
• Sweating
• Third-space fluid shifts- movement of fluid from the vascular system to other body spaces
ü With edema formation in burns
ü Ascites with liver dysfunction
• Diabetes insipidus
• Osmotic diuresis
• Hemorrhage
• Acute weight loss
• Decreased skin turgor
• Oliguria
• Concentrated urine
• Orthostatic hypotension due to volume depletion
• A weak, rapid heart rate
• Flattened neck veins
• Increased temperature
• Thirst
• Decreased or delayed capillary refill
• Decreased central venous pressure
• Cool,clammy ,pale skin related to peripheral vasoconstriction
• Anorexia
• Nausea
• Lassitude
• Muscle weakness
• Cramps
• BUN elevated out of proportion to the serum creatinine
• Urine specific gravity is increased
• Decreased urinary sodium and chloride.
• Urine osmolality can be greater than 450 mOsm/kg
v Management
Fluid Replacement:
• Isotonic electrolyte solutions
ü Lactated Ringer's solution 0.9% sodium chloride
Ø Frequently used to treat the hypotensive patient with FVD because they expand plasma volume
ü Hypotonic electrolyte solution
Ø 0.45%sodiumchlorideis often used to provide both electrolytes and water for renal excretion of metabolic
wastes.
• The nurse monitors and measures fluid I&O at least every 8 hours
• Vital signs are closely monitored.
• The nurse observes for a weak, rapid pulse and orthostatic hypotension
• Skin and tongue turgor are monitored on a regular basis
• Measuring the urine specific gravity monitors urine concentration.
• When possible, oral fluids are administered to help correct FVD
• The nurse assists with frequent mouth care and provides nonirritating fluids
• Thepatientmay be offeredsmall volumes of oral rehydration solutions
ü Rehydralyte
ü Elete
ü Cytomax
• If nausea is present, antiemetics may be needed before oral fluid replacement can be tolerated.
• Enteral or parenteral nutrition if oral rehydration are no tolerated until adequate circulating blood volume and renal
perfusion are achieved.
FLUID VOLUME EXCESS (HYPERVOLEMIA)

v Description:It refers to an isotonic expansionof theECF caused by the abnormal retention of water and sodium
in approximately the same proportions in which they normally exist in the ECF.
v Causes:
• Renal failure
• Heart failure
• Liver Cirrhosis
• Edema
• Distended neck veins
• Crackles (abnormal lung sounds)
• Tachycardia
• Increased blood pressure, pulse pressure, and central venous pressure
• Increased weight
• Increased urine output
• Shortness of breath and wheezing.
• BUN and hematocrit are decreased because of plasma dilution
• The urine sodium level is increased if the kidneys are attempting to excrete excess volume.
• Chest x-raymay reveal pulmonary congestion.
v Management:
• Management of FVE is directed at the cause
ü Excessive administration of sodium-containing fluids, discontinuing the infusion may be all that is needed.
• Diureticsareprescribedtoreduce edema by inhibiting the reabsorption of sodium and water by the kidneys.
ü Thiazide diuretics- block sodium reabsorption in the distal tubule
ü Loop diuretics- can cause a greater loss of both sodium and water because they block sodium reabsorption
in the ascending limb of the loop of Henle
Ø Furosemide (Lasix)
Ø Bumetanide (Bumex)
Ø Torsemide (Demadex)
• Potassium supplements can be prescribed to avoid hypokalemia from the use of diuretics (Potassium-wasting)
• Hyperkalemia can occur with diuretics that work in the last distal tubule (eg, spironolactone)
• Hemodialysis or peritoneal dialysis may be used to remove nitrogenous wastes and control potassium and acid—
base balance, and to remove sodium and fluid.
• Dietary restriction of sodium.
ü An average daily diet not restricted in sodium contains 6 to 15 g of salt
ü Low-sodium diets can range from a mild restriction to as little as 250 mg of sodium per day
• Patients are instructed to read food labels carefullyto determinesalt content.
• Protein intake may be increased in patients who are malnourished or who have low serum protein levels in an
effort to increase capillary oncotic pressure and pull fluid out of the tissues into vessels for excretion by the
kidneys.
• The patient is weighed daily.
ü Weight gain of 2.2 lb (1 kg) is equivalent to a gain of approximately 1 L of fluid.
• Breath sounds are assessed at regular intervals in at-risk patients
• The nurse monitors the degree of edema in the most dependent parts.
ü Pitting edema is assessedby pressing a finger into the affected part, creating a pit or indentation that is
evaluated on a scale of 1 (minimal) to 4 (severe).
ü Peripheral edema is monitored by measuring the circumference of the extremity with a tape marked in
millimeters
• Avoid over-the-counter medications because these substances may contain sodium.
• Regular rest periods may be beneficial, because bed rest favors diuresis of edema fluid
• If dyspnea or orthopnea is present, the patient is placed in a semi-Fowler's position to promote lung expansion.
• Patient is turned and repositioned at regular intervals because edematous tissue is more prone to skin breakdown
than normal tissue.
METABOLIC ACIDOSIS
v Expected blood gas changes include a low pH (less than 7.35) and a low bicarbonate level (less than 22 mEq/L)
Causes
• There may be an overproduction of hydrogen ions
• Lactic acidosis in fever or seizure, diabetic ketoacidosis, starvation, alcohol or aspirin intake
• Deficient elimination of hydrogen ions
• Deficient production of bicarbonate ions (renal failure, pancreatic insufficiency)
• Excesseliminationofbicarbonateions (diarrhea).
• Lethargy due to increased hydrogen ion concentration in blood
• Tachycardia early in acidosis; later, cardiac electrical conduction slows, causing bradycardia and increasing risk for
heart block or arrhythmia
• Hypotension due to vasodilation
• Rapid, deep breathing (hyperventilation) as body attempts to compensate
• Hyperkalemia may accompany metabolic acidosis as a result of the shift of potassium out of the cells, Later, as the
acidosis is corrected, potassium moves back into the cells and hypokalemia may occur
Treatments
• Administer bicarbonate if bicarbonate levels are low.
• Correct the underlying condition that is causing the imbalance
• Administer insulin and fluids in diabetic ketoacidosis
• Hemodialysis if necessary to restore normal balance in system or remove offending substance.
• Monitor intake and output
• Monitor vital signs for changes
• Monitor lab test results.
• Monitor ABG results
METABOLIC ALKALOSIS
v Evaluation of arterial blood gases reveals a pH greaterthan 7.45 and a serum bicarbonate concentration greater than
26 mEq/L.
v The acid-base balance of the blood is basic because of either a decrease in acidity or an increase in bicarbonate
v Alkalosis is often associated with decreased levels of potassium or calcium
Causes
• Excess intake of antacids,
• Long-term parenteral nutrition
• Prolonged vomiting or nasogastric suctioning
• Use of thiazide diuretics
• Muscle weakness due to neuromuscular changes and hypokalemia
• Musclecrampingandtwitching due to electrolyte changes
• Serum potassium low, chloride low
Treatment
• Sufficient chloride must be supplied for the kidney to absorb sodium with chloride (allowing the excretion of excess
bicarbonate).
• In patients with hypokalemia, potassium is administered as KCI to replace both K and CI losses
• Monitor arterial blood gases and electrolyte levels.
• Administerfluids and electrolytes as necessary.
• Administer supplemental oxygen if necessary.
• Administer electrolyte replacement as indicated.
• Monitor vital signs for changes.
• Monitor cardiovascular status for changes in heart rate, rhythm.
• Monitor intake and output.
• Assessintravenoussiteforsignsof infiltration.
• Check neurological status for changes.

RESPIRATORY ACIDOSIS
v Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg
Cause
• Respiratory acidosis is always due to inadequate excretion of CO2 with inadequate ventilation, resulting in elevated
plasma CO2 concentrations and, consequently, increased levels of carbonic acid.
Acute respiratory acidosis occurs in the following situations, such as:
• Aspiration of a foreign object
• Atelectasis
• Pneumothorax
• Overdose of sedatives
• Sleep apnea
• Acute respiratory distress syndrome
Respiratory acidosis can also occur in diseases that impair respiratory muscles, such as:
• Muscular dystrophy
• Myasthenia gravis
• Guillain- Barre syndrome
• Increased pulse and respiratory rate
• Feeling of fullness in the head. An elevated PaCO2, greater than 60 mmHg
• Hyperkalemia may result as the hydrogen concentration overwhelms the compensatory mechanisms and H moves
into cells, causing a shift of potassium out of the cell.
Treatment
• Treatment is directed at improving ventilation
• Adequate hydration (2 to 3 L/day) is indicated to keep the mucous membranes moist and thereby facilitate the
removal of secretions. Supplemental oxygen is administered as necessary.
RESPIRATORY ALKALOSIS
v Respiratory alkalosis is a clinical condition in which the arterial pH is greater than 7.45 and the PaCO2 is less than 35
mm Hg.
Causes
• Respiratory alkalosis is always caused by hyperventilation, which causes excessive "blowing off" of CO2 and, hence, a
decrease in the plasma carbonic acid concentration
• Extreme anxiety
• Gram-negative bacteremia
Assessment
• Lightheadedness due to vasoconstriction and decreased cerebral blood flow
• Evaluation of serum electrolytes is indicated to identify any decrease in potassium, as hydrogen is pulled out of
the cells in
exchange for potassium
Management
• Treatment depends on the underlying cause of respiratory alkalosis.If the cause is anxiety, the patient is
instructed to breathe more slowly to allow CO2 to accumulate or to breathe into a closed system.

BURNS
DEFINITION
v Cell destruction of the layers of the skin and the resultant depletion of fluid and electrolytes.
CLASSIFICATION OF BURNS:
v SIZE
• Localized Burns
ü Body’s response is localized or contained to the injured area.
• Extensive Burns
ü 25 % or more of the total body surface area (TBSA).
ü Body’s response to injury is systematic.
ü Affect all major systems of the body.
v BURN DEPTH
1. First Degree (Superficial-Partial Thickness)

• Epidermis, possibly a portion of dermis.
• Tingling, hyperesthesia
• Pain soothed by cooling.
• Reddened, blanches with pressure.
• Dry, minimal or no edema, possible blisters; complete recovery within a week, no scarring, peeling.
2. Second Degree (Deep-Partial Thickness)

• Epidermis, upper dermis, portion of deeper dermis.
• Pain, hyperesthesia.
• Sensitive to cold air.
• Blistered.
• Mottled red base.
• Weeping surface, edema
• Recovery 2 to 4 weeks
• Some scarring and depigmentation.
• Contractures, infection may convert it to full thickness.
3. Third Degree (Full-Thickness)

• Epidermis, entire dermis and sometimes subcutaneous tissue.
• May involve connective tissue, muscle and bone.
• Pain-free/Insensate
• Shock, hematuria and hemolysis.
• Possible entrance and exit wounds (Electrical burn)
• Dry, pale white, leathery or charred, broken skin with fat exposed.
• Edema
• Eschar sloughs, grafting necessary.
• Scarring and loss of contour and function, contractures.
v EXTENT OF BURN INJURY

1. Minor Burn Injury
• Second- degree burns of < 15 % total body surface area (TBSA) in adults or < 10 % in children.
• Third degree burn of < 2 % TBSA not involving care areas.
• Excludes electrical injury, inhalation injury, or concurrent trauma and all poor- risk patients.
2. Moderate, Uncomplicated Injury

• Second degree burns of 15- 25 % TBSA in adults or 10- 20 % in children.
• Third degree burns of < 10 % TBSA not involving special care areas.
• Excludes electrical injury, inhalation injury, or concurrent trauma and all poor- risk patient.
3. Major Burn Injury

• Second- degree burns > 25 % TBSA in adults or > 20 % in children.
• All degree burns of > 10 % TBSA
• All burns involving eyes, ears, face, hands, feet, perineum, joints.
• All inhalation injury, electrical injury, or concurrent trauma, and all poor- risk patients.
ESTIMATING THE EXTENT OF BODY SURFACE AREA INJURY
1. Lund and Browder (L&B) Method

• Modifies percentages for body segments according to age.
• More accurate estimate of burn size
• Uses a diagram of the body divided into sections with the representative % of the TBSA for ages throughout
the lifespan.
• Should be reevaluated after initial wound debridement.
2. Rule of 9’s
ADULTS
ü Head- 9 %
ü Arms- 9 % each
ü Legs- 18 % each
ü Chest- 18 %
ü Back- 18 %
ü Groin- 1 %
CHILDREN
ü Head- 18 %
ü Arms- 9 % each
ü Legs- 14 % each
ü Chest- 18 %
ü Abdomen- 18 %
3. Palm Method
• In patients with scattered burns, a method to estimate the percentage of burn is the palm method. The
size of the patient’s palm is approximately 1 % of TBSA.
ASSESSMENT OF BURN INJURY

S-ize
C-ause
A-ge
L-ocation
D-epth
TYPES OF BURNS
1. Thermal Burns
• Exposure to flames, hot liquids, steam or contact to hot objects.
• MOST common type.
2. Chemical Burns
• Tissue contact, ingestion or inhalation of acids or alkali.
• Systemic toxicity from cutaneous absorption can occur.
3. Electrical Burns
• Heat generated by electrical energy as it passes through the body (direct damage.)
• Results in internal tissue damage.
• Cutaneous burns cause muscle and soft tissue damage that may be extensive, particularly in high voltage
electrical injuries.
• Alternating current is more dangerous than direct current because it is associated with cardiopulmonary
arrest, ventricular fibrillation, tetanic muscle contractions, and long bone or vertebral fractures.

4. Radiation Burns
• Exposure to UV light, x- rays, or radioactive sources.
5. Smoke Inhalation Burns

• Inhalation of superheated air, stream, toxic fumes, or smoke causing respiratory tissue damage.
• Assessment:
ü Facial burn
ü Erythema
ü Swelling of oro/ nasopharynx
ü Singed nasal hair
ü Stridor, wheezing and dyspnea
ü Flaring nostrils
ü Sooty sputum and cough
ü Hoarse voice
ü Agitation and anxiety
ü Tachycardia
v Carbon Monoxide Poisoning

• Carbon monoxide is colorless, odorless and tasteless gas that has an affinity for Hgb 200 times greater
than that of oxygen.
• Oxygen molecules are displaced and carbon monoxide reversibly binds to Hgb to form
carboxyhemoglobin.
• Can lead to coma and death.
• Assessment:
ü Bright cherry red, in face and upper torso.
ü Cherry red nail beds, lips and oral mucosa.
ü Headache
ü Muscular weakness
ü Palpitation
ü Dizziness
• Management:
ü Oxygen is administered until the carboxyhemoglobin level is less than 5 %
v Smoke Poisoning
• Inhalation of by-products of combustion.
• A localized inflammatory reaction occurs causing a decrease in bronchial ciliary action and a decrease in
surfactant.
Assessment:
ü Mucosal edema in the airways
ü Wheezing on auscultation
ü After several hours, sloughing of the tracheo-bronchial epithelium.
ü Hemorrhagic bronchitis.
v Direct Thermal Heat Injury
• Can occur to the lower airways by:
• Can occur to the upper airways, w/c appear erythematous and edematous, with mucosal blisters and
ulcerations.
• Mucosal edema especially during the First 24 to 48 hours.
• Monitored for airway obstruction,
• ET intubation if obstruction occurs.
PATHOPHYSIOLOGY OF BURNS
↑ Vascular permeability
↓
Edema
↓
↓ IV volume
↓
↑ Hematocrit
↓
↑Viscosity
↓
↑ Peripheral resistance
↓
↓ Cardiac output
THE BODY’S RESPONSE TO A BURN

1. LOCAL RESPONSE:
v Zone of Coagulation
• Point of maximum damage.
• Inner zone of injury where cellular death occur.
v Zone of Stasis
• Decreased tissue perfusion.
• Middle area, inflammation and tissue injury.
v Zone of Hyperemia
• Outermost; tissue perfusion increased and sustains the least damage.
2. SYSTEMATIC RESPONSE:
v Fluid and Electrolyte Changes
• Local edema caused by thermal injury is often extensive resulting in blister formation.
• Patients with more severe burns develop massive systemic edema.
• As edema increases, pressure on small blood vessels and nerves in the distal extremities causes an obstruction
of blood flow and consequent ischemia (tourniquet effect).
v Cardiovascular Changes
• Cardiac output continues to decrease and the blood pressure drops. This is the onset of burn shock.
• Myocardial contractility may be suppressed by the release of the inflammatory cytokine necrosis factor.
v Respiratory Changes
• Inflammatory mediators cause bronchoconstriction
• Pulmonary hypertension can develop, resulting in a decrease in the arterial O2 tension and a decrease in lung
compliance.
• ARDS can occur.
v Metabolic Changes
• Basal Metabolic Rate (BMR) increases up to 3 times its original rate.
v Immunological Changes
• Immune system function is depressed, resulting in immunosuppression and thus increasing the risk of infection
and sepsis.
• Sepsis continues to be the leading cause of morbidity and with thermal.
v Hemodynamic/ Systemic Changes
• Initially hyponatremia and hyperkalemia followed by hypokalemia as fluid shifts occur and K+ is not replaced.
• Hematocrit level increases as a result of plasma loss; this initial increase falls to below normal at 3rd to 4th day
postburn as a result of the RBC damage and loss at the time of injury.
• Initially, body shunts blood from the kidneys, causing oliguria; then the body begins to reabsorb fluid, and
diuresis of the excess fluid occurs over the next days to weeks.
• Evaporative fluid losses through the burn wound are greater than normal, and the fluid losses continue until
complete wound closure occurs.
• If the intravascular space is not replenished with IV fluids, hypovolemic shock and ultimately death will occur.
v Gastrointestinal Changes
• Blood flow to the GIT is diminished, leading to intestinal ileus, GI dysfunction and Curling’s ulcer.
PHASES OF MANAGEMENT OF THE BURN INJURY EMERGENT/RESUSCITATIVE PHASE

v Begins at the time of injury, ends with complete fluid resuscitation
v first 24-48 hours after the injury
v Fluid shift from intravascular to interstitial space causing hypovolemia
v Goal: Prevent hypovolemic shock and preserve vital organ functioning.
v Priorities:
• First aid
• Fluid resuscitation
• Prevention of shock
• Prevention of respiratory distress
• Detection and treatment of concomitant injuries
• Wound assessment and initial care
v On the scene care:
• Airway
• Breathing
• Circulating
v Emergency Procedure:
Extinguish the flames
ü “Stop, drop, and roll”
ü Smother the flames, a blanket, rug, or coat, may be used
Cool the burn
ü Adherent clothing are soaked with cool water.
ü Never apply ice directly to the burn.
Remove restrictive objects
Cover the wound
ü Minimize bacterial contamination,
ü Maintain body temperature
ü Decrease pain
ü Ointments and salves should not be used.
Irrigate chemical burns
ü Rinse all areas of the body that have come in contact with the chemical.
ü In the shower or any other source of continuous running water.
ü The eyes should be flushed with cool, clean water immediately.
R- Rescue the patient
A- Activate Alarm
C- Confine the fire
E- Extinguish the fire
v Assessment Findings:
• Third spacing/Edema
• Hypovolemia
• Dehydration
• Hypotension
• Tachycardia
• Oliguria
• Thirst
v Diagnostic tests:
• Hyperkalemia (K+ leaks into blood vessels)
• Hyponatremia
• Elevated hematocrit (Hemoconcentration)
• Metabolic acidosis (Loss of bicarbonate)
v Management:
Remove person from source of burn
• Thermal: smother burn beginning with the head.
• Smoke inhalation: ensure patent airway
• Chemical: remove clothing that contains chemical; wash area with copious amounts of water.
• Electrical: note victim position, identify entry/ exit routes of electricity; maintain airway; assess heart rate and
rhythm
v Wrap in dry, clean sheet or blanket to prevent further contamination of wound and provide warmth.
v Assess how and when burn occurred.
v Provide IV route if possible
v Transport immediately
v Includes pre- hospital care and emergency room care.
l Amount of fluid administered is based on the client’s weight and extent of injury (e.g. Parkland Formula).
l Most fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the
hospital.
ACUTE / IMMEDIATE/ DIURETIC PHASE
v Begins when client is hemodynamically stable diuresis has begun.
v Ends at the completion of wound closure
v 2- 5 days after the time of injury
v Interstitial fluid returns to the vascular compartment
v Goals: Wound closure, Prevention of complications
v Focus:
• Infection control.
• Wound care
• Wound closure
• Nutritional support
• Pain management
• Physical therapy
v Assessment Findings:
l Diuresis
l Decreased Hematocrit (Hemodilution)
l Hypertension
l Increased urine output
v Diagnostic tests:
l Hypokalemia (K+ shifts back into the cells)
l Hyponatremia
l Metabolic acidosis
REHABILITATIVE/ CONVALESCENT PHASE
v Final phase of burn care
v From wound closure to return to optimal level of functioning
v Goes beyond hospitalization.
v Goals: Gain independence and achieve maximal function.
v Focus:
l Prevention of scars and contractures
l Physical and occupational rehabilitation
l Functional and cosmetic reconstruction
l Psychosocial counseling
v Assessment:
l Dry, waxy- white, appearance of full-thickness burn changing to dark brown
l Drying out of wet, shiny and serious exudates (in partial thickness burns)
MANAGEMENT OF THE BURN INJURY
FLUID RESUSCITATION
v Indications:
l Adults with burns involving more than 15 %- 20 % TBSA.
l Children with burns involving more than 10- 15 % TBSA.
l Patients with electrical injury, the elderly, or those with cardiac or pulmonary disease and compromised response to
burn injury.
v The amount of fluid administered depends on how much intravenous fluid per hour is required to maintain a urinary
output of 30- 50 ml/hr.
v Successful fluid resuscitation is evidenced by:

l Stable vital signs
l Palpable peripheral pulse
l Adequate urine output
l Clear sensorium
v Urinary output is the most sensitive assessment parameter for cardiac output and tissue perfusion. Monitor hourly.
v If Hgb and Hct levels decrease or if the UO >50 ml/hr, the rate of IV fluid administration may be decreased.
v Generally, a crystalloid (Ringer’s lactate) solution is used initially. Colloid is used during the 2nd day (5% albumin,
plasmate or hetastarch).
v Formulas:

l Parkland/ Baxter Formula
Lactated Ringer’s Solution:
4 mL x kg body weight x % TBSA burned
ü Day 1: Half to be given in first 8 hours; half to be given over next 16 hours.
ü Day 2: varies: colloid is added.
Example: Patient’s weight: 70 kg; % TBSA burn: 80 %
v 1st 24 HOURS:
l 4ml x 70kg x 80 % TBSA = 22, 400ml of
lactated Ringer’s
ü 1st 8 hours= 50 % = 11,200ml
ü 2nd 8 hours= 25 %= 5,600ml
ü 3rd 8 hours= 25 %= 5,600ml
v 2ND 24 HOURS:
l (0.5mL colloid x weight in kg x TBSA) + 2000ml D5W run concurrently over the 24 hours period
l 0.5ml x 70kg x 80 %= 2,800ml colloid
+ 2000 ml D5W
l 2,800/24 h= 117mL colloid/ h
l 2,000/ 24 h=84 mL D5W/ h
l Brooke Army Formula

Colloids: 0.5ml x kg body weight x % TBSA
burned.
1. Electrolytes (lactated Ringer’s solution):

1.5mL x kg body weight x % TBSA burned.
2. Glucose (5 % in water): 2000 mL for insensible
loss.
ü Day 1: Half to be given in first 8 h; remaining
half over next 16 h.
ü Day 2: Half of colloids, half of electrolytes;
all of insensible fluid replacement. Second
and third degree burns exceeding 50 %
TBSA are calculated on the basis of 50 % TBSA.
PAIN MANAGEMENT
v Opioid administration (Morphine Sulfate or Meperidine) via the IV route.
v Morphine sulfate remains the analgesic for treatment
of acute burn pain.
v Avoid IM or SC routes because absorption through the
soft tissue is unreliable when hypovolemia and large fluid shifts are occurring.
v Avoid administering medication by oral route, because
of GI dysfunction.
ü Note: Oral route is preferred when patient is already for discharge and when IV is already discontinued
v Medicate client 30 minutes prior to painful procedures
or wound care.
v Position burned areas in proper alignment.
NUTRITION
v Essential to promote would healing and prevent infection.
v Maintain NPO status until bowel sounds are heard; then advance to clear liquids as prescribed.
v Nutrition may be provided via enteral tube feeding, peripheral parenteral nutrition, or total parenteral nutrition.
l Indications for parental nutrition:
ü Weight loss greater than 10 % of normal body weight.
ü Clinical Status
ü Prolonged wound exposure
ü Malnutrition or debilitated condition before injury.
l Diet:
ü High in protein
ü High carbohydrates (5000 calories per day)
ü High calories, vitamins and minerals.

ü Protein requirements may range from 1.5 to 4.0 g of protein per kilogram of body weight every 24 hours.
l Schedule would care and other treatment at least 1 hour before meals.
PREVENT GI COMPLICATIONS
v Assess for signs & symptoms of paralytic ileus
v Assist with insertion of NGT to prevent/ control Curling’s / stress ulcer; monitor patency & drainage.
v Administer prophylactic antacids, Proton Pump Inhibitors (PPI) or H2 blockers as ordered

v Monitor bowel sounds
v Test stools for occult blood
WOUND CARE
v The cleansing, debridement and dressing of the burn wounds.
v Place client in controlled sterile environment.
1. Hydrotherapy
l Wounds are cleansed by immersion, showering or spraying done for 30 minutes or less, to prevent increased
sodium loss through the burn wound.
l Client should be pre- medicated prior to the procedure
l Not used for hemodynamically unstable or those with new skin grafts.
l The temperature of the water is maintained at 37.8 C.
l During the bath, the patient is encouraged to be as active as possible. It provides an excellent opportunity for
exercising the extremities.
2. Wound dressing
l Burned areas are patted dry and topical agents are applied.
l Light dressing:
o Joint areas to allow motion
o Areas with splint to conform to the body
l Circumferential dressing:
o Distally to proximally
o Fingers and toes should be wrapped individually.
l Occlusive dressing
o Thin gauze impregnated with a topical antimicrobial agent
o Used over new skin grafts
o Protects the graft and promotes adherence of graft to recipient site.
o Remains in place for 3 to 5 days.
o Administer analgesic 20 minutes prior to dressing changes.
3. Debridement
l Removal of eschar
ü To prevent bacterial proliferation under the eschar.
ü To promote wound healing.
l Natural debridement
ü The dead tissue separates from the underlying viable tissue spontaneously.
ü Bacteria that are present at the interface of the burned tissue and the variable tissue underneath gradually liquify the
fibrils of collagen that hold the eschar in place for the first or second postburn week.
l Mechanical Debridement
ü Involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar.
ü Debridement by these means is carried out to the point of pain and bleeding.
ü Coarse-mesh dressings applied dry or wet-to-dry (applied wet and allowed to dry) will slowly debride the wound of
exudate and eschar when removed.
l Surgical debridement
ü Operative procedure involving either primary excision of the full thickness of the skin down to the fascia or shaving
of the burned skin layers to freely bleeding, viable tissue.
ü Early excision is carried out before the natural separation of eschar is allowed to occur.
ü The procedure creates a high risk of extensive blood loss (as much as 100 to 125 mL of blood per percent of body
surface excised.)
4. Escharotomy
• A lengthwise incision is made through the burn eschar to relieve constriction and pressure and to improve
circulation.

• Usually performed in circumferential burn wounds.
• After escharotomy, assess pulses, color, movement, and sensation of affected extremity and control any
bleeding with pressure.
• Pack incision gently with fine mesh gauze for 24 hours after escharotomy, as prescribed.
• Apply topical antimicrobial agents as prescribed.
5. Fasciotomy
• An incision is made, extending through the SQ tissue and fascia.
• Performed if adequate tissue perfusion does not return after an escharotomy.
• Performed in OR under General Anesthesia.
6. Topical Antimicrobial Agents
• Silver Sulfadiazine (Silvadene) cream
ü Most bactericidal agent
ü Minimal penetration of eschar
ü Use with either open treatment, light or occlusive dressings.
ü Applied 1 to 3 times daily after thorough wound cleansing.
ü Observe for and report hypersensitivity reactions (rash, itching, burning sensation in unburned areas).
ü May cause transient leukopenia that disappears 2-3 days of treatment.
ü Anticipate formation of pseudoeschar, which is removed easily after 72 hours.
ü Store drug away from heat.
• Mafenide Acetate 5% or 10% Cream (Sulfamylon)
ü Penetrates eschar
ü Agent of choice for electrical burns.

ü Painful during and for a while after application. Administer analgesic 30 minutes before application.
ü May cause metabolic acidosis.
ü Not used if >20 % TBSA
ü Open: 2 times a day. Dressed: 4 times a day
ü Provide daily baths for removal of previously applied cream.
• Silver Nitrate 0.5 % Solution
ü Bacteriostatic, fungicidal
ü Does NOT penetrate eschar.
ü Keep dressing wet; cover with dry gauze.
ü Remoisten every 2 hours.
ü Redress twice daily.
ü Handle carefully, solution leaves a gray or black stain on skin, clothing and utensils.
ü Monitor serum sodium (Na+) and potassium (K+).
• Other Topical Dressings
ü Cerium nitrate
ü Povidone iodine (Betadine)
ü Gentamycin
Ø Assess vestibular/ auditory
Ø Assess renal functions
ü Polymyxin B
ü Bacitracin ointment
Wound Closure
v Prevents infection and loss of fluid.
v Minimize heat loss through evaporation.
v Promotes healing.
v Prevents contractures.
v Performed on the 5th to 21st day depending on the extent of the burn.
1. Autografting
• Permanent wound coverage.
• Surgical removal of a thin layer of the client’s own unburned skin, which is then applied to the excised wound.
• Monitor for bleeding beneath an autograft can prevent adherence.
• Immobilized after the surgery for 3-7 days to allow time to adhere and attach to the wound bed.
• Care of the graft site
ü Occlusive dressings are commonly used initially after grafting to immobilize the graft.
ü The first dressing change is usually performed 2 to 5 days after surgery, or earlier in the case of purulent
drainage or a foul odor.
• Care of the donor site
ü A moist gauze dressing is applied at the time of surgery to maintain pressure and to stop any oozing.
ü A thrombostatic agent such as thrombin or epinephrine may be applied directly to the site as well.
ü Because a donor site is usually a partial thickness wound, it will heal spontaneously within 7 to 14 days with
proper care.
ü Donor sites are painful, and additional pain management must be a part of patient’s care.
2. Allograft (Homograft)
• Temporary wound covering.
• Donated human cadaver skin is harvested w/in 24 hours after death.
• Monitor for wound exudates and signs of infection.
• Rejection can occur w/in 24 hours.
3. Xenograft (Heterograft)
• Porcine (pig) skin is harvested after slaughter and preserved.
• Rejection can occur w/in 24- 72 hours.
• Replaced every 2-5 days until the wound heals naturally or until closure with autograft is complete.
4. Biosynthetic and Synthetic

• Artificial skin graft
• Visual inspection of wound is possible, as dressings are transparent or translucent.
THE BURNED CHILD
v PEDIATRIC DIFFERENCES
• Very young children who have been severely burned have a higher mortality rate than older children adults
with comparable burns.
• Lower burn temperatures and shorter exposure to heat can cause a more severe burn in a child than in an adult
because a child’s skin is thinner.
• Severely burned children are at increased risk for fluid and heat loss, dehydration, and metabolic
acidosis than an adult.
• The higher proportion of body fluid to mass in children increases the risk of cardiovascular problems.
• Burns involving more than 10 % of TBSA require some form of fluid resuscitation.
• Infants and children are at increased risk for protein and calorie deficiency because they have smaller
muscle mass and less body fat than adults.
• Scarring is more severe in a child.
• An immature immune system presents an increased risk of infection.
• A delay in growth may occur following a burn.
CARE OF MAJOR BURN INJURY
• Main goals: To restore form, function, and feeling through 7 phases of burn management.
ü Rescue- Get the individual away from the source of injury and provide first aid.
ü Resuscitate- Immediate support must be provided for any failing organ system.
ü Retrieve- After initial evacuation to an accident and ER, patients with serious burns may need transfer to a
specialist burns unit for further care.
ü Resurface- Skin and tissues that have been damaged by the burn must be repaired.
ü Rehabilitative- Begins on the day a patient enters hospital and continues for years after he or she has
left.
ü Reconstruct- Scarring that results from burns of the leads to functional impairment that must be
addressed.
ü Review- Burn patients, especially children, require regular review for many years so that problems can be
identified early and solutions provided.

NEUROLOGIC SYSTEM
DEFINITION
v Controls motor, sensor, autonomic, cognitive and behavioral activities
v Two divisions:
• Central Nervous System
ü Brain & spinal cord
• Peripheral Nervous System
ü Cranial nerves, spinal nerves and autonomic nervous system.
NEURON
v Basic function unit
v Composed of the following:

• Dendrites
ü Extension that carry impulses toward the cell body.
• Axon
ü Transmits impulses away from the cell body
v Types of Neurons
• Sensory Neurons
ü also known as Afferent Neurons
ü transmit impulses from receptors to the CNS.
• Motor Neurons
ü Also termed as Efferent Neurons
ü Transmit impulses from the central nervous system to the effectors (muscles, glands)
• Interneurons
ü Found entirely within the central nervous system.
ü Specialized to transmit sensory/ motor impulses.
NEUROTRANSMITTERS
v Communicate message from one neuron to another or from a neuron to a specific target tissue
v Potentiate, terminate or module a specific action and can either excite or inhabit the target cell activity.
Dopamine • Excitatory
• Control complex movements, motivation, cognition
• Regulates emotion response
Norepinephrine • Excitatory
• Causes changes in attention, learning and memory, sleep and wakefulness,
mood
Epinephrine • Excitatory
• Controls fight-or-flight response
Serotonin • Inhibitory
• Controls fluid intake, sleep and wakefulness, temperature regulation, pain
control, sexual behavior, regulation of emotion
Acetylcholine • Excitatory/inhibitory
• Controls sleep and wakefulness cycle
• Signals muscles to become alert
Gamma-aminobutyric acid • Inhibitory
(GABA) • Modulates other neurotransmitters
Glutamine • Excitatory
• Results in neurotoxicity if levels are too high
CENTRAL NERVOUS SYSTEM

v CEREBRUM
• Frontal lobe
ü Larges lope
ü Major function: concentration, abstract thought, information storage and memory function.
ü Contains Broca’s area (motor control of speech)

ü Generates the impulses that bring about voluntary movement

• Parietal lobe
ü Sensory function
Ø Touch, taste, temperature
ü This is where sensations are felt
• Temporal lope
ü Sensory areas for hearing and olfaction
ü Plays a role in memory of sound and understanding of language and music
ü Wernicke’s area: language comprehension
• Occipital lobe
ü Visual interpretation & memory
v Cerebellum
• Controls fine movement, balance, and position or proprioception.
v Medulla
• Contains cardiac centers, respiratory centers, vasomotor centers & reflex centers (coughing, sneezing, swallowing
& vomiting)
v Pons
• Anterior to the cerebellum and superior to the medulla.
• Contains two respiratory centers (apneustic & pneumotaxic) responsible to produce a normal breathing
rhythm
v Midbrain
• Regulates visual reflexes, auditory reflexes & righting reflex
v Hypothalamus
• Functions:
ü Production of hormones
ü Regulation of body temperature
ü Regulation of food and fluid intake
ü Integration of the functioning of the autonomic nervous system
v Thalamus
• Functions are primarily concerned with sensation.
• Capable of suppressing minor sensations
PERIPHERAL NERVOUS SYSTEM

v Cranial Nerves
CRANIAL NERVE TYPE FUNCTION
I (olfactory) Sensory Sense of smell
II (optic) Sensory Visual acuity
III (oculomotor) Motor Muscles that move the
eye and lid, pupillary constriction, lens accommodation
IV (trochlear) Motor Muscles that move the eye
V (trigeminal) Mixed Facial sensation, corneal reflex, mastication
VI (abducens) Motor Muscles that move the eye
VII (facial) Mixed Facial expression and muscle movement, salivation and tearing,
taste, sensation in the ear
VIII (vestibulocochlear) Sensory Hearing and balance/equilibrium
IX (glossopharyngeal) Mixed Taste, sensation in pharynx and tongue, pharyngeal muscles
X (vagus) Mixed Muscles of pharynx, larynx, and soft palate; sensation in
external ear, pharynx, larynx, thoracic and abdominal viscera;
parasympathetic innervation of thoracic and abdominal organs
XI (spinal accessory) Motor Sternocleidomastoid and trapezius muscles
XII (hypoglossal) Motor Movement of the tongue
v Spinal Nerves
• Composed of 31 pairs
ü Cervical:8
ü Thoracic: 12

ü Lumbar: 5
ü Sacral:5
ü Coccygeal: 1
v Autonomic Nervous System
• Regulates the activities of the organs.
• Primary responsibility: Maintenance and restoration of internal homeostasis
Two major divisions

• Sympathetic Nervous System
ü Those neurological ganglia nerves, plexuses which innervate the involuntary motor/ sensory receptions
ü Fight and flight response
• Parasympathetic Nervous System
ü Dominates during relaxed, non-stressful situations
Structure or active Parasympathetic Sympathetic Effect

Effects
Pupil of the eye circulatory Constricted Dilated
system
Rate and focus of heartbeat decreased Increased
Blood vessels
In heart muscles Constricted Dilated
In skeletal muscles Dilated
In abdominal viscera and the Constricted
skin
Blood pressure decreased increased
Respiratory system
bronchioles Constricted Dilated
Rate of breathing Decreased increased
DIGESTIVE SYSTEM
Peristaltic movements of increased Decreased
digestive system tube
Muscular sphincters of digestive Relax Contracted
system
Secretion of salivary glands Thin, watery saliva Thick, viscid saliva
Secretion of stomach, intestine, Increased -
and pancreas
Conversion of liver glycogen to Increased
glucose
Genitourinary system
Urinary bladder muscle walls contracted Relax
Sphincters relaxed Contracted
Muscles of the uterus Relax; variable Contracted under some
conditions, varies with
menstrual cycle and
pregnancy
Blood vessels of external Dilated
genitalia
Integumentary System
Secretion of sweat Increased
Pilomotor muscles Contracted (goose-flesh)
Adrenal medulla Secretion of epinephrine
and norepinephrine

ASSESSMENT OF NUEROLOGICAL SYSTEM

v Physical examination
• Categories:
ü Cerebral Function (LOC, mental status)
ü Cranial nerve
Ø Motor function
Ø Sensory function
ü Reflexes
CEREBRAL FUNCTION
v Assess degree of wakefulness/ alertness
v Note the intensity of stimulus to cause a response
v Apply a painful stimulus over the nailbed with a blunt instrument
v Ask question to assess orientation to person, place & time
Glasgow Coma Scale

• Easy method of describing mental status and abnormality detection
• Test three (3) areas:
ü Eye opening
ü Verbal response
ü Motor response
• Evaluation
Scores
ü 15=highest score; patient is fully alert and oriented
ü <7= comatose patient
ü 3=deep coma
Updated Glasgow Coma Scale: GCS-P (2015)
Eye Opening Spontaneous 4

To sound 3
To pressure 2
No response 1
Non testable NT
Verbal response Oriented 5
Confused 4
Words 3
Sounds 2
No response 1
Non testable NT
Motor response Obeys commands 6
Localized pain 5
Withdrawal from pain (Normal flexion) 4
Abnormal flexion(Decorticate) 3
Abnormal extension (Decerebrate) 2
No response 1
Non testable NT
Pupil Reactivity Both pupils unreactive 2
One pupil unreactive 1
Neither pupil unreactive 0
Note: For total GCS score, subtract pupil reactivity score from calculated GCS.

CRANIAL NERVES
v Cranial nerves I (Olfactory)

• With eyes closed, patient is asked to identify familiar odors (cinnamon, coffee)
• Each nose is tested separately
• Problem: anosmia = loss of sense of smell
v Cranial nerves II (Optic)

• Assess vision using a Snellen eye chart
• Assess visual fields
• Perform ophthalmoscopic examination
• Problem: hemianopia (loss of one-haft of the visual field, either unilateral or bilateral); decreased visual acuity/
blindness
v Cranial nerves III (Oculomotor)

• Test the eye movement towards the nose
• Inspect for conjugate movements and nystagmus
• Evaluate papillary size and test for papillary reactive to light
• Inspect ability to open eyelids
• Problem: Dysconjugate gaze; Double vision; Dilated pupil; with or without impaired papillary reaction to light
v Cranial nerves IV (Trochlear)

• Test for upward eye movement
• Inspect for conjugate movements and nystagmus
• Problem: Dysconjugate gaze; gaze weakness or paralysis; double vision
v Cranial nerves V (Trigeminal)

• Instruct client to close his/her eyes
• Ask the patient to identify touch on different parts of the face
• Ophthalmic, maxillary & mandibular
• While the patient looks up, light touch a wisp of cotton against the temporal surface of each cornea. A blink reflex
and tearing are normal responses.
• Have the client clench and move the jaw from side to side. Palpate the masseter and temporal muscles, noting
strength and equality.
• Problem: impaired or absent corneal reflex, facial numbness and jaw weakness
v Cranial nerves VI (Abducens)

• Test for Bilateral eye movement
• Inspect for conjugate movement
• Problem: dysconjugate gaze; gaze weakness or paralysis; double vision
v Cranial nerves VII (Facial)

• Ask the patient to frown, smile, and wrinkle forehead
• Check for symmetry
• Problem: facial weakness, inability to completely close the eyelids & impaired taste
v Cranial nerves VIII (Vestibulocochlear)

• Performing whisper/ watch-tick test
• Test for lateralization (Weber test)
• Test for air & bone condition (Rinne test)
• Assess standing balance with eyes closed (Romberg test)
• Problem: decreased hearing/ deafness & impaired balance
v Cranial nerves IX (Glossopharyngeal)

• Assess patient’s ability to swallow
• Assess ability to discriminate between sugar & salt on posterior third of the tongue
• Problem: dysphagia & impairs taste

v Cranial nerves X (Vagus)

• Depress a tongue blade on the posterior tongue to elicit gag reflex
• Note any hoarseness in voice
• Check ability to swallow
• Have the patient say “ah”
• Observed for symmetric rise of uvula and soft palate
• Problem: weak or absent gag reflex; Dysarthria (defective in speech due to impairment of the muscles
essential to articulation); Hoarseness
v Cranial nerves XI (Spinal Accessory)
• Ask the patient to turn head and shrug the shoulders against resistance
• Problem: weak or absent shoulder shrug & inability to turn head to the side
v Cranial nerves XII (Hypoglossal)
• Ask the patient to stick out the tongue & move it from side to side
• Problem: difficult swallowing & slurred speech
ABNORMAL REFLEXES
v Positive Brudzinski Sign
• Client is supine position
• Head flexed to the chest
• (+) pain, (+) resistance, (+) flexion of hips & knees= (+) meningeal irritation
v Positive Kernig’s Sign
• Client in supine position
• Knees & hips are flexed
• Check for excessive pain and/or resistance
• If present, (+) for meningeal irritation
v Positive Babinski Reflex
• Stroke the lateral aspect of the foot
• Normal: toes contract & draw together
• Abnormal: toes fan out and draw back
v Decorticate Position
• Upper arms close to sides

• Elbows, wrist and fingers flexed
• Legs extended with internal rotation
• Feet are fixed
• Body parts are pulled into core of the body
• Posture of an individual with a lesion at or above the upper brain stem.
v Decerebrate Posture
• More dangerous
• Upper and lower extremities are extended
• Arms are internally rotated
• Damage in the area of the brain
DIAGNOSTIC TESTS
v Skull and spinal X-ray

• Identify fracture, dislocation, compression, spinal cord problem
Nursing Care
• Proved support for the confuse or combative patient
• Remove metal items
• Maintain immobilization
v CT Scan
• Used for diagnosing neurological disorder of the brain or the spine
• Can detect:
ü Hemorrhage
ü Cerebral atrophy
ü Tumors
ü Skull fractures
ü Abscesses
Nursing Care
• Assess for iodine allergies
• Instruct to lie still on a movable table
• Inform patient there may be hot, flushed sensation & metallic taste in the mouth
• Remove hairpins and other metallic object
v Magnetic Resonance Imaging
• Used for diagnosis of degenerative diseases, intracranial and spinal abnormalities
• Not useful when looking for bony abnormalities
v Electroencephalography (EEG)
• Graphic recording of electrical activity of the brain by several small electrodes placed on the scalp
• Nursing Care
ü Withhold medication that may interfere with the result
ü Anticonvulsants
ü Sedatives
ü Stimulants
ü Instruct adult client to sleep no more than 5 hours the night before
v Cerebral Angiography
• Injection of radiopaque substance into the cerebral circulation via carotid, vertebral, femoral or brachial artery
followed by x-ray
• Used to visualized cerebral vessels and detect:
ü Tumors
ü Aneurysm
ü Occlusion
ü Hematomas
ü Abscesses
NEUROLOGIC DISORDERS
HEADACHES
v Other term: Cephalgia
v It is a symptom rather than a disease entity
• Pressure pain & tight feeling in the temporal area
• Nausea
v Classification
1. Primary Headache
• No organic cause can be identified
Migraine
• It is a complex of symptoms characterized by periodic and recurrent attacks of severe headache lasting from
4 to 72 hours in adults.
• Throbbing, boring, viselike and pounding pain.
Types of Migraine
• Classic Migraine
ü Gas a pre-headache in which the patient may experience visual disturbance, difficulty with speaking,
and/or numbness or tingling
• Common Migraine
ü Does not have a pre-headache, but the patient experience an immediate onset of a throbbing
headaches
Four Phase of Migraine

• Prodromal Phase
ü Symptoms that occur hour to days before a migraine headaches
ü Depression
ü Irritation
ü Feeling cold
ü Anorexia
ü Changes in activity level
ü Increased urination
ü Diarrhea/constipation
• Aura Phase
ü Last less than 1 hour
ü Characterized by focal neurologic symptoms.
ü Visual disturbance (light flashes & bright spots)
ü Numbness & tingling of the lips, face or hands
ü Mild confusion
ü Slight weakness of an extremity
ü Drowsiness & dizziness
• Headaches Phase
ü Several hours of throbbing headaches
ü Photophobia
ü N/V
ü Duration of manifestation: 4 to 72 hours
• Recovery Phase
ü Also termed as Termination/Postdrome
ü Pain gradually subside
ü Muscles contraction in the neck
ü Localized tenderness
ü Exhaustion
Tension-Type
• most common type of headaches
• chronic & less severe
Cluster headaches
• Severe form of vascular headaches
• Most frequent in men
Secondary Headaches
• Symptom associated with an organic cause (brain tumor aneurysm)
v Medication Management
• Abortive approach
ü Best use in patient who have less frequent attacks
ü Aimed at relieving or limiting a headache at the onset or while it is in progress
• Preventive approach
ü Used in patient who experience more frequent attacks at regular or predictable intervals
ü May have medical condition that precludes the use of abortive therapies

• Anti-migraine Agents
Cause vasoconstriction, reduce inflammation and may reduce pain transmission
Triptans
1. Sumatriptan
ü Most widely used
ü Effective for the treatment of acute migraine & cluster headaches
ü Contraindicated: Ischemic heart
ü diseases (causes chest pain)
2. Naratriptan
3. Rizatriptan
4. Zolmitriptan
5. Almotriptan
Serotonin Receptor Agonists

1. Ondansetron
2. Granisetron
3. Dolasetron
• Goals:
ü Enhance pain relief
ü Treat acute event of headache
ü Prevent recurrent episodes
• Provide comfort measures

ü Quiet, dark environment
ü Elevation of the head of the bed to 30 degrees
ü Application of local heat / massage
ü Administration of analgesic agents
• Biofeedback / Stress reduction

ü This helps the patient participate in the treatment of the headache and provides in the treatment of the
headache and provides a sense of control over his or her illness
• Exercise Programs
• Meditation
INCREASED INTRACRANIAL PRESSURE

v Increase in intracranial bulk due to increase in any of the major intracranial components: brain, CSF, or blood.
v Normal: 0 to 10 mm Hp: 15 mm Hg (upper limit of normal)
v Causes
• Brain abscesses
• Hemorrhage
• Edema
• Hydrocephalus
• Early Manifestations
ü Changes in LOC (earliest)
ü Pupillary changes (fixed, slowed response)
ü Slowing of speech Restlessness
ü Confusion
ü Increasing drowsiness
• Late Manifestations

ü Decortication
ü Decerebrate
• Cushing's Triad
ü Bradycardia
ü Hypertension
ü Bradypnea
v Diagnostic Tests
• CT Scan & MRI (most common)
• Cerebral Angiography
• Positron Emission Tomography (PET)
• Scan
v Complications
• Brain Stem Herniation
• Diabetes Insipidus
• SIADH
v Medical Management
• Goals:
ü Decreasing cerebral edema
ü Lowering the volume of CSF
• CSF Drainage
• Maintain patent airway
• Elevate the head of the bed 30 to -15
degrees unless contraindicated.
• Assist in administering 100% oxygen
• Prevent Valsalva Maneuver and the activities that may increase ICP
• Administer prescribed medications:
ü Mannitol
ü Corticosteroid
ü Anticonvulsant
CEREBROVASCULAR ACCIDENT
v Refers to a functional abnormality of the central nervous system (CNS) that that occurs when the normal blood
supply to the brat is disrupted.
v Transient Ischemic Attack

• Neurologic deficit typically lasting less than 1 hour
• Sudden loss of motor, sensory or both functions
v Types
• Ischemic Stroke
ü Caused by thrombus (common) and embolus
Types based on cause:

ü Large artery thrombotic strokes
Ø Due to atherosclerotic plaques in the large blood vessels of the brain.
ü Small penetrating artery

Ø Thrombotic strokes affect one or more vessels
Ø Most common type of ischemic stroke
ü Cardiogenic embolic strokes

Ø Associated with dysrhythmias usually atrial fibrillation
ü Cryptogenic stroke
• Hemorrhagic Stroke
ü Caused commonly by hypertension
Types based on cause:
ü Intracerebral Hemorrhage
Ø Most common in patients with
hypertension & cerebral atherosclerosis
ü Intracranial Aneurysm
Ø Dilation of the walls of a cerebral artery that develops as a result of weakness in the arterial wall
ü Arteriovenous Malformation
Ø This is due to an abnormality in embryonal development that leads to a tangle of arteries and veins in the brain
without capillary bed.
ü Subarachnoid Hemorrhage
Ø Most common cause is a leaking aneurysm in the area of the Circle of Willis or a congenital AVM of the brain
v Diagnostic Tests
• CT Scan
• MRI
• Angiography
v Risk Factors
• Hypertension (major risk factor)
• Hyperlipidemia
• DM
• Advanced Age (>55 y/o)
• Race (African-American)
• Smoking
• Asymptomatic Carotid Stenosis
• Obesity
• Excessive alcohol consumption
Cognitive Disturbance
• Confusion / Altered LOC
Visual-Perceptual Disturbance
• Homonymous Hemianopsia (loss of half
of the visual field)
• Loss of peripheral vision
• Double vision
Motor Loss
• Hemiplegia (most common)
• Hemiparesis
• Loss/Decrease in deep tendon reflexes
• Ataxia
Communication Loss
• Dysarthria (difficulty in speaking)
• Dysphasia (impaired speech)
• Apraxia (inability to perform a previously
learned actions)

• Expressive Aphasia
ü Unable to form words that are understandable
ü May be able to speak in single-word responses
• Receptive Aphasia
ü Unable to comprehend the spoken word
ü Can speak but may not make sense
• Global (Mixed) Aphasia

ü Combination of both receptive and expressive aphasia
Sensory Loss
• Paresthesia
Emotional Deficits
• Loss of self-control
• Emotional lability
• Decreased tolerance to stressful situations
• Depression
• Withdrawal
• Fear, hostility & anger
• Feelings of isolation
ü
v Comparison of Left & Right Hemispheric Strokes
Left Hemispheric Stroke Right Hemispheric Stroke

Paralysis or weakness on right side of the body Paralysis or weakness on the left side of the body
Right visual field deficit Left visual field deficit
Aphasia (expressive, receptive, or global) Spatial-perceptual deficits
Altered intellectual ability Increased distractibility
Slow, cautious behavior Impulsive behavior and poor judgement
Lack of awareness of deficits
• Thrombolytic Therapy
• Platelet-inhibiting Medications
• For TIA and Mild Stroke:
✓ Carotid Endarterectomy (removal of an atherosclerotic plaque or thrombus from the carotid artery)
• For Severe Stenosis:
ü Carotid Stenting
• Prevent shoulder adduction
• Ensure patent airway
• Give 100% 02 (decreases /CP)
• Maintain a quiet, restful environment - Position: Lateral (initially): Low fowlers with neck aligned (stable)
• Monitor VS & GCS, pupil size
• •Provide safety measures (Hemianopsia)
ü Approach client on unaffected side
ü Place personal belongings. foods
on unaffected side
ü Instruct/remind the patient to turn
head in the direction of visual loss
to compensate for loss of visual field
• Manage dysphagia
ü Check gag reflex before feeding client
ü Maintain calm, unhurried approach
ü Upright position
ü Place food in unaffected side of the

mouth
ü Offer soft foods
Give mouth care before and after meals
• Manage motor deficits
ü Place objects within the patient
reach on the non-affected side
ü Instruct the client to exercise and increase the strength on the unaffected side
ü Encourage the client to provide range-of-motion exercises to the affected side
ü Maintain body alignment in
functional position as needed.
• Manage verbal deficits
ü Encourage patient to repeat sounds of the alphabet
ü Explore the patient's ability to write as an alternative means of communication
ü Speak slowly and clearly
ü Explore the patient's ability to read as an alternative means of communication
ü Speak clearly in simple sentences
ü Use gestures or pictures when able
• Manage cognitive deficits
ü Reorient patient to time, place and situation frequently.
ü Provide familiar objects
MENINGITIS
v It is an inflammation of the lining around the brain & spinal cord
v Causes
• Bacteria (Neisseria meningitides)
• Viruses
• Other microorganisms
v May reach the brain via
• Blood
• CSF
• Direct extension from adjacent (Fracture of frontal or facial bones)
• Headache and fever (initial symptoms)
• Positive Kernig's sign
• Positive Brudzinski's sign
• Photophobia
• Nuchal rigidity
• Opisthotonus
v Diagnostic Test
• Bacterial culture & Gram Staining of CSF & blood through lumbar puncture
• Vancomycin
• Cephalosporins
• Dexamethasone
• Fluid volume expanders
• Administer large doses of antibiotics IV as ordered
• Enforce respiratory isolation for 24 hours after initiation of antibiotic medication"
• Provide bed rest; keep room dark and 1 quiet
• Administer analgesics for headache ordered
• Maintain fluid and electrolyte balance
• Monitor vital signs and neurol assessment frequently
• Diet: High calorie, high protein, small frequent feeding
• Monitoring daily body weight
• Prevent development of pressure & pneumonia
ENCEPHALITIS
v It is an acute inflammatory process of brain tissue

v Etiologic Agents
• Herpes simplex virus (most common)
• Fungi (Cryptococcus neoformans)
• Arthropod-borne virus
• Headache & fever (most presenting symptoms)
• Nuchal rigidity
• Confusion
• Decreased level of consciousness
• Seizures
• Sensitivity to light
• Ataxia
• Abnormal sleep patterns
• Tremors
• Hemiparesis
v Complications
• Cognitive Disabilities
• Personality Changes
• Motor deficits
• Blindness
v Diagnostic Tests
• CT Scan
• MRI
• Lumbar puncture
• EEG
• Anticonvulsants
• Antipyretics
• Analgesics
• Sedatives
• Antiviral (Acyclovir)
• Perform neurological assessment frequently
• Provide nursing care for confused / unconscious client
• Comfort measures to reduce stress:
ü Dimming the lights
ü Limiting the noise
ü Administering analgesics
• Injury prevention is key because of the potential for falls and seizures
SEIZURES
v Sudden abnormal and excessive electrical discharges from the brain that can change motor or autonomic
function, consciousness or sensation.
v Epilepsy — it is a chronic neurological disorder characterized by recurrent seizure activity
v Status Epilepticus
• One or a series of grand mal seizures lasting more than 30 minutes without waking intervals
v Etiologic Factors
• Idiopathic (genetic/developmental)
• Traumatic brain injury
• Infection
• Vascular diseases
• Drugs
• Chemical poison
• Drug & alcohol withdrawal
• Allergies
v Classifications of Seizure
1. Partial Seizures
• Seizures beginning locally
• Repetitive purposeless behaviors (classic symptoms)
• Patient appears to be in a dream-like state while picking at his / her clothing, chewing or smacking his or her lips
v Simple Partial
• Does not lose consciousness
• Symptoms confined to one hemisphere
• Affectation of the motor change in posture), sensory (hallucinations), or autonomic (flushing / tachycardia)
• Lasts for less than 1 minute
v Complex Partial
• Also termed as psychomotor seizure
• Consciousness is lost
• May last from 2 to 15 minutes
2. Generalized Seizures
• Entire cerebral cortex is involved
Absence Seizures
• Also referred to as petit mal seizure
• Most often seen in children
• Manifested by a period of staring for several seconds
• Precipitated by stress, hypoglycemia, fatigue, hyperventilation.
Tonic-clonic
• Also termed as grand mal seizures
• Lasts for 30 to 60 seconds
• Characterized by rigidity, fixed & dilated
• pupils, hands and jaws are clenched
• Patient's breathing may temporarily stop
• Urinary incontinence
Cyclonic
• Repeated shock like, often violent contractions in one or more muscle.
v Diagnostic Tests
• EEG (most useful test)
• CT Scan
• MRI
During Seizure
• Remove harmful objects from the patient's surrounding
• Ease the client to the floor
• Protect the head of the patient
• Observe and note for the duration, parts of the body affected, behaviors before and after the seizure
• Loosen constrictive clothing
• Do not restrain, or attempt to place tongue blade or insert oral airway
After Seizure
• Document the events during and after
the seizure
• Side-lying position (prevent aspiration)
• Suction equipment should be available

• Place bed in low position
MYASTHENIA GRAVIS
v Defect in transmission of nerve impulse at the myoneural junction
v Deficiency in acetylcholine due to increased acetylcholine destruction
v Causes
• Unknown
• Autoimmune
• Diplopia & Ptosis (earliest)
• Dysphonia (voice impairment)
• Dysarthria
• Generalized weakness
• Respiratory paralysis (cause of death)
v Diagnostic Tests
• Tensilon Test (Edrophonium chloride)
ü Fast-acting acetylcholinesterase inhibitor
ü Positive (+) = resolved facial muscle weakness & ptosis (5 minutes)
ü Atropine sulfate = for edrophonium toxicity
• EMG
ü Detects delay or failure of neuromuscular transmission.
v Treatment
• Pyridostigmine (first line of therapy)
• Neostigmine
• Plasmapheresis (plasma exchange; centrifugation of plasma in order to separate packed cells and plasma)
• Thymectomy
v Medications to be AVOIDED
• Muscle relaxant
• Barbiturates
• Morphine sulfate
• Tranquilizers
• Neomycin
• Assess gag reflex before feeding
• Place client in fowlers position
• Offer thick fluids
• Flex the neck during feeding (prevent aspiration)
• Administer medication 20-30 minutes before meals
• Administer medication based on the scheduled time
• Protect from falls due to weakness
• Start meal with cold beverages to improve ability to swallow
• Avoid exposure to infection Provide adequate rest and activity
v Myasthenic Crisis
• Caused by undermedication
• Increase BP & HR
• Increase Secretions
• Intervention: Give Neostigmine
v Cholinergic Crisis
• Caused by overmedication
• Weakness with difficulty of swallowing
• Intervention: Discontinue all cholinergic drugs

MULTIPLE SCLEROSIS
v Degenerative disease
v Demyelination of the nerve fibers
v Chronic, slowly progressive
v Characterized by periods of remission and Exacerbation
v Causes
• Unknown
• Post viral infection
v Diagnostic Tests
• MRI
• Electrophoresis (CSF)
• EEG
CHARCOT'S TRIAD
• Scanning speech
• Intentional tremors
• Nystagmus
Visual Disturbances
• Blurring of vision
• Diplopia
• Patchy blindness
• Total blindness
Sensory Nerve Disturbances

• Paresthesia
• Proprioception loss
• Pain
Cognitive Disturbance
• Memory loss
• Decreased concentration
• Dementia
• Poor abstract reasoning
Cerebellum / Basal Ganglia Involvement

• Ataxia
• Tremors
• Weakness of muscle in throat and face
Others:
• Bowel & Bladder dysfunction
• Importance
• Muscle hypertonicity
v Management
• Interferon beta
• Methylprednisolone
• Baclofen (medication of choice for spasticity)
• Steroids
Promoting physical mobility
• Walking
• Use of assistive devices

Others:
• Warm packs (minimizes spasticity of contractures)
• Avoid hot baths (increases risk for burn injury)
• Swimming & stationary bicycling are useful in treating muscle spasticity
• Strenuous exercises are to be avoided (this may exacerbate symptoms)
• Instruct client to prevent cuts and burns
• Eye patch for diplopia
• Respiratory distress precautions
• Bowel and bladder program
GUILLAIN — BARRE SYNDROME

v An autoimmune attack of the peripheral nerve myelin
v Acute, rapid segmental demyelination of peripheral nerves and some cranial nerves
v Neuromuscular disease
v More frequent in males
v Causes
• Unknown
• Post viral infection
v Diagnostic Tests
• EMG
• CSF
• ECG
• Diminished reflexes and muscle weakness that goes upward
• Clumsiness (initial symptom)
• Paralysis of the diaphragm
• Dysphagia
• Paresthesia
• Paralysis of the ocular muscles
• Ataxia
v Complications
• Respiratory failure
• Cardiac dysrhythmias
• Transient hypertension
• Pulmonary embolism
• Plasmapheresis
• Corticosteroids
• Mostly supportive
• Maintain adequate ventilation
• Incentive spirometry
• Chest physiotherapy
• Perform range-of-motion
• Assess gag reflex before starting the
feeding
• Check cranial nerve function
• Administer corticosteroids to suppress
immune function

PARKINSON'S DISEASE
v It is a slowly progressing neurologic movement disorder that eventually leads to disability
v Associated with decreased levels of dopamine
v Causes
• Idiopathic
• Degenerative
• Viral infection
• Head trauma
• Use of anti-psychotic medications
• Excessive accumulation of oxygen free radicals
v Clinical Manifestations Cardinal Signs
• Tremors
• Rigidity
• Bradykinesia
• Postural instability
Others
• Pill rolling (fingers)
• Mask-like face
• Monotone speech
• Drooling of saliva
• Excessive and uncontrolled sweating
• Festinating gait
• Gastric and urinary retention
• Micrographia (very minute and often illegible handwriting)
• Dysphonia (abnormal voice quality caused by weakness and incoordination of speech muscles)
v Pathophysiology
Destruction of dopaminergic neuronal cells in the substantia nigra
Depletion of dopamine stores
Degeneration of the dopaminergic pathway
Imbalance of excitatory (acetylcholine) & inhibiting neurotransmitters in the corpus

striatum
Impairment of extrapyramidal tracts controlling complex body movements
Sign: Tremors, Rigidity Bradykinesia, Postural changes
v Diagnostic Tests
• PET Scan
• Single Photon Emission Computed Tomography (SPECT)

ü It is a three-dimensional imaging technique that uses radionuclides and instruments to detect single
photons.
v Management

Pharmacologic Treatment
1. Anti-parkinsonian Drugs
• Levodopa (most effective agent and
the mainstay of treatment)
• Carbidopa
2. Anti-viral Drugs
• Amantadine
3. Dopamine Agonists
• Bromocriptine
• Pergolide
4. Antihistamines
• Benadryl
• Phenindamine hydrochloride
5. Anticholinergic Drugs
• Cogentin
• Artane
• Akineton
Surgical Treatment
• Thalamotomy
ü Most common complications:
Ataxia and Hemiparesis
• Pallidotomy
ü Involves destroying part of the ventral aspect of the medial globus pallidus through electrical stimulation in
patients with advanced disease
• Pacemaker-like brain implants
• Improve client's mobility
ü Walking
ü Riding stationary bicycle
ü Swimming
ü Gardening
ü Provide warm baths and massage
• Increase fluid intake to prevent constipation

• Aspiration Precaution
• Provide semi-solid diet and thick fluids
• Use of small electronic amplifier may lessen client's hearing deficit
Health Teaching during Levodopa Therapy

Side Effects of Levodopa
• Nausea & vomiting
• Insomnia
• Agitation
• Mental confusion
• Renal damage
Drugs that block the effect of Levodopa

• Phenothiazines
• Reserpine
• Pyridoxine (Vitamin B6)
Foods to Avoid
• Tuna
• Pork
• Dried beans
• Salmon
• Beef liver
AMYOTROPHIC LATERAL SCLEROSIS

v Also termed as Lou Gehrig's Disease
v It is a progressive, degenerative condition
that affects motor neurons responsible for the control voluntary muscles.
v Causes
• Unknown
• 5-10% Genetically transmitted
• Over-excitation of the neurotransmitter glutamate
• Fatigue
• Muscle weakness
• Cramps
• Fasciculation (spontaneous contraction of the muscles)
• Dysphagia
• Difficulty of breathing
• Inappropriate emotional outburst of laughing and crying Constipation
• Urinary urgency problem
v Diagnostic Tests
• Electromyography
• Muscle biopsy
• MRI
• EEG
• CSF
Glutamate Antagonist
• Riluzole
Other drugs:
• Manage spasticity
ü Baclofen
ü Dantrolene
ü Diazepam
Mechanical ventilation
• Maximize functional abilities
ü Prevent complications of immobility
ü Promote self-care
ü Maximize effective communication
ü Promote use of assistive devices
• Ensure adequate nutrition
• Prevent respiratory complications

ü Promote measures to maintain adequate airway
ü Promote measures to improve gas-exchange (02 therapy, ventilatory assistance)
ü Promote measures to prevent respiratory infection
• Help client and family deal with the problem
SPINAL CORD INJURY

v Injury to the spinal cord which characterized by a decrease or loss of sensory and motor functions below the
level of the injury.
v Causes
• Motor vehicle accidents
• Gunshot
• Falls
• Sports injuries
v Risk Factors
• Young age
• Alcohol and drug abuse
• Male
v Affectation
• Cl — C4 = Respiratory Depression
• C1 — C8 = Quadriplegia (with some arm and hand movement)
• T1 — T6 = Paraplegic, some trunk movement, legs paralyzed
• T7 — T12 = Paraplegic, good upper back and abdominal strength, may function well in wheelchair
• Lumbar, Sacral & Coccygeal
ü Bowel, Bladder & Sexual Dysfunction
v Diagnostic Tests
• X-ray
• CT Scan
• MRI
v Complications
• Spinal and Neurogenic Shock
• Deep Vein Thrombosis
• Pressure Ulcers
• Orthostatic Hypotension
• Autonomic Dysreflexia
v Management
• Respiratory function is the first priority especially in cervical spinal cord injury.
• Immobilization (flat, firm surface)
• Cervical collar (if cervical injury is suspected)
• Transport client as a unit
• Do not attempt to realign body parts
• Suctioning may be indicated, but used with caution
• Position change at least every two hours
• Intermittent catheterization for bladder distention
• Diet: High-calorie, High protein, High-fiber
• Anticoagulants
• Anti-embolism stockings
• Adequate hydration
• Bowel Training program (depending on
the affectation)
AUTONOMIC DYSREFLEXIA
v Life threatening complication that occurs in patients with injuries above the T6 level.
v Impairs the normal equilibrium between the sympathetic and parasympathetic divisions of the Autonomic Nervous
System.
v Causes
• Bladder distention (most common)
• Bowel impaction
• UTI
• Ingrown toenails
• Pressure ulcers
• Pounding headache
• Profuse sweating
• Nasal congestion
• Piloerection
• Bradycardia
• Blurring of vision
v Management
• Position the patient in sitting position to decrease BP
• Catheterization (bladder distention)
• Check for fecal impaction
• Monitor Blood pressure
• Administer anti-hypertensive agents
ü DOC: Hydralazine (Apresoline)
ALZHEIMER'S DISEASE
v Progressive, irreversible, degenerative neurologic disease

v Begins with gradual losses of cognitive function and disturbances in behavior and affect.
v Etiology
• Unknown/Idiopathic
• Viral / Bacterial infection
• Trisomy 21 (40 y/o)
• Decrease in the level of acetylcholine transferase activity in the cortex and hippocampus
v Pathophysiology
Cortical atrophy & loss of neurons (parietal and temporal lobes)
Ventricular Enlargement (because of loss of brain tissue)
Development of amyloid-containing neuritic plaques & neurofibrillary tangles in cerebral cortex
Warning Signs
• Memory loss affecting ability to function
in job
• Difficulty with familiar tasks
• Problems with language and abstract thinking
• Disorientation, changes in mood and personality

Stage
• Appears healthy and alert
• Cognitive deficits are undetected
Stage I
• Subtle personality changes
(Early)
• Memory lapses and forgetfulness
• Seems restless and uncoordinated
• Memory deficits
ü May lose ability to recognize familiar places, faces and objects
✓ May get lost in familiar environment
• Impaired language
• Difficulty with motor activity and object recognition
Stage II
• Inability to carry out ADLs
(Middle)
• Impaired judgment
• Sundowning: increased agitation, wandering, disorientation in the
afternoon and evening hours
• Astereognosis (inability to identify objects by touch)
• Inability to write
• Complete dependency & loss of language
Stage III
• Loss of bowel and bladder control
(Final)
• Progressive loss of cognitive abilities
v Diagnostic Tests
• Cerebral biopsy (confirmatory)
• Clinical examination
• MRI
• CT Scan
• Positron Emission Tomography
• Single Photon Emission Computed
Tomography
• Cholinesterase inhibitors
ü For mild to moderate symptoms
ü Enhances acetylcholine uptake in the brain
ü Donepezil (Aricept)
ü Rivastigmine (Exelon)
ü Tacrine hydrochloride (Cognex)
• N-methyl-D-aspartate (NMDA) Antagonist

ü Prevents over-excitation of NMDA
receptors in the brain.
ü Memantine (Namenda)
• Antidepressants
• Antipsychotics
• Anti-anxiety
Nursing Management
Cognitive Function
• Provide a calm, predictable environment
• Speak in a quiet and pleasant manner
• Use memory aids and cues
• Encourage active participation
• Promote contact with reality
Safety
• Remove all hazards

• Avoid restraints (increases agitation)
• Secure the doors from the house
• Supervise all activities at home (let patient wear identification bracelet)
Anxiety and Agitation Reduction

• Provide constant emotional support
• Keep the environment organized, familiar and noise-free
• Provide structured activities
• Familiarize oneself with the patients
predicted responses to certain stressors
Communication
• Use clear, easy-to-understand sentences
• List simple written instructions
• Patient may use nonverbal communication
• Tactile stimuli (signs of affection)
Independence in self-care activities

• Simplify daily activities
• Collaborate with occupational therapy
• Direct patient supervision
• Encourage patient to make decisions
Socialization
• Provide simple recreational activities
Nutrition
• Keep mealtime simple and calm
• One dish is offered at a time
• Cut food into small pieces
• Provide familiar foods that look appetizing and tastes good
• Provide adaptive equipment
necessary
BELL'S PALSY
v Unilateral inflammation of the seventh cranial nerve
v Produces unilateral facial weakness and paralysis
v Rapid onset
v May equally happen to both sexes
v Adults (< 45 y/o)
v Cause
• Unknown
• Autoimmune
• Viral (Herpes Simplex / Herpes Zoster)
• Bacterial infection
v Pathophysiology
Inflamed and edematous facial nerve
Compression

Facial nerve damages
Occlusion of blood supply
Ischemic necrosis of the facial nerve
• Inability to close eye completely on the affected side
• Ptosis
• Pain around the jaw or ear
• Unilateral facial weakness
• Ringing in the ear
• Eating difficulty
• Taste distortion on the anterior portion of the tongue (affected side)
• Flat nasolabial fold
v Diagnostic Tests
• History and Physical Exam
• EMG
v Management
Medications
• Prednisone (7 to 10 days)
• Analgesics (pain control)
• Antiviral drugs
Comfort measures
• Heat application on the involved side
• Gentle massage
• Electrical nerve stimulation
• Nutrition: Soft diet
• Instruct to chew on the unaffected side
• Avoid hot fluids/food
• Administer drugs as ordered
• Artificial tears is recommended (prevents corneal irritation)
• Facial exercise (grimacing; wrinkling, whistling, puffing of the cheeks, blowing out air)
HUNTINGTON'S DISEASE
v Progressive atrophy of basal ganglia and some parts of cerebral cortex
v Age (25 to 55 years)
v 1:10, 0000
v Cause
• Autosomal genetic transmission
v Pathophysiology
Degeneration of the corpus striatum & caudal nucleus
progressive loss of normal movement and intellect

• Increased involuntary movements

• Cognitive progressive decline
• Impaired chewing & swallowing
• Chorea
• Dystonic posture
• Dysarthria
• Personality changes
• Depression
• Psychosis
• Hesitant speech & eye blinking
v Diagnostic Tests
• History and Physical Exam
• MRI
• CT Scan
• Genetic Testing
• Thiothixene hydrochloride (chorea)
• Haloperidol
• Levodopa (rigidity)
• Foster independence in ADL
• Reinforce the use of assistive devices
for ambulation as needed
• Aspiration precaution
• Provide soft foods
• Give directions in a calm but firm tone
• Provide safety environment
• Get emotional support from support groups
• Seek genetic counselling
TRIGEMINAL NEURALGIA
v Other Term: Tic Douloureux
v It is a condition of the fifth cranial nerve characterized by paroxysms of pain in the area innervated by any of the
three branches
v Second and third branches of the trigeminal nerve (most common)
v 400 times more common in patients with Multiple Sclerosis (MS)
v Men with MS > Women with MS
v Causes
• Chronic compression or irritation of trigeminal nerve
• Degenerative changes in the Gasserian ganglion
• Vascular pressure from structural abnormalities encroaching on the trigeminal nerve, Gasserian ganglion or
root entry zone
• Intense recurring episodes of pain (sudden, jabbing, burning or knifelike)
• Episodes of pain begin and end suddenly, lasting for few seconds to minutes.
• Unilateral pain
v Diagnostic Tests
• History of symptoms and direct observation of an attack
• CT Scan
• MRI

• Anti-seizure agents (Carbamazepine, Phenytoin)
• Alcohol or phenol injection of the Gasserian ganglion and peripheral branches of the trigeminal nerve
Surgical Treatment
Microvascular Decompression of the Trigeminal Nerve
• With the aid of an operating microscope, the artery loop is lifted from the nerve to relieve the pressure, and a
small prosthetic device is inserted to prevent recurrence of impingement on the nerve.
Radiofrequency Thermal Coagulation

• Percutaneous radiofrequency produces a thermal lesion on the trigeminal nerve.
Percutaneous Balloon Micro-compression

• Percutaneous balloon microcompression disrupts large myelinated fibers in all three branches of the trigeminal
nerve.
Preventing Pain
• Recognize factors that may aggravate facial pain
ü Food that is too hot or too cold
ü Jarring of the patient's bed or chair
ü Washing the face, combing hair or brushing the teeth
• Providing cotton pads and temperature
• water for washing the face
• Rinse with mouthwash after eating
• Chew on the unaffected side
• Soft foods
Postoperative Care
• Sensory deficits
ü Instruct not to rub the eye
ü Assess the eyes for redness
ü Artificial tears

ORTHOPEDICS
MUSCULOSKELETAL SYSTEM
ANATOMY
There are 206 bones in the body divided into four categories:
v Long bones- designed for weight bearing and movement
v Short bones- consist of cancellous bone covered by a layer of compact bone
v Flat bones-important sites of hematopoiesis and frequently protect vital organs.
v Irregular bones- have unique shapes related to their functions.
Three Types of Bone Cells:
v Osteoblasts- function in bone formation by secreting bone matrix
v Osteocytes- mature bone cells involved in bone maintenance, located in lacunae
v Osteoclasts- are multi nuclear cells involved in dissolving and resorbing bone
Parts of the Bone:
v Osteon- microscopic functioning unit of mature cortical bone
v Periosteum- dense, fibrous membrane covering the bone
v Endosteum- a thin, vascular membrane that covers the marrow cavity of long bones and the spaces in
cancellous bone
v Bone Marrow- is a vascular tissue located in the medullary cavity of long bones and in flat bones
v Epiphyses- ends of the long bones
v Cartilage- tough, elastic, avascular tissue that covers the ends of long bones
v Diaphysis- shaft of the long bone
BONE FORMATION
Osteogenesis- bone formation begins long before birth.
Ossification- the process by which the bone matrix is formed, and hard mineral crystals composed of calcium and
phosphorus are bound to the collagen fibers.
BONE MAINTENANCE
v Remodeling- primary process that occurs by early adulthood; maintains bone structure and function through
simultaneous resorption and osteogenesis, and as a result, complete skeletal turn over occurs every 10 years.
v Resorption- removal or destruction of tissue, such as bone tissue
Factors:
v Physical activity- stimulate bone formation
v Dietary intake of certain nutrients (Calcium)
v Several hormones (calcitriol, PTH, calcitonin, thyroid hormone, cortisol, growth hormone and estrogen and
testosterone.)
BONE HEALING
v Broken bones heal by a process referred to as union. Union takes place in a series of steps.
1. Hematoma formation
• Blood accumulates in the area of break or injury
• Extravascular blood converts from liquid to semisolid clots
• Active phagocytosis removes necrotic tissue and debris
2. Callus formation
• Fibrin cells form a network around the injured area
• The damaged periosteum is stimulated to generate osteoblasts, forming new bony substances referred to as
osteoid.
• Minerals begin to accumulate in a network, forming a collagen callus
3. Calcification process
• Calcification begins and establishes support of the injury.
• Connective tissue proliferates across the site and is usually completely calcified within 6 weeks.
4. Remodeling process
• Excess cellular material is reabsorbed, and the bone resumes its preinjury strength and configuration
• This remodeling phase is enhanced by stress and exercise
• Complete remodeling can take 6 months
to 1 year to complete.

ARTICULAR SYSTEM
Joint- the junction of two or more bones
Three bask kinds of joints
v Synarthrosis
• Immovable
• (eg. skull sutures)
v Amphiarthrosis
• Allow limited motion
• (eg. vertebral joints and the symphysis pubis)
v Diarthrosis
• Freely movable
Ball-and-socket joints
Ø Permit full freedom of movement.
Ø eg, the hip and the shoulder)
Hinge joints
Ø Permit bending in one direction only
Ø (eg, the elbow and the knee).
Saddle joints
Ø Allow movement in two planes at right angles to each other.
Ø The joint at the base of the thumb is a saddle, biaxial joint.
Pivot joints
Ø Characterized by the articulation between the radius and the ulna.
Ø They permit rotation for such activities as turning a doorknob.
ü Gliding joints
Ø Allow for limited movement in all directions and are represented by the joints of the carpal bones in the wrist.
Synovium- membrane lining the capsule which secretes the lubricating and shock absorbing the synovial fluid into the
joint capsule
Ligaments - fibrous connective tissue bands that bind the articulating bones together.
Bursa- sac filled with synovial fluid that cushions the movement of tendons,
ligaments, and bones at a point of friction
Skeletal Muscle Contraction
v Each muscle cell (also referred to as a muscle fiber) contains myofibrils, which in
turn are composed of a series of sarcomeres, the actual contractile units of
skeletal muscle.
v Muscle cells contract in response to electrical stimulation delivered by an
effector nerve cell at the motor end plate.
v Energy is consumed during muscle contraction and relaxation.
v The primary source of energy for the muscle
v cells is adenosine triphosphate (ATP),
which is generated through cellular oxidative metabolism.
v Isometric contraction, the length of the muscles remains constant but the force generated by the
muscles is increased (pushing against an immovable wall).
v Isotonic contraction is characterized by shortening of the muscle with no increase in tension within the
muscle; an example of this is flexing the forearm
Muscle Tone
v Relaxed muscles demonstrate a state of
readiness to respond to contraction stimuli.
• Flaccid- A muscle that is limp and without tone
• Spastic- A muscle with greater-than normal tone.
Exercise, Disuse, and Repair

v Muscles need to be exercised to maintain function and strength
v Hypertrophy- results from an increase in the size of individual muscle fibers without an increase in their number
v Atrophy- decrease in the size of a muscle.
v The patient can decrease the effects of immobility by isometric exercise of the
muscles of the immobilized part.
v Quadriceps contraction exercises (tightening the muscles of the thigh) and
gluteal setting exercises (tightening of the muscles of the buttocks) help maintain the larger muscle groups that are
important in
ambulation
DIAGNOSTIC TESTS
1. X-ray Studies
v Determine bone density, texture, erosion, and changes in bone relationship
2. Computed Tomography
v Shows in detail a specific plane of involved bone, reveal tumors of the soft tissue or injuries to the ligaments or
tendons.
v The patient must remain still during the procedure.
3. Magnetic Resonance Imaging
v Noninvasive imaging technique that uses magnetic fields, radiowaves, and computers to demonstrate
abnormalities of soft tissues.
v Patient with any metal implants, clips, or pacemakers are not candidates for MRI. Intravenous contrast agents
may be
used. The patient must lie still and will hear a rhythmic knocking sound.
v Patients who experience claustrophobia may be unable to tolerate the confinement of closed MRI
equipment
without sedation.
4. Arthrography
v A radiopaque contrast agent or air is injected into the joint cavity to visualize irregular surfaces.
v After an arthrogram, a compression elastic bandage is applied as prescribed and the joint is usually rested for 12
hours.
v Assess contraindications to the study
• Pregnancy
• Claustrophobia
• Inability to tolerate required positioning due to age and disability
• Metal implants
v If contrast agents will be used for CT scan, MRI, or arthrography, the patient is assessed for possible allergies.
5. Bone densitometry
v used to estimate bone mineral density.
v Use of x-rays or ultrasound.
6. Bone scan
v Detect:
• Metastatic and primary bone
tumors
• Osteomyelitis
• Some fractures
• Aseptic necrosis.
v A bone-seeking radioisotope is injected into the joint.
v The scan is performed 2 to 3 hours after the injection
• The nurse inquires about possible allergies to the radioisotope
• Assess for any condition that would contraindicate performing the procedure (eg, pregnancy)
• Encourage the patient to drink plenty of fluids to help distribute and eliminate the isotope
• The patient is asked to empty the bladder before the procedure because a full bladder interferes with
accurate scanning of the pelvic bones.
• A sterile dressing is applied after aspiration.
• There is a risk of infection after this procedure.

7. Electromyography
v Provides information about the electrical potential of the muscles and the nerves leading to them.
v The test is performed to evaluate muscle weakness, pain, and disability.
v Needle electrodes are inserted into selected muscles, and responses to electrical stimuli are recorded on
an oscilloscope.
v Warm compresses may relieve residual discomfort after the study.
8. Biopsy
v Biopsy may be performed to determine the structure and composition of bone marrow, bone, muscle, or
synovium to help diagnose specific diseases.
v The nurse monitors the biopsy site for edema, bleeding, pain, and infection. Ice is applied as prescribed to control
bleeding and edema.
v Analgesic agents are administered as prescribed for comfort.
9. Arthroscopy
v Procedure that allows direct visualization of a joint to diagnose joint disorders.
Uses:
• Treatment of tears, defects, and disease processes.
v The procedure is performed in the operating room under sterile conditions; injection of a local anesthetic
agent into the joint or general anesthesia is used
v Complications:
• Infection
• Hemarthrosis
• Neurovascular compromise
• Thrombophlebitis
• Stiffness
• Effusion
• Adhesions
• Delayed wound healing.
• After the arthroscopic procedure, the joint is wrapped with a compression dressing to control swelling.
• Ice may be applied to control edema and enhance comfort.
• Frequently, the joint is kept extended and elevated to reduce swelling.
• It is important to monitor and document the neurovascular status.
• Analgesic agents are administered as needed.
• The patient is instructed about activities and exercises that may be performed.
10. Arthrocentesis
v (Joint aspiration) is carried out to obtain synovial fluid for purposes of examination or to relieve pain to
effusion.
v Normally, synovial fluid is clear, pale, straw colored, and scanty in volume.
v Using aseptic technique, the physician inserts a needle into the joint and aspirates fluid
• Anti-inflammatory medications may be injected into the joint
• A sterile dressing is applied after aspiration.
PATIENT IN A CAST
Definition
v A rigid external immobilizing device that is molded to the contours of the body.
v Mold- used for splinting the affected part of the body wherein there is an infection, swelling and wound
Purposes
v Immobilize a reduced fracture

v Correct deformity
v Apply uniform pressure to underlying soft tissue
v Support and stabilize weakened joints
Types of Casts
v Casts in the Trunk Area
• Collar Cast
ü affectation of the cervical spine
• Body Cast
ü affectation of the lower thoracic and upper lumbar spine
• Minerva Cast
affectation of the cervical and the
upper dorsal spine.
• Rizzer's Jacket
ü affectation of the thoraco-lumbar spine; for scoliosis
• Shoulder spica cast
ü affectation of the upper portion of the humerus and the shoulder joint
• Sugar Tong
ü compound affectation of the humerus with open wound, inflammation and swelling
v Casts in the Upper Extremities
• Short arm circular cast
ü affectation of the carpals and
metacarpals
• Short arm posterior mold
ü affectation of the carpals and
metacarpals with open wound, inflammation or swelling
• Munster/ Fuenster Cast
ü affectation of the radius-ulna with callus formation
• Long arm circular cast
ü affectation of the radius-ulna
• Hanging cast
ü affectation of the shaft of the humerus;
• Functional Cast
ü affectation of the shaft of the humerus with callus formation
• Airplane cast
ü affectation of the neck of humerus; recurrent shoulder dislocation
• Thumb spica cast
ü Affectation of the first metacarpal bone
v Casts in the Lower Extremities
• Short leg circular cast
ü affectation of tarsals and metatarsals
• Short leg posterior mold
ü affectation of tarsals and metatarsals with open wound, inflammation or swelling
• Walking cast
ü affectation of tarsals and metatersals with callusformation
• Long Leg Circular Cast
ü affectation of tibia-fibula
• Long leg Posterior mold
ü affectation of tibia-fibula with open wound, inflammation and swelling
• Patellar Tendon Bearing cast
ü affectation of tibia-fibula with callus formation
• Delvitt cast
ü affectation of the distal third of tibia-fibula with callus formation
• Cylinder cast
ü affectation of the patella with open
wound, inflammation or swelling
• Ischial weight bearing cast
affectation of the shaft of femur
with callus formation
• Basket cast
for massive bone injury of the patella to facilitate wound dressing
• Cast brace
fracture of the distal third of femur and proximal third of tibia with callus formation
• Single hip spica cast
affectation of one hip and one femur
• One and one half cast
affectation of two hips and one femur
• Double hip spica cast
affectation of two hips and two femur
• single hip spica mold
affection of one hip and one febur with open would, inflammation or swelling
• Pantalon case
affection of pelvis
• Frog cast
for congenital hip dysplasia
• Internal rotator board
for post hip surgery to maintain knee adduction
• Night splint
ü for post poliomyelitis with contractures of hip and knee; applied at night only
Casting materials
v Fiberglass
• Made of an open-weave, no fabric impregnated with hardeners
• Water-activated polyurethane resin
• Lighter in weight
• Costly
• Stronger and more durable
• Water resistant
• Dries completely within 10 to 15 minutes
• Can bear weight within 30 minutes
v Plaster Cast
• Rolls of crinoline with powdered
anhydrous calcium sulfate (gypsum crystals) mixed with water swells and
forms into a hard cement
• Traditional
• Plaster of Paris
• Less costly
• Achieve a better mold not as durable and take longer to dry
• Requires 24 to 72 hours to dry completely
Materials/ Instruments in cast Application or
Removal
v Stockinette
v Wadding sheet and gauze bandage
v Plaster of Paris/ fiberglass
v Trimming knife
v Cast spreader
v Stryker cast cutter
v Bandage scissors
Cast Techniques
v Windowing
• Putting a hole on a cast on the site of an
open wound of the casted extremity.
• Purposes:
Visualization
Inspection
Dressing
Application of medications
v Bivalving
• Cutting the cast into two halves from the upper portion to the bottom part
• Purposes:

Relieving possible cast tightness
X-ray
Inspection of the casted extremity
v Reinforcing
• Reapplication of Plaster of Paris
• Purpose:
Regaining its strength in case of
wetting the cast which resulted to
its instability.
Nursing Management for Casts
v The nurse should prepare the patient for the sensation of increasing warmth so that the
patient does not become alarmed.
v Promote cast drying
• Do not cover
• Leave exposed to circulating air.
v Handle damp plaster cast with palms of the hands
v Do not rest the cast on hard surfaces or sharp edges that can dent soft
cast.
v Control swelling and pain
• Elevate immobilized extremity to heart level
• Apply intermittent ice bag if prescribed
• Take analgesic agents as prescribed.
v Report pain uncontrolled by elevation and analgesics, may indicate compartment syndrome or pressure ulcer
v Avoid excessive use of injured extremity; observe prescribed weight-bearing limits
v Manage minor skin irritation
• Pad rough edges with tape
• Relieve itching
• Blow cool air from hair dryer
• Do not insert objects inside the cast.
v Check neurovascular status (8 P's)
v Report promptly to physician:
• Uncontrolled swelling and pain
• Cool, pale fingers or toes
• Paresthesia
• Paralysis
• Purulent drainage staining cast
• Signs of systemic infection
• Cast breaks
PATIENT IN SPLINTS AND BRACES
Splints
v May be used for conditions that do not require rigid immobilization

v Immobilize and support the body part in a
functional position and must be well padded to prevent pressure, skin abrasion and skin
breakdown.
v For short-term use
Examples Of Splints
Cock-up Splint- For wrist drop

Banjo Splint- For peripheral nerve injury
Oppenheimer- For radial nerve injury

Lively Finger Splint- For fracture of the finger
Arm sling- To support affected upper extremity
Shoulder Strap- For scoliosis
Braces
v Mechanical support for weakened muscles, joints and bones in rehabilitation
Purposes:
• Provide support
• Control movement
• Prevent additional injury.
v For longer use
Example of Braces
v Collar Brace
• For cervical spine affectation
• Shantz and Philadelphia
v Four Poster Brace
• For cervical spine and upper thoracic
spine affectation
v Somi Brace
• Sterno- Occipito- Mandibular Immoblizer
• Forester Brace
• Cevico-thoraco-lumbar spine affectation
v Knight Taylor Brace
• Affectation of the upper thoracic spine
v Chair Back Brace
• For lumbo-sacral spine affectation
v Jewette Brace
• For dorso lumbar and upper lumbar spine affectation
v Milwaukee Brace
• For scoliosis
• Affectation of T9 and below
v Yamamoto Brace
• For scoliosis
• Affectation of T9 and above
v Scottish Rite
• For Coxa Plana or Legg Calve Perthes
Disease
v Long Leg Brace
• For post poliomyelitis with residual
paralysis
v Short Leg Brace
• For clubfoot
v Dennis Browne Shoe
• For congenital clubfoot (Talipes Equino-Varus)
Nurse Management
• Assess the neurovascular status before application

• Nurse gives information about the underlying pathologic condition and the purpose and
expectations of the prescribed treatment regimen.
• Prepare the patient for the application of the cast, brace, or splint by describing the anticipated sights,
sounds, and sensations
• Evaluate pain associated with the musculoskeletal condition
Alert: A patient's unrelieved pain must be immediately reported to the physician to avoid possible paralysis and
necrosis.
• The nurse monitors circulation, motion, and sensation of the affected extremity
• Normal findings include minimal edema, minimal discomfort, pink color, warm to touch, rapid capillary refill
response, normal sensations, and ability to exercise fingers or toes
Eight “P”’s
v Pain
v Pallor
v Pulselessnes
v Paresthesia
v Paralysis
v Poikilothermia (Cold extremity)
v Poor capillary refill
v Poor hair growth
Complication
v Compartment Syndrome
• Occurs when there is increased tissue pressure within a limited space that compromises the circulation and the
function of the tissue within the confined area
• Management:
ü The cast must be bivalved (cut in half longitudinally) while maintaining alignment
ü Extremity must be elevated no higher than heart level to ensure arterial perfusion
ü A fasciotomy may be necessary to relieve the pressure within the muscle compartment.
v Pressure Ulcers
• Main Pressure sites:
ü Heel
ü Malleoli
ü Dorsum of the foot
ü Head of the fibula
ü Anterior surface of the patella.
ü Medial epicondyle of the humerus
ü Ulnar styloid
• Pain and tightness in the area.
• A warm area on the cast or brace
suggests underlying tissue erythema
• The drainage may stain the cast 7
brace and emit an odor
• Bivalve or cut an opening (window) in
the cast.
v Disuse Syndrome
• Muscle atrophy and loss of strength
brought about by immobilization hum cast, brace and splint
v Tense or contract muscles (eg, isometric muscle contraction) without moving the part
v Muscle-setting exercises
• Quadriceps-setting
• Gluteal-setting exercises
NURSING MANAGEMENT FOR PATIENT'S WITH
IMMOBILIZED EXTREMITIES
Upper:
v Frequent rest periods are necessary.
v To control swelling, the immobilized arm
elevated.
v A sling may be used when the patient
ambulates
v Volkmann's contracture, a specific type of compartment syndrome. Contracture of the fingers and wrist occurs as
the result a' obstructed arterial blood flow to the forearm and hand. Permanent damage develops.
v Neurovascular checks must be done frequently
Lower:
v The patient's leg must_ be supported on pillows to heart level to control swelling
v Ice packs should be applied as prescribed over the fracture site for 1 or 2 days.
v The patient is taught to elevate the immobilized leg when seated.
v The patient should also assume a recumbent position several times a day with the immobilized leg elevated to
promote venous return and control swelling.
v Nerve function is assessed by observing the patient's ability to move the toes and by asking about the sensations in
the foot.
Alert: Injury to the peroneal nerve as a result of pressure is a cause of footdrop (the inability to maintain the foot in a
normally flexed position). Consequently, the patient drags the foot when ambulating.
NURSING MANAGEMENT FOR PATIENT

WITH SPICA BODY CAST
v Assisting with skin care and hygiene,

v The nurse turns the patient as a unit toward the uninjured side every 2 hours to relieve pressure and to allow the
cast to dry.
v The nurse turns the patient to a prone position, twice daily if tolerated, to provide postural drainage of the
bronchial tree and to relieve pressure on the back.
v The nurse inspects the skin around the edges of the cast frequently for signs of irritation.
v The perineal opening must be large enough for hygienic care. Monitoring for cast syndrome
• Psychological component is similar to a claustrophobic reaction.
• Physiologic cast syndrome responses (eg, superior mesenteric artery syndrome) are associated with immobility in
a body cast. Ileus may occur.
• Management:
ü Decompression (nasogastric intubation connected to suction)
ü Intravenous (IV) fluid therapy until gastrointestinal motility is restored
ü The abdominal window must be enlarged if the abdomen restricts.
Alert: The nurse monitors the patient in a large
body cast for potential cast syndrome, noting bowel sounds every 4 to 8 hours, and reports distention, nausea, and
vomiting to the physician.
THE PATIENT WITH AN EXTERNAL
FIXATOR
External fixators
v Used to manage open fractures with soft tissue damage.
v Provides stable support for severe comminuted (crushed or splintered) fractures while permitting active
treatment of damaged soft tissues
v The fracture is reduced, aligned, and immobilized by a series of pins inserted in the bone.
v Pin position is maintained through attachment to a portable frame
Nursing Management:
v After the external fixator is applied, the extremity is elevated to reduce swelling.
v If there are sharp points on the fixator or pins, they are covered with caps to prevent device-induced injuries.
v Monitor the neurovascular status of the extremity every 2 to 4 hours
v Assess each pin site for redness, drainage, tenderness, pain, and cleaning each pin site separately one or two
times a day with cotton-tipped applicators soaked in chlorhexidine solution.
v If signs of infection are present or if the pins or clamps seem loose, the nurse notifies the physician.
v The nurse encourages isometric and active exercises as tolerated
Alert: The nurse never adjusts the clamps on the external fixator frame. It is the physician's responsibility to do so.
THE PATIENT IN TRACTION
v Traction is the application of a pulling force to a part of the body.
v Purposes:
• Minimize muscle spasms
• To reduce, align, and immobilize fractures
• To reduce deformity
• To increase space between opposing surfaces

v Principles:
• Traction must be continuous to be effective in reducing and immobilizing fractures.
• Skeletal traction is never interrupted.
• Weights are not removed unless intermittent traction is prescribed.
• Any factor that might reduce the effective pull or alter its resultant line of pull must be eliminated:
• The patient must be in good body alignment in the center of the bed when traction is applied.
• Ropes must be unobstructed.
• Weights must hang freely and should not rest on the bed or floor.
• Knots in the rope or the footplate must not touch the pulley or the foot of the bed.
TYPES OF TRACTION
v Skin Traction- traction applied to the skin, non-invasive
v Skeletal traction- traction applied directly to the bony skeleton, invasive
v Manual Traction- traction applied with the hands, temporary traction that may be used when applying a cast,
giving skin care under a Buck's extension foam boot, or adjusting the traction apparatus.
SKIN TRACTION
v Used to control muscle spasm and to immobilize an area before surgery.
v Pulling force is applied to the skin, transmitted to the muscle, then to the bones.
v The amount of weight applied must not exceed the tolerance of the skin.
ADHESIVE SKIN TRACTION
v Use of adhesive tape, elastic bandage,
wooden spreader and wadding sheet
1. Dunlop Traction
• Affectation of Supracondylar of the humerus
2. Zero Degrees Traction

• Affectation of the surgical neck of the humerus and the shoulder joint
3. Buck's Extension Traction

• Is skin traction to the lower leg
• Affectation of the hip and the femur
v Avoid wrinkling and slipping of the traction bandage and to maintain countertraction.
v Proper positioning must be maintained to keep the leg in a neutral position.
Skin Breakdown
v Removes the foam boots to inspect the skin,the ankle, and the Achilles tendon three times a day.
v Provides back care at least every 2 hours to prevent pressure ulcers. The patient who must remain in a
supine position is at increased risk for development of a pressure ulcer.
v Uses special mattress overlays (eg, air-filled, high density foam) to prevent pressure ulcers.
Nerve Damage
v The nurse should immediately investigateany complaint of a burning sensation under the traction bandage or
boot.
Circulatory Impairment
v Nurse assesses the foot within 15 to 30 minutes and then every 1 to 2 hours.
v Circulatory assessment consists of the following:
• Peripheral pulses
• Color
• Capillary refill
• Temperature of the fingers or toes
4. Bryant Traction
• The Affectation of the hip and femur for children below 3 yrs. Old
5. Boot Cast Traction
• For post poliomyelitis with residual
paralysis of the hip and knee
NON-ADHESIVE SKIN TRACTION

v Use of canvas, slings, leathers, straps with buckles, laces and ribbons
1. Head Halter Traction
• For cervical spine affection
2. Pelvic Girdle Traction
• For Lumbo-sacral spine affection
• For Herniated Nucleus Pulposus
3. Cotrei Traction
• For Scoliosis
• A combination of head halter and pelvic
girdle Traction
4. Hammock Suspension Traction
• For affectation of the pelvis
• For Malgained Fracture (double
fractures of the pelvic ring causing
instability of the pelvis)
5. Bohler Braun Splint
• Supports the lower leg
• For fracture of Proximal 3rd and Middle
3rd of tibia-fibula.
v Skeletal traction is applied directly to the bone by use of a metal pin or wire that is inserted through the bone
distal to the fracture, avoiding nerves, blood vessels_ muscles, tendons, and joints.
v Skeletal traction frequently uses 7 to 12 kg (15 to 25 lb) to achieve the therapeutic effect
v Supports the affected extremity off the bed and allows for some patient movement without disruption of the line
of pull.
1. Kirschner's wire holder
• Affectation of the radius ulna
• Thinner than the Steinmann's pin
2. Steinmann's pin holder
• Affectation of the humerus, femur, tibia,
fibula
3. Crutchfield tong
• Affectation of the upper dorsal cervical
Spine
• Inserted at the parietal area

4. Balanced suspension traction
• Affectation of the hips and or femur
5. Overhead traction
• Supracondylar Fracture of the humerus
6. Ninety-ninety degrees Traction
• Subtrochanteric and 3rd fracture of femur
7. Halo-pelvic traction
• For C-type Scoliosis
8. Halo-femoral traction
• For S-type Scoliosis
9. Stove-in Traction
• For massive rib fracture
• Maintain alignment of the patient's body in traction
• Avoid foot drop ( plantar flexion), inward rotation (inversion), and outward rotation (eversion)
• Protect the elbows and heels and inspect them for pressure ulcers.
• Assess neurovascular status at least every hour for the first 4 hours.
• The nurse encourages the patient to do active flexion—extension ankle exercises and isometric contraction of the
calf muscles (calf-pumping exercises) 10 times an hour while awake to decrease venous stasis.
• Anti-embolism stockings, compression devices, and anticoagulant therapy may be prescribed to help prevent
thrombus
formation
• Pin site care is performed initially one or two times a day.
• Chlorhexidine solution is recommended as the most effective cleansing solution; however, water and saline are
alternate
choice.
• The nurse must inspect the pin sites every 8 hours for reaction and infection
• Patients permitted to take showers within 5 to 10 days of pin insertion are encouraged to leave the pins
exposed
to water flow.
Alert: The nurse must never remove weights from skeletal traction unless a life-threatening situation occurs. Removal
of the weights completely defeats their purpose and may result in injury to the patient.
v Complications:
1. Atelectasis and Pneumonia
• The nurse auscultates the patient's lungs every 4 to 8 hours
• To assess respiratory status:
ü Teach the patient deep breathing and coughing exercises to aid in fully expanding the lungs and
clearing pulmonary secretions
2. Constipation and Anorexia
• Diet:
Ø high in fiber and fluids may help stimulate gastric motility
• Therapeutic measures may include stool softeners, laxatives, suppositories, and enemas.
• To improve the patient's appetite, the patient's food preferences are included, as appropriate, within the
prescribed therapeutic diet
3. Urinary Stasis and Infection.

• The patient is encouraged to drink fluids to prevent dehydration and associated hemoconcentration, which
contribute to stasis.
4. Venous Thromboembolism
• The nurse monitors the patient for
signs of DVT, including unilateral
calf tenderness, warmth, redness,
and swelling (increased calf
circumference).
BALANCED SKELETAL TRACTION

v Equipment
• Ropes
ü Thigh (short)
ü Traction (long)
ü Suspension (longest)
• Foot board/foot pedal
ü For foot support
ü Avoid foot drop
• Paper clips/Safety Pins
• Slings
ü Wider and longer for thigh part
ü Shorter for leg part
• Splints/Attachments
ü Pearson Attachment
ü Rest Splint
ü Thomas Splint (with half ring)
• Weight Bags (2)
ü Traction - 10% of the patient's body weight
ü Suspension - 50% or 1/2 of the traction bag
v Checking the efficiency of traction
• Flex the unaffected leg
• Hold-on the overhead trapeze
• Swing the affected leg
ü Forward and backward
ü Side by side (right and left)
v Principles:
• Avoidance of friction
ü Ropes run freely along the groove of the pulley
ü Knots away from the pulley
• Continuous traction
Observe wear and tear on the bags
and ropes
Weight bags hanging freely
• Line of pull in line with deformity
ü 1ST pulley in line with the inguinal/groin area
ü 2ND pulley in line with the knee
ü 3rd pulley in line with the 1ST and 2nd
ü pulley
• Opposite pull or Countertraction
ü Patient's weight
• Supine/ Dorsal Recumbent position
• General hygiene and comfort
Sponging of affected leg
• Conditioning exercises
ü Deep and Coughing exercises
ü Dorsiflexion and plantar flexion of toes to prevent foot drop
ü Active ROM to unaffected extremity
ü Static quadriceps to affected extremity
ü Alternate contraction and relaxation
• Prevention of complications
ü Hypostatic Pneumonia
Ø Deep breathing
Ø Keep back dry
Ø Frequent turning/ repositioning
ü Bed sore/Decubitus ulcer
Ø Linen free from wrinkles and

crumbs
Ø Keep back dry
Ø Lift buttocks (use of overhead
trapeze)
Ø Frequent turning/repositioning
Ø Massage
ü Joint contractures and muscle atrophy
ü Constipation / UTI
Ø Increase fluid and roughage
diet
Ø Exercise
Ø Bedpan at regular interval
Ø Repositioning
ü Infection/ neurovascular status of affected extremity
Ø Aseptic technique
Ø Sterile dressing
ü Provide diversional activities
ü Meet nutritional needs
Ø Vit. C, Calcium and Protein
ü Pertinent inspection and observation of the patient
Ø Attend to any complaint
THE PATIENT UNDERGOING

ORTHOPEDIC SURGERY
v Patients with severe joint pain and disability may undergo joint replacement.
ü Preoperative skin preparation frequently begins 1 or 2 before the surgery.
ü Prophylactic antibiotic 60 minutes prior to incision are effective in preventing postoperative infection
ü Culture of the joint during surgery may be important in identifying and treating subsequent infections.
ü Persistent infection at the site of the prosthesis usually requires removal of the implant and joint revision.
• Promoting Ambulation
ü Assist the patient in achieving the
ü goal of independent ambulation.
ü The nurse encourages transferring to a chair several times a day for short periods and walking for
progressively greater distance.
TOTAL HIP REPLACEMENT
v Replacement of a severely with an:
• Artificial joint
• Osteoarthritis
• Rheumatoid arthritis
• Femoral neck fractures
• Failed prosthesis
• Osteotomy
• Legg-Calve-Perthes
• Preventing Dislocation of Prosthesis
ü Maintenance of the femoral head component in the acetabular cup

ü Positioning the leg in abduction, which helps prevent dislocation of the prosthesis.
ü The use of an abduction splint, a wedge pillow or two or three pillows between the legs keeps the hip in
abduction.
ü The patient's hip is never flexed more than 90 degrees.
ü High-seat (orthopedic) chairs, semi-reclining wheelchairs, and raised toilet seats are used to
minimize hip joint flexion
ü The patient should not cross his or her legs.
ü The patient should not bend at the waist to put on shoes and socks.
ü If a prosthesis becomes dislocated, the nurse (or the patient, if at home) immediately notifies the
surgeon.
• Monitoring Wound Drainage
ü Drainage of 200 to 500 mL in the first hours is expected
ü The nurse promptly notifies the physician of any drainage volumes greater than anticipated.
• Preventing Deep Vein Thrombosis
ü Anti-embolism stockings
ü Signs of DVT include calf pain, swelling, and tenderness.
ü Medications:
Fondaparinux (Arixtra)
Ø Low-molecular-weight heparin (eg, enoxaparin [Lovenox], dalteparin [Fragmin])
ü Potential sources of infection are avoided.
ü Prophylactic antibiotics are prescribed if the patient needs any future surgical or invasive procedures
ü Severe infections may require surgical debridement or removal of the prosthesis
ü If an infection occurs, antibiotics are prescribed.
TOTAL KNEE REPLACEMENT

v considered for patients who have severe pain and functional disabilities related to destruction of joint surfaces by
osteoarthritis or rheumatoid arthritis.
v The knee is dressed with a compression bandage.
v Ice may be applied to control edema and bleeding.
v The nurse assesses the neurovascular status of the leg.
v It is important to encourage active flexion of the foot every hour when the patient is awake.
v Preventing complications
v A wound suction drain removes fluid accumulating in the joint
v If extensive bleeding is anticipated, an autotransfusion can be used.
v Use of a continuous passive motion
(CPM) device which increases circulation and range of motion of the
knee joint is recommended.
AMPUTATION
v The removal of a body part, often an extremity.
v Causes:
• Peripheral Vascular Disease (Diabetes Mellitus)
• Fulminating gas gangrene
• Crushing injuries
• Burns
• Frostbite
• Electrical Burns
• Ballistic injuries
• Congenital deformities
• Chronic osteomyelitis
• Malignant tumor
v Purposes:
• Relieve symptoms
• Save or improve the patient's quality of life
v Levels of Amputation
• Most distal point that will heal successfully.
• Factors:
ü Circulatory adequacy
ü Type of prosthesis
ü Function of the part
ü Muscle balance
• Objectives:
ü Conserve as much extremity length
as needed to preserve function

ü Achieve a good prosthetic fit
• Upper extremities
ü Above elbow (AE)
ü Below Elbow (BE)
• Lower extremities
ü Above knee (AK)
ü Knee disarticulation
ü Below Knee (BK)
ü Syme (modified ankle disarticulation amputation)
• Complications
ü Hemorrhage- severed blood vessels
ü Infection- risk with all surgical procedures
ü Skin breakdown-due to prosthesis
ü Phantom Limb Pain- caused by the severing of peripheral nerves.
ü Joint Contracture- caused by positioning and a protective flexion withdrawal pattern associated
with pain and muscle imbalance.
• Relieving Pain
ü Surgical pain can be effectively controlled with opioid analgesics
ü Placing a light sandbag on the residual limb to counteract the muscle spasm.
• Minimizing Altered Sensory
Perceptions
Phantom Limb pain- unusual sensations, such as numbness,
tingling or muscle cramps, feeling that the extremity is present, crushed, cramped or twisted in an
abnormal position.
Acknowledge these feelings as real
Encourage the patient to verbalize when in pain
Keep the patient active
Early intensive rehabilitation, residual limb desensitization with kneading massage
Distraction techniques
Local anesthetics
Beta-blockers to relieve burning discomfort
Anti-depressant to improve mood and coping ability
Promoting Wound Healing
ü Wrap the residual limb with an elastic compression bandage to prevent edema
Enhancing Body Image
ü Encourage the patient to look at, feel and care for the residual limb
Helping the Patient to Resolve Grieving
ü Encourage the patients to express and share their feelings and work through the grief process.
Promoting Independent Self-care
Helping the Patient to Achieve Physical Mobility
ü Proper positioning
ü Abduction, external rotation and flexion of the lower extremity are avoided.
ü The residual limb is placed in extended position or elevate for brief period of time
ü To prevent flexion contracture of the hip:
Ø The residual limb should not be placed on a pillow
Ø Turn side to side Assume prone position
ü To prevent abduction deformity:
Ø The legs should be closed together
ü Use assistive devices when performing self-care
ü Postoperative Range of Motion exercises are done early to prevent contractures
ü Environmental barriers are identified to promote safety
ü A well-fitting shoe with a non-skid sole should be worn
ü The patient with an upper extremity amputation may wear a cotton T-shirt to prevent contact between the
skin and shoulder harness and to promote reabsorption of perspiration
ü The residual limb must be shaped into a conical form to permit accurate fit, maximum comfort, and
function of the prosthetic device
ü Adjustment of the prosthetic sockets occur during the first 6 months to 1 year after surgery

• Monitoring and Managing Potential
Complications
ü Massive hemorrhage
Ø A large tourniquet should be in plain sight at the patients bedside
Ø Notifies the surgeon in the event of excessive bleeding
ü Infection
Ø Antibiotic as prescribed
Ø Careful skin hygiene
Ø The healed residual limb is washed and dried gently at least twice daily
Ø Monitor the drainage. Mark the stain on the bandage to know if there is increasing drainage which
suggests infection
PROVIDING RANGE OF MOTION

EXERCISES
v Active Range of Motion Exercises
• Isotonic exercises in which the
clients move each joint in the body
through its complete range of movement, maximally stretching all muscle groups within each plane over the
joint.
• Guidelines:
ü Perform each ROM exercise as taught to the point of slight resistance, but not beyond, and never to
the point of discomfort.
ü Perform the movements systematically, using the same sequence during each session
ü Perform each exercise three times
ü Perform each series of exercises twice daily
v Passive Range of Motion Exercises
• Another person moves each of the client's joints through its complete range of movement, maximally
stretching all muscle groups within each piece over each joint
• Guidelines:
ü Support the client's limb above and below the joints as needed to prevent muscle strain or injury done
by cupping joints in the palm of hand or cradling limbs along your forearm
ü Avoid moving or forcing a body part beyond the existing range of motion
ü If muscle spasticity occurs, stop temporarily but continue to apply slow, gentle pressure on the part until the
muscle relaxes, then proceed with the motion.
v Active-assistive Range of Motion
Exercises
• The client uses a stronger, opposite arm or leg to move each of the joints of a limb incapable of active motion.
• This activity increases active movement on the strong side of the client's body and maintains joint flexibility on
the weak side
• Clients who require passive ROM exercises after a disability should have a goal of progressing to active-
assistive ROM exercises and, finally, to active ROM exercises.
ASSISTIVE DEVICES
CANES
v Two Types:
• Standard cane- straight-legged cane
• Quadcane- has four feet and provides
the most support
v Principles:
• Hold the cane with the hand on the stronger side of the body to provide maximum support and appropriate
body alignment when walking
• Position the tip of a standard cane (and the nearest tip of other canes) about 15 cm (6 inches) to the side and
15cm (6
inches) in front of the near foot, so that the elbow is slightly flexed
• Move the cane and weak leg, weight is borne by the stronger leg
• Move the stronger leg, weight is borne by the cane and the weak leg
CRUTCHES
v Kinds of Crutches:
• Underarm or Axillary crutch
• Lofstrand crutch- extends only to the forearm
v Principles:
• The weight should be borne by the arms rather than the axillae (armpits).
• Continual pressure on the axillae can injure the radial nerve and eventually cause crutch palsy (weakness of the
muscles of the forearm, wrist and hand)
• Maintain an erect posture as much as possible to prevent strain on muscles
v Measuring Clients for crutches
• Method 1:
ü Client lies supine position
ü Nurse measures from the anterior fold of the axilla to the heel of the foot
ü Add 2.5 cm (1 in)
• Method 2:
ü Client stands erect and positions
the crutch with elbow flexion angle of 30 degrees
ü Nurse makes sure the shoulder
rest on crutch is at least 3 fingers
widths, that is, 2.5 to 5 cm (1 to 2
in) below the axilla.
v Crutch Gaits
• Crutch stance
ü Tripod (triangle position)
Ø Crutches are placed about 15 cm (6 in) in front of the feet and out laterally about 15 cm (6 in)
• Four-point gait
ü Most elementary
ü Safest gait
ü Provides at least three points of support at all times
ü Used when walking in crowds
ü Needs to bear weight on both legs.
1. Move the right crutch ahead a suitable distance
2. Move the left front foot forward
3. Move the left crutch forward
4. Move the right foot forward
• Three-point gait
ü The two crutches and the unaffected leg bear weight alternately
1. Move both crutches and the weaker leg forward
2. Move the stronger leg forward
• Two-point alternate gait
ü Faster than the four-point gait
ü Require more balance because
only two points support the body at one time
ü Requires least partial weight bearing on each foot
1. Move the left crutch and the right
foot forward
2. Move the right crutch and the left
foot ahead together.
• Swing-To Gait
ü Used by clients with paralysis of the legs and hips
ü Prolonged use of this gaits results in atrophy of the unused muscles. The swing-to gait is the easier of
these two gaits.
1. Move both crutches ahead
Together
2. Lift body weight by the arms and

swing to the crutches
• Swing-Through Gait
ü Requires considerable skill, strength and coordination

1. Move both crutches forward
together
2. Lift body weight by the arms and swing through and beyond the crutch
• Going up stairs
ü Transfer the body weight to the crutches and move the unaffected leg onto the step
ü Transfer the body weight to the unaffected leg on the step and move the crutches and affected leg up to the
step
ü The affected leg is always supported by the crutches.
• Going down Stairs
ü Shift the body weight to the unaffected leg, and move the crutches and affected leg down
onto the next step
ü Transfer the body weight to the crutches, and move the unaffected leg to that step
ü The affected leg is always supported by the crutches
LOW BACK PAIN
CAUSE
• Acute lumbosacral strain
• Unstable lumbosacral ligaments
• Weak back muscles
• Osteoarthritis of the spine
• Spinal stenosis
• Intervertebral disk problems unequal Leg length and obesity
• Pain radiating to the legs (radiculopathy) or (sciatica) - presence of this signifies nerve
involvement
• Leg motor strength, and sensory perception maybe affected.
• Increased muscle tone of the back postural muscles
• Loss of the normal lumbar curve and possible spinal deformity.
MEDICAL MANAGEMENT
• Priority is pain management
• Most back pain is self-limiting and resolves within 4 weeks with analgesics and rest
• Tylenol and non-steroidal anti-inflammatory drugs (NSAIDs) (eg.,ibuprofen)
• Muscle relaxants
• TCA (eg., amitryptyline [Elavil]) are effective in relieving chronic back pain
• Opioids (eg., Morphine, tramadol and
benzodiazepines)
NONPHARMACOLOGIC INTERVENTIONS
• Application of superficial heat
• Chiropractic therapy-spinal manipulation).
• Acupuncture, massage and yoga are all
effective non pharmacologic interventions for Chronic Back pain not Acute back pain
• Avoid twisting, Bending, lifting, and reaching all of which put on stress on the back
• Change positions frequently
• Sitting should be limited to 20 to 50 mins
• Bed rest for 2 days max of 4 days if pain is severe
• Proper body mechanics
• Major goal is pain relief
• Improved physical mobility and weight, reduction
• A bed board is recommended for use instead of a soft mattress
• Avoid prone position
BURSITIS AND TENDINITIS

v Bursae are fluid filled sacs that prevent friction between joints structures during joint activity.
v Inflammation causes proliferation of synovial membrane and pannus formation, which restricts joint movement
v Inflammatory conditions that commonly affect the shoulders

TREATMENT
• Arthroscopic synovectomy may be considered if shoulder and weakness persist
NURSING MANAGEMENT
• Rest of the extremity
• Intermittent ice and heat application
• NSAID's to control the pain
CARPAL TUNNEL SYNDROME
v Entrapment Neuropathy that occurs when the median nerve at the wrist is compressed by a thickened
flexor tendon sheath, skeletal encroachment, edema or soft tissue mass
v Common to women between 30 to 60 years of age
v Caused by repetitive hand and wrist movement
v Hands are repeatedly exposed to cold temperatures, vibration or extreme direct pressure
ASSESSMENT
Phalen's Test Place the backs of both of your hands together and hold the wrists in forced flexion for a full minute.
(Stop at once if sharp pain occurs) . If this produces numbness or "pins and needles" along the thumb side half of the
hand, you most likely have Median nerve entrapment
(Carpal Tunnel Syndrome)
Tinel's sign may be elicited in patients with carpal tunnel syndrome by percussing lightly over the median nerve, located
on the inner aspect of the wrist. If the patient reports tingling, numbness, and
pain, the test for Tinel's sign is considered positive
TREATMENT
• Intra-articular injections of corticosteroids and oral corticosteroids
• Application of wrist splints to prevent hyperextension and flexion of the wrist
• Traditional open nerve release or endoscopic laser surgery are the two most common surgical management
options
NURSING MANAGEMENT
• The patient may need assistance with personal care and ADLs. Full recovery of motor and sensory
function after either type of nerve release surgery may take several weeks or months.
GANGLION
v Collection of gelatinous material near the tendon sheats and joint, appears as a round, firm, cystic swelling,
usually on the dorsum of the wrist.
v The ganglion is locally tender and may cause aching pain.
TREATMENT
• Aspiration and corticosteroid injection or surgical excision after treatment, a compression
dressing and immobilization splint are used.
DUPUYTREN'S DISEASE
v Slowly progressive contracture of the palmar fascia
ASSESSMENT
• Flexion of the fourth and fifth finger and frequently the middle finger.
• It renders the fingers more or less useless
• Hereditary
• Common in men older than 50 yrs
• Dull-aching discomfort, morning numbness, cramping, and stiffness in the affected fingers
TREATMENT
• Intranodular injections of corticosteroids (eg, triamcinolone) may prevent contractures
• With contracture development, palmar and digital fasciectomies are performed to improve function.
OSTEOPOROSIS
v (Porous bones) it is a disease of bones that
leads to increased risk of fracture. Bone mineral density is reduced. Bone micro architecture deteriorates
RISK FACTORS
• Caucasian or Asian
• Female
• Post menopause
• Advanced age
• Decreased calcitonin
• High phosphate
• Intake of carbonated beverages
• Sedentary lifestyle
• Lack of weight-bearing exercise
• Medications eg:
ü Corticosteroids
ü Anti-seizure medications
ü Heparin
ü Thyroid hormone
ü
"these medications affect calcium absorption and metabolism"
TYPES
v Primary osteoporosis occurs in women after menopause (usually between the ages of 45 and 55 years) Failure to
develop optimal peak bone mass during childhood, adolescence and young adulthood contributes to the
development of osteoporosis.
v Secondary osteoporosis Is a result of medications or other conditions and diseases that affect bone
metabolism
• Diseases: celiac disease., hypogonadism
• Medications: corticosteroids, antiseizure medications
The degree of osteoporosis is related to the duration of medication therapy.
Patients who have had bariatric surgery are at increased risk for osteoporosis as the duodenum is bypassed, which is
the primary site for absorption of calcium as are patients who have gastrointestinal diseases that cause
malabsorption (eg, celiac disease).
ASSESSMENT
• Loss of height
• Respiratory dysfunction
• Increased risk of subsequent fractures,

especially hip fractures
• Colles fractures of the wrist.
• Development of kyphosis (ie, "dowagers hump")
DIAGNOSIS
• Osteoporosis may be undetectable on routine x-rays until there has been 25% to 40% demineralization,
resulting in radiolucency of the bones Osteoporosis is diagnosed by dual-energy x-ray absorptiometry (DXA)
TREATMENT
• Elderly need to consume approximately 1200 mg of daily calcium and vitamin D it adequate to maintain
bone remodeling and body functions.
• Percutaneous vertebroplasty or kyphoplasty (injection of polymethylmethacrylate bone cement into the
fractured vertebra, followed by inflation of a pressurized balloon to restore the shape of the affected vertebra
• Regular weight-bearing exercise promotes bone formation.
• From 20 to 30 minutes of aerobic exercise (eg, walking), 3 days or more a week, is Recommended
• Calcitonin (miacalcin) directly inhibits osteoclasts, thereby reducing bone loss and increasing bone mass
density.
ü Calcitonin is administered by nasal spray or by subcutaneous or intramuscular injection. It should not be
prescribed for patients with seafood allergies
• Teriparatide (Forteo) is subcutaneously administered anabolic agent that is administered once daily. As a
recombinant it stimulates osteoblasts to build bone matrix and facilitates overall calcium absorption
• Bisphosphonates that include daily or weekly oral preparations of alendronate (Fosamax) or risedronate
(Actonel),
Assess risk for and prevent injury in client’s personal environment.
• Assist client to identify and correct hazards in his or her environment.
• Position household items and furniture for an unobstructed walkway
• Use side rails to prevent falls
• Instruct in use of assistive devices such as a cane or walker
• Instruct the client in the use of good body mechanics.
• Instruct the client in exercises to strengthen abdominal and back muscles to improve posture and provide support for
the spine.
• Instruct the client to avoid activities that can cause vertebral compression.
• Instruct the client to eat a diet high in protein, calcium, vitamins C and D, and iron.
• Instruct the client to avoid alcohol and coffee.
• Administer calcium, vitamin D, and phosphorus as prescribed for bone metabolism.
• Administer calcitonin as prescribed to inhibit bone loss.
• Administer estrogen or androgens to decrease
the rate of bone resorption as prescribed.
OSTEOMALACIA
v Metabolic bone disease characterized by inadequate mineralization of bone softening and weakening of the skeleton
ASSESSMENT
• Pain, tenderness to touch, bowing of the bones, and pathologic fractures
• Skeletal deformities (spinal kyphosis)
• Bowed legs give patients an unusual appearance and a waddling or limping gait.
PATHOPHYSIOLOGY
The primary defect in osteomalacia is a deficiency of activated vitamin D (calcitriol), which promotes calcium
absorption from the gastrointestinal tract and facilitates mineralization of bone. Without adequate vitamin D, calcium and
phosphate are not moved to calcification sites in bones.
CAUSES
• Malabsorption syndrome or from excessive loss of calcium from the body.
• Gastrointestinal disorders
ü Celiac disease

ü Chronic biliary tract obstruction,
ü Chronic pancreatitis
ü Small bowel resection
ü Liver and kidney diseases
• Severe renal insufficiency results in acidosis. The body uses available calcium to combat the acidosis, and Parathyroid
hormone stimulates the release of skeletal calcium in an attempt to reestablish a physiologic pH
• Hyperparathyroidism leads to skeletal Decalcification
• Prolonged use of anti-seizure medication (eg, phenytoin [Dilantin], phenobarbital) poses a risk of osteomalacia
• Insufficient vitamin D (dietary, sunlight). malnutrition (deficiency in vitamin D often associated with poor intake of
calcium
• On x-ray studies, generalized demineralization of bone is evident.
• Laboratory studies show low serum calcium and phosphorus levels
• moderately elevated alkaline phosphatase concentration
• Bone biopsy demonstrates an increased amount of osteoid, a demineralized, cartilaginous bone matrix that is
sometimes referred to as "prebone.
MEDICAL MANAGEMENT
• If osteomalacia is caused by malabsorption, increased doses of vitamin D, along with supplemental calcium
Nursing alert
High doses of vitamin D are toxic and increase the risk for hypercalcemia,
• Exposure to sunlight may be recommended; ultraviolet radiation transforms a cholesterol substance (7-
dehydrocholesterol) present in the skin into vitamin D
• Some persistent orthopedic deformities may need to be treated with braces or surgery (eg, osteotomy may be
performed to correct long bone deformity
PAGET'S DISEASE
v Paget's disease (osteitis deformans) is a disorder of localized rapid bone turnover, most commonly affecting the
skull, femur, tibia, pelvic bones, and vertebrae
ASSESSMENT
• Skeletal deformities
• Bowing of the femur
• Enlargement of the skull
• Deformity of pelvic bones
• Occurrence of cortical thickening of the long bones
• Patient may report that a hat no longer fits
• Patient may report that a hat no longer fits
• This give the face a small, triangular appearance
• Most patient with skull involvement have impaired hearing from cranial nerve compression and dysfunction.
• Femurs and tibia tend to bow, producing a wadding gait.
• Spine is bent forward and is rigid
• Pain, tenderness, and warmth over the bones may be noted. The temperature of the skin overlying the affected
bone increases because of increased bone vascular
PATHOPHYSIOLOGY
• In Paget’s disease, there is primary proliferation of osteoclasts, which induce bone resorption in population older than
50 years. As bone turnover continues, a classic mosaic (disorganized) pattern of bone develops. Because the
diseased bone is highly vascularized and structurally weak, pathologic fractures develop
• Elevated serum alkaline phosphatase
• Normal blood calcium levels
• X-rays confirm the diagnosis of Paget’s disease
• local areas of demineralization and bone overgrowth produce characteristic mosaic patterns and irregularities
MEDICAL MANAGEMENT
• Pain usually responds to NSAIDs
• Gait problems from bowing of the legs are managed with walking aids, shoe lifts, nd physical therapy
• Anti-osteoclastic therapy medications reduce bone turnover
• Calcitonin retards bone resorption by decreasing the number and availability of osteoclasts.

ü Side effect includes blushing of the face and nausea
ü The effect of calcitonin therapy is evident in 3 to 6 months through reduction of bone loss and pain.
• Plicamycin (Mithracin), cytotoxic antibiotic This medication has dramatic effects on pain reduction and on serum
calcium, alkaline phosphate, level
ü Administered by IV infusion diet with adequate calcium and vitamin
OSTEOMYELITIS
v Infection of the bone that result in inflammation, necrosis, and formation of new bone
CLASSIFICATION:
• Hematogenous osteomyelitis (ie. Due to bloodborne spread of infection)
• Contiguous-focus osteomyelitis, from contamination from bone surgery, open fracture, or traumatic injury (eg.
Gunshot wound)
• Osteomyelitis with vascular insufficiency, seen most commonly among patients with diabetes and peripheral
vascular disease,
ü Most commonly affecting the feet
RISK FACTORS
• Poor nourished
• Elderly
• Obese client
• Impaired immune systems
• Chronic illness (eg, diabetes, rheumatoid arthritis)
• Those receiving long-term corticosteroid
FACTS
• Bone infection are more difficult to eradicate than soft tissue infections because the infected bone is mostly
avascular not accessible to the body’s natural immune response
• It is also said that it has decreased penetration by antibiotics
CAUSATIVE OORGANISM
• Staphylococcus aureus. (most common)
• Other organism
ü Streptococci
ü Enterococci
ü Pseudomonas
• In bloodborne infection, the onset is usually sudden, occurring often with the clinical and laboratory manifestation of
sepsis (eg, chills, high fever, rapid pulse, general malaise).
• Pulsating pain that intensifies with movement as a result of the pressure of the collecting purulent material
• Non healing ulcer that overlies the infection bone with a connecting sinus that will intermittently and spontaneously
drain pus
• Blood studies reveal leukocytosis and an elevated ESR.
• X-ray findings demonstrate soft tissue edema
• In about 2 to 3 weeks, areas of periosteal elevation and bone necrosis are evident
• Radioisotope bone scans particularly the isotope-labeled white blood cell (WDC) scan, and magnetic resonance
imaging (MRI) help with early definitive diagnosis
MEDICAL MANAGEMENT
• The area affected with osteomyelitis. is immobilized to decrease discomfort and to prevent pathologic fracture of
the weakened bone
• IV antibiotic therapy begins, based on the assumption that infection results from a staphylococcal organism that
is sensitive to a penicillin or cephalosporin.
• The aims is to control the infection before
the blood supply to the area diminishes as a result of thrombosis
• IV antibiotic therapy continues for 3 to 6 weeks

SURGICAL MANAGEMENT
• If the infection is chronic and does not respond to antibiotic therapy, surgical debridement is indicated

• The infected bone is surgically exposed, the purulent and necrotic material is removed, and the area is irrigated with
sterile saline solution.
• Antibiotic-impregnated beads may be placed in the wound for direct application of antibiotics for 2 to 4 weeks
• All dead, infected bone and cartilage must be removed before permanent healing can occur.
• Management of osteomyelitis include the following:
ü Affected part may be immobilized with a splint to decrease pain and muscle spasm
ü Wound care
ü I.V antibiotic therapy
ü Monitor the patient for response to the treatment, signs and symptoms of super infections
ü Monitoring for adverse drug reaction
RHEUMATOID ARTHRITIS
v Is a systemic inflammatory disease which manifests itself in multiple joints of the body.
v The inflammatory process primarily affects the lining of the joints (synovial membrane), but can also affect other
organs.
v The inflamed synovium leads to erosions of the cartilage and bone and sometimes joint deformity.
v Pain, swelling, and redness are common joint manifestations
CAUSE
• RA is believed to be the result of a faulty immune response. RA can begin at any age and is associated with fatigue
and prolonged stiffness after rest.
• There is no cure for RA
• In RA, the autoimmune reaction primarily occurs in the synovial tissue.
• Phagocytosis produces enzymes within the joint. The enzymes break down collagen, causing edema, proliferation of
the synovial membrane, and ultimately pannus formation
ASSESSMENT
• Bilateral and symmetric stiffness, tenderness, swelling, and temperature changes in the joints
• X-rays show bony erosions and narrowed joint spaces
• Arthrocentesis shows synovial fluid that is cloudy, milky, or dark yellow and contains numerous inflammatory
components, such as leukocytes and complement
TREATMENT
• Corticosteroids
• Non-steroidal anti-inflammatory drugs
(NSAIDs) then slowly progressed for fewer people to non-biologic disease-modifying antirheumatic drugs (DMARDs)
and finally progressed for even fewer people to biologic DMARDs if people had not responded to the previous drugs.
• Today, a much more aggressive treatment approach is advocated for people with RA, with prescription of non-
biologic DMARDs within three months of diagnosis
NURSING MANAGEMENT
• Enable the patient to maintain as much independence as possible,
• Take medications accurately
• Use adaptive devices correctly.
ü Teaching focuses on the disorder itself, the possible changes related to the disorder, the therapeutic regimen
prescribed to treat it, the potential side effects of medications, strategies to maintain independence and function,
and patient safety in the home
OSTEOARTHRITIS
v Degeneration of cartilage and its underlying bone within a joint as well as bony overgrowth.
v The breakdown of these tissues eventually leads to pain and joint stiffness
v “wear and tear” related to aging
• The joint most commonly affected are the knees, hips, and those in the hands and spine.
• The specific causes of are believed to be a result of both mechanical and molecular events in the affected
joint.
• Disease onset is gradual and usually begins after the age of 40.
• There is current no cure for OA.
• Treatment for OA focus on relieving symptoms and improving functions and can include a
combination of patient education, physical therapy, weight control, and use of medications.
• also known as degenerative joint disease
• Most common form of arthritis.

ASSESSSMENT
Preventive measure can slow the progress if undertaken early enough:
• Weight reduction
• Joint rest
• Avoidance of joint overuse,
• Orthotic devices (eg, splints, braces to support inflamed joints,
• Isometric and posture exercise, and aerobic exercise
• Initial analgesic therapy is acetaminophen
• NSAIDs
• Cox-2 enzyme blockers.
• Intra-articular corticosteroids
NURSING MANAGEMENT
• Pain management and optimal function ability are major goals of nursing intervention Weight loss and exercise
are important approaches to pain and disability improvement
• Referral for physical therapy or to an exercise program for people with similar problems can be very helpful.
Canes or other assistive device for ambulation should be considered
• Exercise such as walking should be begun in moderation and increased gradually
GOUT
v Genetic defect of purine metabolism that result in hyperuricemia
v Is a rheumatic disease resulting from deposition of uric acid crystals (monosodium urate) in tissue and fluids within
the body.
v This process is caused by an overproduction or under excretion of uric acid.
ASSESSMENT
• Acute onset of excruciating pain in joint due to accumulation of uric acid within the joint
• Redness due to inflammation around the joint
• Nephrolithiasis (kidney stone) due to uric acid deposits in the kidney
• Uric and crystal accumulate in joints, most commonly the big toe (podagra)
DIAGNOSTIC FINDINGS
• The gold standards for diagnosing gout is aspiration and microscopic analysis for urate crystals in joint fluid or a
tophi
• Elevated erythrocyte sedimentation rate (ESR)
• Elevated serum uric acid level
TREATMENT
• Acute treatment is managed with colchicine and nonsteroidal anti-inflammatory
• Chronic gout is treated with allopurinol or an uricosuric agent to reduce the amount of uri acid in the system
• Diet and lifestyle (weight loss, avoiding alcohol, reducing dietary purine intake)
Modifications may help prevent future attacks.
• Immobilize the joint for comfort.
• Have the patient drink 3 liters of fluid per day to avoid crystallization of uric in the kidneys. Increased fluids help
flush the uric acid through the kidney
• Assist with positioning for comfort
• Avoid touching inflamed joint unnecessarily
• Explain to patient which foods are high-purine proteins:
ü Turkey
ü Organ meals
ü sardines
ü smelts
ü mackerel
ü anchovies
ü herring
ü bacon
• Avoid alcohol, which inhibits renal excretion of uric acid.
SCOLIOSIS

v Scoliosis is a progressive condition causing
the spine to curve or twist into a "C" or "S" shape.
Dextroscoliosis is a scoliosis with the convexity on the right side.
Levoscoliosis is a scoliosis with the convexity on the left side.
Rotoscoliosis: Pronounced rotation of the vertebrae
Cause is unknown or idiopathic. Contrary to common belief, scoliosis does not come from slouching, sitting in awkward
positions, or sleeping on an old mattress
ASSESSMENT
• Uneven hip and shoulder levels
• Uneven musculature on one side of the spine
• Asymmetric rib cage
• Visible curvature of the spine
• Uneven pelvis
TREATMENTS
• Up to 20-degree curvature: Exercise to enhance muscle tone and posture.
• Between 20 and 40 degree curvature: Apply a brace to maintain curvature.
• Greater than 40 degree curvature: Spinal fusion surgery.
ü Bracing - for example the Milwaukee brace, bracing is done when the patient has bone growth remaining,
and is generally implemented in order to hold the curve and prevent it from progressing to the point where
surgery is necessary.
If spinal fusion surgery is performed:
• Use log rolling to reposition the child every 2 hours to inhibit development of pressure sores and to adequately inflate
lungs.
• Monitor vital signs following surgery.
• Apply antiembolism stockings while the patient is on bed rest.
• Remove the antiembolism stocking for 1 hour three times a day.
LEGG-CALVE-PERTHES DISEASE
v This disease is characterized by necrosis of the femoral head that occurs in children between 2 and 12 years of age
caused by a decreased blood supply to the femoral head
v This disease is self-limiting, and the child will fully recover after the disease has run its course
THREE STAGES OF LEGG-CALVE-PERTHES
DISEASE:
1. Avascular: Blood supply to the head of the femur is interrupted within 1 year.
2. Revascularization: Creeping substitution occurs where connective and vascular tissue enter the necrotic bone
causing live noncalcified bone to replace the necrotic tissue.
3. Healing: The bone ossifies over 3 years.
ASSESSMENT
• Pain in the groin

• Pain in the anterior thigh
DIAGNOSIS
Radiograph: Shows decreased bone mass, ossification centers, and possibly subchondral fracture
TREATMENT
• Legg-Calve-Perthes disease is self-limiting.
• Physical therapy to restore range of motion.
• Administer analgesic to reduce pain.
• Perform range-of-motion activities to maintain normal motion of the joint.
• Teach the patient how to use crutches.
• Explain to the parents and the patient that the disease is self-limiting and that the patient will fully recover once the
disease has run its course.
FRACTURES
v A break in the continuity of the bone as a result of trauma, twisting, or bone decalcification
v Fractures occur when the bone is subjected to stress greater than it can absorb. Fractures may be caused by direct
blows, crushing forces, sudden twisting motions, and extreme muscle contractions.

TYPES
• A complete fracture involves a break across the entire cross section of the bone and is frequently displaced (removed
from its normal position).
• An incomplete fracture (eg, greenstick fracture) involves a break through only part of the cross-section of the bone.
• A comminuted fracture is one that produces several bone fragments. A closed fracture (simple fracture) is one that does not
cause a break in the skin.
• An open fracture (compound, or complex, fracture) is one in which the skin or mucous membrane wound extends to the
fractured bone.
ASSESSMENT
The clinical signs and symptoms of a fracture include acute pain, loss of function, deformity, shortening of the
extremity, localized edema and ecchymosis
EMERGENCY MANAGEMENT
• Immediately after injury, if a fracture is suspected, it is important to immobilize the body part before the patient
is moved. Adequate splinting is essential. Joints proximal and distal to the fracture must be immobilized to
prevent movement of fracture fragments
Reduction:
ü Restoring the bone to proper alignment
Closed reduction:
ü Accomplished by manual alignment of the fragments, followed by immobilization
Open reduction:
ü Surgical insertion of internal fixation devices, such as rods, wires, or pins, that help maintain alignment while
healing occurs
BONE TUMORS
v Neoplasm of the musculoskeletal system
TYPES
BENIGN BONE TUMORS
• Benign tumors of the bone and soft tissue are more common than malignant primary bone tumors
• Slow growing
• Well circumscribed
• Encapsulated
• Osteochondroma is the most common benign bone tumor.
• It usually occurs as a large projection of bone at the end of long bones (at the knee or shoulder
MALIGNANT BONE TUMORS
• Rare and arise from connective and supportive tissue cells (sarcomas) or bone marrow elements
• Osteosarcoma (ie, osteogenic sarcoma) is the most common and most often fatal primary malignant bone tumor.
• Prognosis depends on whether the tumor has metastasized to the lungs
• Appears most frequently in children,
adolescents and young adults (in bones that grow rapidly)
• Most common sites are the distal femur, the
proximal tibia, and the proximal humerus
METASTATIC BONE DISEASE
• Metastatic bone disease (secondary bone tumor) is more common than primary bone tumors
• Tumors arising from tissues elsewhere in the body that may invade the bone
• The most common primary sites of tumors that metastasize to bone are the kidney, prostate. lung, breast,
ovary, and thyroid
• Most frequently attack the skull, spine, pelvis. femur, and humerus
CLINICAL MANIFESTATION OF PATIENTS WITH
BONE TUMORS
• Have pain that ranges from mild an: occasional to constant and severe
• Varying degrees of disability Weight loss malaise, and fever may be present
• Serum alkaline phosphatase levels are frequently elevated in osteogenic sarcoma
• Serum acid phosphatase in metastatic carcinoma of the prostate
• Hypercalcemia is present with bone metastases from breast, lung, or kidney cancer.
• A surgical biopsy is performed for histologic identification
MANAGEMENT FOR PRIMARY BONE TUMORS

• The goal of primary bone tumor treatment is to destroy or remove the tumor through:
ü Surgical excision
ü Radiation therapy
ü Chemotherapy
• Chemotherapy is started before and continued after surgery in an effort to eradicate micro metastatic lesions
• Chemotherapy may be delivered intra-arterially for patients with osteosarcoma
MANAGEMENT FOR SECONDARY BONE TUMORS
• The treatment of metastatic bone cancer es palliative
• Goal is to relieve the patient's pain and discomfort while promoting life.
• Patients with metastatic disease are at higher risk than other patients for postoperative pulmonary congestion
• Hypercalcemia results from breakdown of bone
• Treatment includes hydration with IV administration of normal saline solution; dieresis; mobilization; and
medication such as bisphosphonates, (e.g. pamidronate [Aredia]) and calcitonin.
NURSING TREATMENT
• The nurse prepares the patient and gives support during painful procedures
• Prescribe IV or epidural analgesic medications are used during the early postoperative period
• Affected extremities should be support and handled gently.
• Prophylactic antibiotics and strict aspect dressing techniques are used to diminish the occurrence of osteomyelitis
and wound infections
• The symptoms of hypercalcemia must be recognized and treatment initiated promptly

SENSES
EYES AND EARS
EYES
ANATOMY OF THE EYE
v Cornea- transparent, avascular, dome-like structure that serves as the main refracting surface of the eye
v Aqueous Humor- Produced by the ciliary body that nourishes the cornea
v Uvea- Consists of iris, ciliary body and choroid
v Iris- Colored part of the eye
v Pupil- A space that dilates and constricts in response to light
v Lens- Colorless and biconvex structure that enables focusing for near vision and refocusing for distance
vision(accommodation)
v Choroid- A vascular tissue, supplying blood to the portion of the sensory retina closest to it.
v Vitreous Humor- Occupies 2/3 of the eye's volume and helps maintain the shape of the eye.
v Retina- Composed of 10 microscopic layer
• It is a neural tissue, an extension of the optic nerve
• Macula is the part of the retina that is responsible for central vision
• Rods - responsible for night vision
• Cons- responsible for bright light and color vision
TESTING VISION
v Snellen Chart
• Composed of series of progressively smaller rows of letters that is used to test distance vision
• 20/20 is considered standard of normal vision
• A person whose vision is 20/200 can see an object from 20 feet away that a person with 20/20 vision can see
from
200 feet away
v Ophthalmoscope
• Examines fundus, optic cup, periphery of the retina and macula
v Slit Lamp
• Binocular microscope that examines the eye with magnification of 10 to 40 times the real image
v Tonometer
• Measures IOP by determining the pressure necessary to indent or flatten small anterior area of the eye
• Normal IOP is 10-21 mmHg
v Perimetry
• A tool that evaluates the field of vision or the area or exent of physical space visible to an eye in a given
position

v Ishihara Color Plate Test
• Use to identify color vision deficit/ color-blindness
• Dots of primary colors are integrated into a background of secondary colors which is arranged in simple
patterns
such as numbers or shapes
v Amsler Grid
• Test often used for patients with macular problems, such as macular degeneration
• Consists of a geometric grid of identical squares with a central fixation point
• The patient is instructed to stare at the central fixation spot on the grid
• For patients with macular problems, some of the squares may look faded, or the lines may be wavy
TERMS
v Aphakia- without lens
v Astigmatism- irregularity in the curve of the cornea
v Blindness- Best corrected visual acuity (BCVA) ranges from 20/400
v Legal Blindness- BCVA that does not exceed 20/200
v Diplopia- double vision
v Emmetropia- Normal vision
v Hyperopia- far sighted
v Myopia- near sighted
v Hyperemia - red eye
v Nystagmus - involuntary oscillation of the Eyeball
v Proptosis - downward displacement of the eyeball
v Ptosis - drooping eyelid
v Papilledema - swelling of the optic disc
v Strabismus - a condition in which there is deviation from perfect ocular alignment
v Enucleation is the removal of the entire eye and part of the optic nerve
v Evisceration involves the surgical removal of the intraocular contents through an incision or opening in the cornea
or sclera
v Exenteration is the removal of the eyelids, the eye, and various amounts of orbital contents
CONDITIONS OF THE EYELIDS AND CONJUNCTIVA

v Blepharitis
• An inflammatory reaction of the eyelid margin or seborrheic skin condition
• Caused by bacteria (usually Staphylococcus aureus)
v Clinical manifestation
• Flaking
• Redness
• Irritation
• Recurrent styes
v Management
• If S. aureus is likely, antibiotic ointment is prescribed 1 to 4 times per day to eyelid margin
• Teach patient to scrub eyelid margin with cotton swab to remove flaking
• Apply ointment with cotton swab as directed.
v Hordeolum (stye)/Chalazion
• The term stye refers to an inflammation or infection of the glands and follicles of the eyelid margin
• External hordeolum involves the hair follicles of the eyelashes
• Chalazion is a granulomatous (chronic) infection of the meibomian glands.
v Etiology
• Caused by bacteria, usually staphylococcus, and seborrhea are the causes
• Pain
• Redness
• Foreign body sensation
• Pustule may be present.
v Treatment
• Warm soaks to help promote drainage
• Good hand washing and eyelid hygiene
• Application of antibiotic ointment
• In some cases, incision and drainage in may be necessary
• Teach patient how to clean eyelid margins and not to squeeze the stye.
v Conjunctivitis
• Inflammation or infection of the bulbar (covering the sclera and cornea) or palpebral (covering
inside lids) conjunctiva
• The term pink eye usually refers to infectious conjunctivitis.
v Etiology
• Bacterial Conjuctivitis are caused by Streptococcus pneumoniae, Haemophilus influenzae, and
Staphylococcus aureus
• Viral Conjunctivitis are caused by adenovirus and herpes simplex virus
• Allergic conjunctivitis is a hypersensitivity reaction that occurs as part of allergic rhinitis (hay fever) or
allergic reaction due to pollens or other environmental pollutants
• Foreign body sensation in the eyes
• Scratching or burning sensation
• Itching and photophobia
• Warm soaks (10 minutes four times per day) is used when crusting and drainage are present for bacterial
conjunctivitis
• Cold compress for viral conjunctivitis
• If topical antibiotic (broad spectrum) is ordered, teach patient instillation technique
• Urge good hand washing to prevent spread of infection
• Allergic conjunctivitis treated with topical or oral antihistamines.
vasoconstrictors, and mast cell stabilizers.
v Corneal Abrasion and Ulceration (Keratitis)
• Loss of epithelial layers of cornea due to some type of trauma, contact with fingernail, tree branch,
spark or other
projectile, or overwearing contact lens
• May lead to corneal ulceration and secondary infection into cornea (keratitis), which may lead to
blindness
• Pain and redness
• Foreign body sensation
• Photophobia
• Increased tearing
• Difficulty opening the eye
• Fluorescein staining
• Woods lamp or slit lamp
v Management
• Treatment is urgent
• Fortified (high concentration) antibiotic eyedrops may be instilled and eye patched for 24 hours _
• Cycloplegics are administered to reduce pain caused by ciliary spasm
• Abrasion heals in 24 to 48 hours.
• Ulceration should be followed by an ophthalmologist
• Make sure that patch is secure enough so patient cannot open eyelid
• Teach patient to use topical antibiotic (or antiviral in cases of herpes simplex dendritic keratitis) after patch
is removed, and follow up as directed
• Review safety practices such as wearing protective eye shields and washing hands frequently.
v Iritis/Uveitis
• Inflammation of the intraocular structure
• Involved structures:
ü Anterior uveitis iris (iritis) or iris and ciliary body (iridocyclitis)
ü Intermediate uveitis structures posterior to the lens (pars plantis or peripheral uveitis)
ü Posterior uveitis choroid (choroiditis), retina (retinitis), or vitreous near the optic nerve and macula
• Anterior uveitis is most common and is usually unilateral
• Posterior uveitis is usually bilateral
v Etiology
• Immune-mediated disorders.
• May be idiopathic
• Ankylosing spondylitis
• Crohn's disease
• Reiter's syndrome
• Lupus
• Trauma
• Onset is acute with deep eye pain
• Photophobia
• Conjunctival redness
• Small pupil that does not react briskly
• Urgent ophthalmology evaluation is Needed
• Inflammation is treated with a topical corticosteroid and a cycloplegic agent
• Teach patient how to instill medications and adhere to dosing schedule to prevent permanent eye
damage
• Suggest sunglasses to decrease pain from photophobia
• Encourage follow-up for intraocular pressure (I0P) measurements because
corticosteroids can increase I0P.
DISORDERS OF THE EYES
CATARACT
• Clouding or opacity of the crystalline lens that impairs vision.
v Etiology
• Senile cataract commonly occurs with aging
• Congenital cataract occurs at birth
• Traumatic cataract occurs after injury
v Risk Factors
• Diabetes
• Ultraviolet light exposure
• High-dose radiation
• Corticosteroids
• Phenothiazines
• Some chemotherapy agents
• Blurred or distorted central vision
• Glare from bright lights
• Gradual and painless loss of vision
• Previously dark pupil may appear milky or white
• Slit-lamp examination to provide magnification and visualize opacity of lens
• Direct and indirect ophthalmoscopy to rule out retinal disease
• Perimetry to determine the scope of the visual field (normal with cataract)
• Snellen visual acuity test
v Management
General
• Surgical removal of the lens is indicated.
• Cataract surgery is usually done under local anesthesia
• Preoperative eyed drops produce decreased response to pain and lessened motor activity
(neuroleptanalgesia).
• Oral medications may be given to reduce 10P.
• IOL implants are usually implanted at the time of cataract extraction, replacing thick glasses that may provide
suboptimal refraction.
• If intraocular lens implant is not used, the patient will be fitted with appropriate eyeglasses or a contact lens
to correct refraction after the healing process.
v Surgical Procedures
Two types of extractions:
• Intracapsular extraction -the lens as well as the capsule are removed through a small incision.
• Extracapsular extraction-the lens capsule is incised, and the nucleus, cortex, and anterior capsule
are extracted. The posterior capsule is left in place and is usually the base to which an IOL is implanted.
v Procedures for Extraction:
• Cryosurgery -a special technique in which a pencil-like instrument with a metal tip is supercooled (-
35° C), then touched to the exposed lens, freezing to it so the lens is easily lifted out
• Phacoemulsification - a portion of the anterior capsule is removed, allowing extraction of the lens,
nucleus and cortex while the posterior capsule and zonular support are left intact. An ultrasonic device
is used to liquefy the nucleus and cortex, which are then suctioned out through a tube
Preparing the Patient for Surgery
• Orient patient and explain procedures and care plan to decrease anxiety.
• Instruct patient not to touch eyes to decrease contamination.
• Obtain conjunctival cultures, if requested, using aseptic technique.
• Administer preoperative eyedrops, antibiotic, mydriatic-cycloplegic, and other medications such as
mannitol solution
I.V., sedative, antiemetic, and opioid as directed.
v Preventing Complications Postoperatively
• Medicate for pain as prescribed to promote comfort.
• Administer medication to prevent nausea and vomiting as needed.
• Notify health care provider of sudden pain associated with restlessness and increased pulse, which may indicate
increased IOP, or fever, which may indicate infection.
• Caution patient against coughing or sneezing to prevent increased IOP.
• Advise patient against rapid movement or bending from the waist to minimize IOP. Patient may be more
comfortable
with head elevated 30 degrees and lying on the unaffected side.
• Allow patient to ambulate as soon as possible and to resume independent activities.
• Assist patient in maneuvering through environment with the use of one eye while eye patch is on (1 to 2 days).
• Wear glasses or metal eye shield at all times following surgery as instructed by the physician.
• Clean postoperative eye with a clean tissue; wipe the closed eye with a single gesture from the inner canthus
outward
v Lens Replacement
Three lens replacement options:
• Aphakic eyeglasses-objects are magnified by 25%, making them appear closer than they actually are
• Contact lenses- provide patients with almost normal vision. Also needs a pair of aphakic glasses
• IOL implants- usual approach to lens replacement
ü Single-focus lens or monofocal IOL
ü Multifocal IOL
ü Accommodative IOL
ACUTE (CLOSE ANGLE) GLAUCOMA
v A condition in which an obstruction occurs at the access to the trabecular meshwork and the canal of Schlemm.
v IOP is normal when the anterior chamber angle is open, and glaucoma occurs when a significant portion of that angle
is closed.
v Glaucoma is associated with progressive visual field loss and eventual blindness if allowed to progress.
v Rapidly progressive visual impairment
• Periocular pain
• Conjunctival hyperemia and congestion.
• Pain may be associated with nausea and vomiting, bradycardia, and profuse sweating.
• Peripheral visual loss
• Severely elevated IOP, corneal edema.
• Pupil is vertically oval, fixed in a semi-dilated position and unreactive to light and accommodation
• Tonometry
• Ophthalmoscopy
• Gonioscopy
• Perimetry
v Management
• An ocular emergency
• Administration of:
ü Hyperosmotic agents such as acetazolamide (Diamox) to reduce 10P by promoting diuresis
ü Topical ocular hypotensive agents, such as pilocarpine and beta-blockers (Betaxolol)
• Possible laser incision in the iris (Iridotomy) to release blocked aqueous and reduce 10P
• Other eye is also treated with pilocarpine eye drops and/or surgical management to avoid a similar
spontaneous attack.
Patient Education and Health Maintenance
• Instruct patient in use of medications. Stress the importance of long-term medication use to control this
chronic disease. Patients commonly forget that eyedrops are medications and that glaucoma is a chronic
illness.
• Remind patient to keep follow-up appointments.
• Instruct patient to seek immediate medical attention if signs and symptoms of increased IOP return such as
severe eye pain, photophobia, and excessive lacrimation.
• Advise patient to notify all health care providers of condition and medications and to avoid use of medications
that may increase IOP, such as corticosteroids and anticholinergics (such as Akineton, Benadryl, Cogentin), unless
the benefit outweighs the risk.
CHRONIC (OPEN-ANGLE) GLAUCOMA
v Disorder of increased IOP, degeneration of the optic nerve, and visual field loss. Open-angle glaucoma makes up
90% of primary glaucoma cases and its incidence increases with age.
v Usually bilateral, but one eye may be more severely affected than the other
v The anterior chamber angle is open and
appears normal
• Mild, bilateral discomfort (tired feeling in eyes, foggy vision).
• Slowly developing impairment of peripheral vision but central vision is unimpaired.
• Progressive loss of visual field.
• Halos may be present around lights with increased ocular pressure.
• Optic nerve may be damage
• Tonometry
• Ocular examination to check for clipping and atrophy of the optic disk
• Visual fields testing
v Management
• Commonly treated with a combination of topical miotic agents (increase the outflow of aqueous humor by
enlarging
the area around trabecular meshwork) and oral carbonic anhydrase inhibitors and beta-adrenergic
blockers (decrease aqueous production).
• If medical treatment is not successful, surgery may be required, such as Laser trabeculoplasty but is delayed
as long as possible.
• Make sure that the patient understands that, although he may be asymptomatic, IOP could still be elevated, and
damage to the eye could be occurring. Therefore, ongoing use of medication and follow-up are essential.
• Teach patient the action, dosage, and adverse effects of all medications
• Alert patient to avoid circumstances that may increase 10P such as straining, heavy lifting, bending, etc.
• Instruct the patient to have a low sodium diet
RETINAL DETACHMENT

v Detachment of the sensory area of the retina (rods and cones) from the pigmented epithelium of the
retina.
v A break in the continuity of the retina may first occur from small degenerative holes and tears, which may lead to
detachment.
v Spontaneous detachment may occur due to degenerative changes in the retina or vitreous body
v Etiology
• Trauma, inflammation, or tumor causes detachment by forming a mass that mechanically separates the
retinal layers.
• The patient notes sensation of particles moving in line of vision (person can see floating across field of
vision when looking at a light background).
• Delineated areas of vision may be blank.
• A sensation of a veil-like coating may be present if detachment develops rapidly.
• Unless the retinal holes are sealed, the retina will progressively detach; ultimately there will be a loss of
central
vision as well as peripheral vision, leading to legal blindness
• Indirect ophthalmoscopy - shows gray or opaque retina.
• Slit-lamp examination and three-mirror gonioscopy
• Optical coherence tomography and ultrasound are used for the complete retinal assessment,
especially if the
• view is obscured by a dense cataract or vitreal hemorrhage.
• Scleral Buckling
ü The retinal surgeon compresses the sclera (often with a scleral buckle or a silicone band) to indent
the scleral wall from the outside of the eye and bring the two retinal layers in contact with each other.
• Pneumatic Retinopexy
ü A gas bubble, silicone oil, or perfluorocarbon and liquids may be injected into the vitreous cavity to
help push the sensory retina up against the RPE (Retinal Pigment Epithelium)
• Cryosurgery or retinal cryopexy
ü Super cooled probe is touched to the sclera, causing minimal damage; as a result of scarring,
the pigment epithelium adheres to the retina.
v Preventing Postoperative Complications
• Caution patient to avoid bumping head.
• Encourage patient not to cough or sneeze or to perform activities that will increase [OP.
• Assist patient with activities as needed.
• Encourage ambulation and independence.
• Administer medications for pain, nausea, and vomiting as prescribed.
• Provide sedation, diversional activities such as radio and audio books.
v Patient Education and Health Maintenance
• Encourage self-care at discharge (Avoid falls, jerks, bumps, or accidental injury.)
• Instruct patient about the following:
ü Rapid eye movements should be avoided for several weeks.
ü Driving is restricted.
ü Within 3 weeks, light activities may be pursued.
ü Within 6 weeks, heavier activities and athletics are possible. Define such activities for the patient.
ü Avoid straining and bending head below the waist.
ü Use meticulous cleanliness when instilling eye medications.
ü Apply a clean, warm, moist washcloth to eyes and eyelids several times a day for 10 minutes to
provide soothing and relaxing comfort.
ü Symptoms that indicate a recurrence of the detachment: Floating spots, flashing light,
progressive shadows. Recommend that the patient contact health care provider if they occur.
ü Advise patient to follow up. The first follow-up visit to the ophthalmologist should occur in 2 weeks.
MACULAR DEGENERATION
v Most common cause of visual loss in people older than 60 years of age
v Two types:
• Dry (non-neovascular, nonexudative) type of the condition, in which the outer layers of the retina slowly
break down
ü When the drusen occur outside of the macular area, patients generally have no symptoms
ü When the drusen occur within the macula, however, there is a gradual blurring of vision that patients
may notice when they try to read
• Wet (neovascular, exudative) type, may have an abrupt onset
ü Patients report that straight lines appear crooked and distorted or that letters in words appear
broken
ü Results from proliferation of abnormal blood vessels growing under the retina, within the choroid
layer of the eye
ü Affected vessels can leak fluid and blood, elevating the retina
• There is no known cure for the dry (nonexudative, non-neovascular)
• Study revealed that use of antioxidants (vitamin C, vitamin E, and betacarotene) and minerals (zinc oxide) in
megadoses can slow the progression of AMD and vision loss for people at high risk for developing advanced
Macular Degeneration
• For Wet type Macular Degeneration following drugs are given:
ü Ranibizumab (Lucentis)
ü Monoclonal antibody bevacizumab (Avastin)
• Amsler grids are given to patients to use in their homes to monitor for a sudden onset or distortion of vision
• Patients should be encouraged to look at these grids, one eye at a time, several times each week with
glasses on. If there is a change in the grid, the patient should notify the ophthalmologist immediately
ORBITAL TRAUMA
v Injury to the orbit is usually associated with a head injury
v The patient's general medical condition must first be stabilized before conducting an ocular examination
v During inspection, the face is meticulously assessed for underlying fractures, which should always be
suspected in cases of blunt trauma
v Soft tissue orbital injuries often result in damage to the optic nerve
v Major ocular injuries indicated by a soft globe, prolapsing tissue, ruptured globe, and hemorrhage require
immediate surgical attention
SOFT TISSUE INJURY AND HEMORRHAGE
(BLUNT OR PENETRATING)
v Manifestations
• Tenderness and ecchymosis
• Lid swelling, hemorrhage and proptosis
• Black eye -closed injuries with subconjunctival hemorrhage
• Penetrating injuries or a severe blow to the head can result in severe optic nerve damage
v Management
• Soft tissue hemorrhage that does not threaten vision is usually conservative and consists of thorough
inspection, cleansing, and repair of wounds
• Cold compresses are used in the early phase followed by warm compress
• Hematomas that appear swollen, fluctuating areas may be surgically drained or aspirated
• If they are causing significant orbital pressure, they may be surgically evacuated
• Corticosteroid therapy is indicated to reduce optic nerve swelling
• Optic nerve decompression may be performed
ORBITAL FRACTURE
v Classifications
• Blowout
• Zygomatic or tripod
• Maxillary
• Midfacial
• Orbital apex
• Orbital roof fractures
v Manifestations
• Muscles, fat and fascia! attachment, the nerve that courses along the inferior oblique muscle may become
entrapped
• The globe may be displaced inward enophthalmos)
• Fractures are usually caused by blunt small objects. such as a fist, knee, elbow, or tennis or golf ball
• Computed tomography (CT) identifies the muscle and its auxiliary structures that are entrapped
v Management
• Orbital roof fractures are dangerous because of potential complications to the brain
• Surgical management (usually non-emergent) of these fractures requires a neurosurgeon and a
ophthalmologist
• Emergency surgical repair is indicated to patient with displaced globe into the maxillary sinus
PENETRATING INJURIES AND

CONTUSION OF THE EYEBALL
• Marked loss of vision
• Hemorrhagic chemosis (edema of the conjunctiva)
• Conjunctival laceration
• Shallow anterior chamber with or without an eccentrically placed pupil
• Hyphema (hemorrhage within the chamber)
• Vitreous hemorrhage
v Management
• No attempt should be made to remove the foreign object
• The object should be protected from jarring or movement to prevent furtherocular damage
• No pressure or patch should be applied to the affected eye
• All traumatic eye injuries should be protected using a metal shield if available or a stiff paper
cup until medical treatment can be obtain
• Prevent bleeding and increased IOP
• Topical corticosteroids are prescribed to reduce inflammation
• Antifibrinolytic agent, aminocaproic acid (Amicar) is given to stabilize clot formation at the site of
hemorrhage
• Primary enucleation (complete removal of the eyeball and part of the optic nerve) is considered if
the globe is irreparable and has no light perception. Enucleation is performed within 2 weeks of the initial
injury to prevent the risk of sympathetic ophthalmia (an inflammation created in the uninjured eye by the
affected eye that can result in blindness of the uninjured eye)
v Splash Injury
• Management
• Eye should be immediately irrigated with tap water or normal saline
• Manipulation of the eye must be avoided until patient is under general anesthesia
• Parenteral, broad-spectrum antibiotics are initiated
• Tetanus antitoxin is administered as well as analgesics
• In cases of a ruptured globe, cycloplegic agents (agents that paralyze the ciliary muscle or topical antibiotics
must be
deferred because of potential toxicity to exposed intraocular tissues
EARS
ANATOMY OF THE EAR
v External Ear
• Auricle — collects the sound waves and directs vibrations into the external auditory canal.
• External auditory canal-Approximately 2.5 cm long, the skin of the canal contains hair, sebaceous
glands, and ceruminous glands, which secrete a brown, wax like substance called cerumen (ear wax).
v Middle Ear
• Tympanic membrane (eardrum) — about 1 cm in diameter and very thin
ü Normally pearly gray and translucent
ü protects the middle ear and conducts sound vibrations from the external canal to the ossicles
• Ossicles
ü Contains the three smallest bones of the body: the malleus, the incus, and the stapes
ü Assist in the transmission of sound
v Inner Ear
• Housed deep within the temporal bone. The organs for hearing (cochlea) and balance (semicircular
canals), as well as cranial nerves VII (facial nerve) and VIII (vestibulocochlear nerve), are all part of
this complex anatomy
• The cochlea and semicircular canals are housed in the bony labyrinth. The bony labyrinth surrounds
and protects the membranous labyrinth, which is bathed in a fluid called perilymph
• Organ of Corti - housed in the cochlea, a snail-shaped, bony tube about 3.5 cm long with two and a half
spiral turns
v Also called the end organ for hearing, transform mechanical Energy into neural activity and
separates sounds into different frequencies.
• In the internal auditory canal, the cochlear (acoustic) nerve, arising from the cochlea, joins the
vestibular nerve, arising from the semicircular canals, utricle, and saccule, to become the
vestibulocochlear nerve (cranial nerve VIII).
AUDITORY ASSESSMENT
v Inspection of the External Ear
• External ear is examined by inspection and direct palpation
The auricle and surrounding tissues should be inspected for deformities, lesions, and discharge, as well as
size, symmetry, and angle of attachment to the head
• External otitis is suspected if there is pain upon manipulation of the auricle
• Mastoiditis is suspected if there is tenderness upon palpation of the mastoid area
• Seborrheic dermatitis is suspected if flaky scaliness on or behind the auricle is present
v Otoscope
• Examines the external auditory canal and tympanic membrane
• Otoscope should be held in the examiner's right hand, in a pencil-hold position, with the examiner's
hand braced against the patient's face
v Whisper Test
• The examiner covers the untested ear then whispers softly from a distance of 1 or 2 feet from the unoccluded
ear. The patient with normal acuity can correctly repeat what was whispered.
v Weber test
• Uses bone conduction to test lateralization of sound.
• A tuning fork is set in motion by tapping it on the examiner's knee or hand, and placed on the patient's head or
forehead
v Rinne test
• Examiner shifts the stem of a vibrating tuning fork between two positions: 2 inches from the opening of the ear
canal (for air conduction) and against the mastoid bone (for bone conduction)
Tuning Fork Tests
EAR CONDITION WEBER TEST RINNE'S TEST
Normal, no hearing loss hears the sound equally in both ears air-conducted sound is louder than
bone-
conducted sound
Conductive loss hears the sound better in the bone-conducted sound is longer
affected ear than air-conducted sound
Sensorineural loss hears the sound in the better- air- conducted sound is longer than
hearing ear bone-conducted sound
v Audiometry
• used in detecting hearing loss
• Pure-tone audiometry -sound stimulus consists of a pure or musical tone (the louder the tone before the
patient perceives it, the greater the hearing loss)
• Speech audiometry -spoken word is used to determine the ability to hear and discriminate sounds and words.
EXTERNAL EAR PROBLEMS

OTITIS EXTERNA
v Refers to an inflammation of the external auditory canal
v Etiology
• Bacterial causes, usually Pseudomonas, and Staphylococcus aureus
• Fungal infection with Aspergillus and Candida albicans
• Trauma to the ear canal, usually from cleaning the canal
• Stagnant water in ear canal after swimming (swimmer's ear)
• Pain and discharge from the external auditory canal
• Aural tenderness
• Fever, cellulitis, and lymphadenopathy.
• Hearing loss or feeling of fullness
• Ear canal is erythematous and edematous
• Discharge may be yellow or green and foul-smelling
• In fungal infections, hair-like black spores may even be visible
v Management
• If canal is swollen and tender, an antibiotic solution containing a corticosteroid is chosen to reduce
inflammation and swelling. If acute inflammation and closure of the ear canal prevent drops from
saturating
canal, a wick may need to be inserted so drops will gain access to walls of entire ear canal.
• Burow's solution (aluminum acetate solution) or topical corticosteroid cream or lotion is used in otitis externa
caused by dermatitis.
• Fungal infection may be treated with a topical antifungal such as nystatin.
• In chronic otitis externa, debris from ear canal may need to be removed through irrigation or suction, after
pain and
swelling have subsided.
• Tympanic membrane perforation or a current Warm compresses and analgesics may be needed.
• Instruct patients not to clean the external auditory canal with cotton-tipped applicators
• Avoid events that traumatize the external canal
• Avoid getting the canal wet when swimming or shampooing the hair
• Infection can be prevented by using antiseptic otic preparations after swimming
MIDDLE EAR PROBLEM

ACUTE OTITIS MEDIA
v An inflammation and infection of the middle ear caused by the entrance of pathogenic organisms, with rapid onset of
signs and
symptoms. It is a major problem in children but may occur at any age.
v Pathogenic organisms gain entry into the normally sterile middle ear, usually through a dysfunctional eustachian
tube
v Most common organisms include Streptococcus pneumoniae, Haemophilus influenzae and Staphyloccocus Aureus
• May involve one or both ears
• Progressive conductive or mixed hearing loss
• May or may not complain of tinnitus
• Normal tympanic membrane but may also reveals a pinkish orange tympanic membrane because of vascular
and bony changes in the middle ear
• Bone conduction is better than air conduction on Rinne testing
• Stapedectomy
ü Involves removing the stapes superstructure and part of the footplate and inserting a tissue graft
and a suitable prosthesis.
ü Balance disturbance or true vertigo may occur during the postoperative period for several days
MENIERE'S DISEASE
v Abnormal inner ear fluid balance caused by a malabsorption in the endolymphatic sac or a blockage in the
endolymphatic duct
• Fluctuating, progressive sensorineural hearing loss
• Feeling of pressure or fullness in the ear
• Meniere’s Triad
ü Tinnitus or a roaring sound
ü Vertigo, often accompanied by nausea and vomiting
ü Sensorineural hearing loss
• Caloric testing to differentiate Meniere's disease from intracranial lesion
ü Fluid, above or below body temperature, is instilled into the auditory canal
ü Will precipitate an attack in patients with Meniere's disease
ü Normal patient complains of dizziness; patient with acoustic neuroma has no reaction
• Audiogram shows sensorineural hearing loss.
• CT scan, MRI to rule out acoustic neuroma
v Management Medical
• Patient can be asked to keep a diary noting presence of aural symptoms (eg, tinnitus, distorted hearing) when
episodes of vertigo occur. This may help diagnose which ear is involved and whether surgery will be needed
• Administration of osmotic diuretics (Diamox)
• Administration of the vestibular suppressant to control symptoms
Meclizine (Antivert, Bonine) up to 25 mg qid
Diphenhydramine (Benadryl) 25 to 50 mg tid to qid
Diazepam (Valium) 2 mg tid or 5 to 10 mg I.M. or I.V. (addictive potential)
• Streptomycin (I.M.) or gentamicin (transtympanic injection) may be given to selectively destroy vestibular
apparatus if vertigo is uncontrollable
• Additional antiemetic, such as Promethazine (Phenergan), may be needed to reduce nausea, vomiting, and
resistant vertigo
Surgery
v Endolymphatic Sac Decompression
• Theoretically equalize-8" the pressure in the endolymphatic space
• A shunt or drain is inserted in the endolymphatic sac through a postauricular incision
v Labyrinthectomy

• Recommended if the patient experiences progressive hearing loss and severe vertigo attacks so normal
tasks cannot be performed; results in total deafness of affected ear
v Vestibular Nerve Section
• Neurosurgical suboccipital approach to the cerebellopontine angle for intracranial vestibular nerve
neurectomy
v Common Complications
• Irreversible hearing loss
• Disability and social isolation due to vertigo and hearing loss
• Injury due to falls
• Help patient recognize aura so patient has time to prepare for an attack
• Encourage patient to lie down during attack, in safe place, and lie still
• Limit foods high in salt or sugar. Be aware of foods with hidden salts and sugars.
• Limit alcohol intake. Alcohol may change the volume and concentration of the inner ear fluid and may
worsen symptoms.
• Avoid aspirin and aspirin-containing medications
• Teach about medication therapy, including side effects
• Advise patient to keep a log of attacks, triggers, and severity of symptoms
• Encourage follow-up hearing evaluations and provide information about surgical care
IMPACTED CERUMEN AND FOREIGN BODIES

v Accumulated cerumen (earwax) may become impacted due to use of cotton swabs to clean ears and may be a
problem for some people
v Cerumen becomes drier in elderly people, making impaction more likely
v Foreign bodies may be lodged in the ear canal intentionally or accidentally by the patient or other person (usually
in children), or the patient may be completely unaware, as in insect obstruction
v Etiology
• May be underlying seborrhea or other dermatologic condition that causes flaking of skin that mixes with
cerumen and becomes obstructive
• Cerumen may be pushed back over tympanic membrane by action of cotton swab
• Insect may fly or crawl into ear, causing initial low rumbling sound; later, feeling that ear is plugged and
decreased hearing acuity
• Children who introduce peas, beans, pebbles, toys, and beads
v Clinical manifestations
• Decreased hearing acuity
• Feeling that ears is plugged
• Pain and fever
• Drainage may occur
v Management
For Impacted Cerumen
• Cerumen can be removed by irrigation.
• Suction, or instrumentation unless the patient has a perforated eardrum or an inflamed external ear
• For successful removal, the water stream must flow behind the obstructing cerumen to move it first laterally
and then out of the canal
• If irrigation is unsuccessful, direct visual, mechanical removal can be performed.
• Instilling a few drops of warmed glycerin, mineral oil, or half-strength hydrogen peroxide into the ear
canal for 30 minutes can soften cerumen before its removal
• Use of cerumen curette, aural suction, and a binocular microscope for magnification
For Foreign Objects
• Irrigation for dislodged bodies and insects are contraindicated
• Insect can be dislodged by instilling mineral oil
• Mechanical removal and aural suction can be performed
• Foreign body may have to be extracted in the operating room with the patient under general anesthesia

OPERATING ROOM NURSING

PERIOPERATIVE NURSING
v It is a term used to describe the nursing care provided in the total surgical experience of the patient. The
perioperative period consists of three phase that begin and end at a particular point in the sequence of events in
the surgical experience.
v Preoperative phase begins when the decision to proceed with surgical intervention is made and ends with the
transfer of the patient onto the operating room (OR) table.
v Intraoperative phase begins when the patient is transferred onto the OR table and ends with admission to the
PACU (Post Anesthesia Care Unit)
v Postoperative phase begins with the admission of the patient to the PACU and ends with a follow-up evaluation in
the clinical setting or home
SURGICAL CLASSIFICATIONS
v Diagnostic (eg, biopsy, exploratory laparotomy)
v Curative (eg, excision of a tumor or an inflamed appendix)
v Reparative (eg, multiple wound repair)
v Reconstructive or cosmetic (eg, mammoplasty or a facelift)
v Palliative (eg, to relieve pain or correct a problem-for instance, a gastrostomy tube may be inserted to compensate
for the inability to swallow food)
ACCORDING TO THE DEGREE OF URGENCY

v Optional – Surgery is scheduled completely at the preference of the patient (eg, cosmetic surgery)
v Elective – The approximate time for surgery is at the convenience of the patient; failure to have surgery is not
catastrophic (eg, a superficial syst)
v Required – The condition requires surgery within a few weeks (eg, eye cataract)
v Urgent – The surgical problem requires attention within 24 to 48 hours (eg, cancer)
v Emergency – The situation requires immediate surgical attention without delay (eg, intestinal obstruction)
INFORMED CONSENT (OPERATIVE PERMIT)

v Informed consent is the patient’s autonomous decision about whether to undergo a surgical procedure. It is
the process of informing the patient about the surgical procedure; that is risks and possible complications of
surgery and anesthesia. Consent is obtained by the surgeon. This is a legal requirement.
v Purposes
• To ensure that the patient understands the nature of the treatment, including potential complications
• To indicate that the patient’s decision was made without pressure
• To protect the patient against unauthorized procedure is performed on the correct body part
• To protect the surgical team and hospital against legal action by a patient who claims that an unauthorized
procedure was performed
THE SURGICAL TEAM
v Circulating Nurse
• Main responsibilities include:
ü Verifying consent
ü Coordinating the team
ü Ensuring cleanliness
ü Proper temperature and humidity
ü Lighting and safe function of equipment and the availability of supplies and materials.
• The circulating nurse monitors aseptic practices to avoid breaks in technique while coordinating the movement of
related personnel (medical, x-ray, and laboratory) as well as implementing fire safety precautions.
• Responsible for ensuring that the second verification of the surgical procedure and site takes place is
documented.
v SCRUB NURSE
• Performs surgical hand scrub
• Setting up the sterile tables
• Preparing sutures, ligatures, and special equipment (eg, laparoscope)

• Assisting the surgeon and the surgical assistants during the procedure by anticipating the instruments and
supplies that will be required, such as sponges, drains, and other equipment
• Scrub nurse and the circulator count all needles, sponges, and instruments to be sure they are accounted for and
not retained as a foreign body in the patient
v SURGEON
• Performs the surgical procedure, heads the surgical team and is specially trained and qualified
• Has the ultimate responsibility for performing the surgery in an effective and safe manner
v ANESTHESIOLOGIST
• Assesses the patient before surgery, selects anesthesia, administers it, intubates patient if necessary, manages
any technical problems related to the administration of the anesthetic agents, and supervises the patient’s
condition throughout the surgical procedure
• During surgery, the anesthesiologist monitors the patient’s blood pressure, pulse, and respirations as well as the
electrocardiogram (ECG), blood oxygen saturation level, tidal volume, blood gas level, blood pH, alveolar gas
concentrations, and body temperature
SURGICAL ENVIRONMENT
v The surgical suite is behind double doors, and access is limited to authorized personnel. External precautions include
adherence to principles of surgical asepsis; strict control of the OR environment is required, including traffic pattern
restriction
v To provide the best possible conditions for surgery, the OR is situated in a location that is central to all
supporting services
v To help decrease microbes, the surgical area is divided into three zones:
o Unrestricted zone: where street clothes are allowed; area in the operating room that interfaces with other
departments; includes patient reception area and holding area
o Semi-restricted zone: area in the operating room where scrub attire (scrub clothes and caps) is required;
may include areas where surgical instruments are processed
o Restricted zone: scrub clothes, shoe cover caps, and masks are worn; includes operating room and sterile
core area
SURGICAL ATTIRE
v SCRUB SUIT
• Two-piece pant suit
• Worn in the semi-restricted
• Must fit the body properly
• Waistline drawstrings must be tucked in
• Wet or soiled garments should be changed
v HEAD COVER
• Should cover the hair completely
• Worn in the Semi restricted
• Never comb your hair when wearing a scrub suit
• Disposable caps are preferred
• Bald head also causes contamination by shedding squamous cells
• Net caps do not prevent contamination
v SHOES AND SHOE COVER
• Worn is semi restricted area
• Should be comfortable and puncture resistant
• Shoe covers are worn during procedures with expected spills/splashes of blood or body fluids
• Street shoes are not used
• Shoe covers should be disposed before leaving the OR
v SURGICAL MASK
• High filtration masks decrease the risk of post wound infection
• Worn inside the restricted area at all times
• Should cover nose and mouth completely
• Should fit tightly
• Double masking - a barrier not a filter
• Masks are changed between patients and should not be worn outside OR
• Handle the mask by the ties or strings
• Front of the mask is contaminated
• Mask should never be hanged on the neck or place on top of cap
• It should not be kept in the pocket after use
• Should not interfere with breathing, speech or vision
v EYE WEAR
• Eyewear or a face shield protects the eyes from splashing of blood and body fluids or from debris when bone
drilling is performed
v LASER EYEWARE
• Protects the eyes from the intense light created by laser surgery
v GLOVES
• Nonsterile gloves: Donned for clean procedures
• Sterile gloves: Donned for sterile procedures
PRINCIPLES OF SURGICAL ASEPSIS
v All surgical supplies, instruments, needles, sutures, dressings, gloves, covers, and solutions that may come in contact
with the surgical wound or exposed tissue must be sterilized before use
v The surgeon, surgical assistants, and nurses prepared themselves by scrubbing their hands and arms with antiseptic
soap and water or alcohol-based product or scrubless soap is used to prepare for surgery
v During surgery, only personnel who have scrubbed, gloved, and gowned touch sterilized objects
v Requires meticulous cleaning and maintenance of the OR environment
v An area of the patient’s skin larger than that requiring exposure during the surgery is meticulously cleansed, and an
antiseptic solution is applied
BASIC GUIDELINES FOR MAINTANING SURGICAL ASEPSIS

v Only sterile surfaces/articles may touch other sterile surfaces/articles.
v Gowns of the surgical team are considered sterile in front from the chest to the level of the sterile field. The
sleeves are also considered sterile form 2 inches above the elbow to the stockinette cuff.
v Only the top surface of a draped table is considered sterile.
v Sterile supplies, including solutions, are delivered to a sterile field or handed to a scrubbed person in such a way
that the sterility of the object or fluid remains intact.
v The movements of the surgical team are from sterile to sterile areas and from unsterile to unsterile areas.
v Movement around a sterile field must not cause contamination of the field.
v Whenever a sterile barrier is breached, the area must be considered contaminated.
v Items of doubtful sterility are considered unsterile.
CLEANING
DISINFECTION STERILIZATION
CHEMICAL
INTERMEDIATE DRY HEAT
LOW LEVEL LEVEL HIGH LEVEL AUTOCLAVE
INSTRUMENT DECONTRAMINATION PROCESS

v CLEANING
• Removal of foreign material from the instrument by a combination of mechanical means (scrubbing) and
chemical means (Enzyme and detergents)
PROCEDURES UNDER HIGH LEVEL DISINFECTION
v PHYSICAL DISINFECTION BY BOILING
• Uses 100°C boiling water to destroy most pathogens except spores
v PASTEURIZATION
• Used for items such as reusable respiratory devices and anesthesia breathing circuit
• Exposure to hot water with temperature of 60°C-80°C for 30 mins.
v CHEMICAL DISINFECTION
• Items are soaked in a disinfectant
• Choice depends on compatibility and effectiveness on the instruments
• Used for heat labile instruments that cannot be boiled or sterilized
STERILIZATION
• Process in which all pathogens are destroyed including spores
• Highest level of decontamination
METHODS OF STERILIZATION
v CHEMICAL STERILIZATION
• Ethylene oxide gas is used to sterilize items that are sensitive to heat or moisture
v AUTOCLAVING
• Most common method
• Uses steam with 121°C temperature and 1 atm pressure for 30 minutes
v DRY HEAT STERILIZATION
• Dry heat in form of air is used
• Sterilizes anhydrous oils, petroleum products and talc powder
INDICATORS USED IN STERILIZATIONS
v Indicators never indicate sterility; it is only a parameter that instruments have undergone sterilization
v Event related not based on time
v Expiration date is only an estimate
v Shelf life depends on
• Amount of handling
• The quality of packaging materials used
• Storage condition
3 CATEGORIES UNDER SPAULDING’S CLASSIFICATION
v NON-CRITICAL
• Items that come in contact with INTACT SKIN.
ü Stethoscope
ü BP cuffs
ü Tourniquet
ü Floor and linens
v SEMI-CRITICAL
• Items that come in contact with MUCOUS MEMBRANES and NON-INTACT SKIN
• High level disinfection
ü Anesthesia equipment
ü GI endoscopes
ü Speculum
ü Bronchoscopes
ü Laryngoscope
ü Thermometer
ü Respiratory therapy equipment
v CRITICAL
• Items that come in penetrate sterile tissues such as BODY CAVITY and VASCULAR SYSTEM
ü Surgical instruments
ü Intra-uterine devices
ü Vascular catheters
ü Implants
ü Urinary catheter, needles
PREOPERATIVE MEDICATION
v Reduce anxiety
v Promote relaxation
v Reduce pharyngeal secretions
v Prevent laryngospasm
v Inhibit gastric secretion
v Decrease amount of anesthetic needed for induction and maintenance of anesthesia
v Anesthesia
•A state of narcosis (severe central nervous system depression produced by pharmacologic agents), analgesia,
relaxation, and reflex loss
v General Anesthesia
• A reversible consisting of complete loss of consciousness that provides analgesia, muscle relaxation, and
sedation, Protective reflexes are lost.
• Lose the ability to maintain ventilator function and require assistance in maintaining a patent airway
ADMINISTRATION OF GENERAL ANESTHESIA

v Inhalation
• Inhaled anesthetic agents include volatile liquid agents and gases.
• Volatile liquid: anesthetic agents produce anesthesia when their vapors are inhaled
ü Halothane (Fluothane)
ü Enflurane (Ethrane)
ü Isoflurane (Forane)
ü Sevoflurane (Ultrane)
ü Desflurane (Suprane)
• Gas anesthetic agents are administered by inhalation and are always combined with oxygen. Nitrous oxide
is the most used gas anesthetic agent.
v Intravenous Administration
• General anesthesia can also be produced by the IV administration of various substances, such as:
• Barbiturates
• Benzodiazepines
• Non-barbiturate hypnotics
• Dissociative agents
• Opioid agents
STAGES OF GENERAL ANESTHESIA
v STAGE 1 (BEGINNING ANESTHESIA/INDUCTION)
• Feeling of detachment
• Drowsy/dizziness
• Hallucination occurs
• Close O.R doors
• Ringing, roaring or buzzing in the ears
• Keep quiet because exaggerated noises are heard by the patient
• Standby to assist the client
v STAGE 2 (EXCITEMENT/DELIRIUM)
• Pupils are dilated, pulse rate are rapid, and may have irregular respiration
• Because of uncontrolled movement of the patient, restraints are necessary
v STAGE 3 (SURGICAL ANESTHESIA)
• Patient is unconscious and lies quietly
• Pupils are small but reactive to light
• Respirations are regular, the pulse and volume are normal
• Skin is pink or slightly flushed
v STAGE 4 (MEDULLARY DEPRESSION/DANGER)
• Too much anesthesia has been administered
• Shallow respiration, weak and thread pulse
• Widely dilated pupils
• Death may occur
• If this stage develops, discontinue anesthesia and initiate respiratory and circulatory support
REGIONAL ANESTHESIA
v Anesthetic agents are injected around nerves so that the region supplied by these nerves is anesthetized
v Patient receiving regional anesthesia is awake and aware of his or her surroundings unless medications are given to
produce mild sedation or to relieve anxiety
v Epidural anesthesia
• Achieved by injecting a local anesthetic agent into the epidural space that surrounds the dura mater of the spinal
cord
• Advantage absence of headache
•Disadvantage: greater technical challenge of introducing the anesthetic agents into the epidural rather than the
subarachnoid space
v Spinal anesthesia
• Extensive conduction nerve block that is produced when a local anesthetic agent is introduced into the
subarachnoid space at the lumbar level, usually between L4 and L5.
• It produces anesthesia of the lower extremities, perineum, and lower abdomen
v Moderate sedation
• Previously referred to as conscious sedation, is form of anesthesia that involves the IV administration of
sedative or analgesic medications to reduce patient’s anxiety and to control pain during diagnostic or
therapeutic procedures
v Monitored anesthesia care (MAC)
• Also referred to as monitored sedation, is moderate sedation administered by an anesthesiologist or
anesthetist who must be prepared and qualified to convert to general anesthesia if necessary
v Local anesthesia
• Injection of a solution containing the anesthetic agent into the tissues at the planned incision site
PREOPERATIVE PHASE
v Preoperative Assessment
• The goal in the preoperative period is for the patient to be as healthy as possible
ü Consent
ü Health history is obtained
ü Nutritional and fluid status
ü Dentition
ü Alcohol and drug use
ü Respiratory status
ü Cardiovascular status
ü Hepatic, Renal and endocrine function
ü Previous medication used
PREOPERATIVE NURSING INTERVENTIONS

Providing Patient Teaching
v Deep Breathing, Coughing and Incentive
• Spirometry
ü Demonstrates how to take deep, slow breath and how to exhale slowly
ü Instruct the patient to breathe deeply, exhale through the mouth, take a short breath, and cough from deep in
the lungs
ü Demonstrates how to use an incentive spirometer
v Mobility and Active Body Movement
• Patient should be taught that early and frequent ambulation, exercise of the extremities and frequent change of
position immediately postoperative as tolerated will help to prevent complications
v Pain Management
• Patient is instructed to take the medication as frequently as prescribed during the initial postoperative period for
pain relief
v Reducing Anxiety and Decreasing Fear
• Assists the patient to identify coping strategies that he or she has previously used to decrease fear
v Managing Nutrition and Fluids
• NPO overnight or longer to prevent aspiration
• Specific recommendations depend on the age of the patient and the type of food eaten (ex. Adult is advised to
fast for 8hours after eating fatty food)
v BOWEL PREPARATION
• Enemas are not commonly prescribed preoperatively unless the patient is undergoing abdominal or pelvic surgery
• Allow satisfactory visualization of the surgical site and to prevent trauma to the intestine or contamination of the
peritoneum by fecal material
• Cleansing enema or laxatives may be prescribed evening before the surgery and may be repeated the morning of
surgery
v SKIN PREPARATION
• Goal is to decrease bacteria without injuring the skin
• Cleanse the skin with soap containing detergent-germicide
• If hair must be removed, electric clippers are used
IMMEDIATE PRE-OP NURSING INTERVENTIONS

v Assist the patient in changing hospital gown
v Cover the head completely with cap
v Inspect the mount, dentures and plates are removed
v Remove all jewelries/body piercing
v If the patient objects in removing wedding ring, secure it with tape
v All valuable articles are given to family members or labelled it clearly and store it in a safe and secured place
according to hospital policy
v Patient should void first before going to OR
v If preanesthetic medication is administered, the patient is kept in bed with the side rails raised
v The completed chart (with the preoperative checklist and verification form) accompanies the patient to the OR with
the surgical consent form attached, along with all laboratory reports and nurse’s records
v Transfer the patient to the holding area/presurgical suite 30-60 minutes before anesthetic agent is administered
v Patient safety in the preoperative area is a priority.
SURGICAL POSITIONS
v SUPINE (DORSAL) POSITION
• Patient is flat on the back, both arms are positioned at the side of the table, one with the hand placed palm
down; the other is carefully positioned on an armboard to facilitate IV infusion of fluids, blood, or medications
• Used for procedures of anterior surface of the body, such as abdominal, abdominothoracic and some lower
extremity procedures.
• Shoulder or anterolateral procedures: the patient is on supine position with a small sandbag/water
bag/roll/pad is placed under the affected side to elevate and expose the shoulder
• Dorsal recumbent: for vaginal or perineal procedures
• Modified dorsal recumbent (frog-leg): surgical procedures in the groin lower extremities
• Arm extension: surgical procedures of the breast, axilla, upper extremities or hand
v TRENDELENBURG’S POSITON
• Usually is used for surgery on the lower abdomen and pelvis to obtain good exposure by displacing the
intestines into the upper abdomen
v REVERSE TRENDELENBURG’S POSITON
• Used for thyroidectomy, laparoscopic gallbladder, biliary tract or stomach procedure
v FOWLER’S POSITION
• Used for shoulder, nasopharyngeal, facial and breast reconstruction procedure
v SITTING POSITION
• Occasionally used for otorhinologic and neurosurgical procedure
v LITHOTOMY POSITION
• Used for perineal, vaginal, urologic and rectal procedures
v PRONE POSITION
• Used for all procedures with dorsal or posterior approach
• Modified prone procedure is used foe neurosurgical and spine procedures
v KRASKE (JACK-KNIFE) POSITION
• Hips are positioned over the center break of the operating table between the body and leg section.
• The leg section of the operating bed is lowered (usually 90°) and the entire operating bed is tilted head
downward to elevate the hips above the rest of the body
• Done for rectal procedures (pilonidal sinus, hemorrhoidectomy)
v KNEE-CHEST POSITION
• Used for sigmoidoscopy or culdoscopy
v LATERAL POSITION
• Used for renal surgery
POTENTIAL INTRAOPERATIVE COMPLICATIONS

v NAUSAE AND VOMITING
• Administer antiemetics preoperatively or intraoperatively as ordered to counteract possible aspiration

If gagging occurs, turn the patient to the side, the head of the table is lowered, and a basin is provided
•
to collect the vomitus
• Suction saliva and vomited gastric content
v RESPIRATORY COMPLICATIONS
• May lead to brain damage if not recognized
• Be vigilant in monitoring the patient’s oxygenation status.
• Check peripheral perfusion frequently
v HYPOTHERMIA
• Patient’s temperature may fall during the anesthesia
• May occur as a result of a low temperature in the OR, infusions of cold fluids, inhalation of cold gases,
open body wounds or cavities and decreased muscle activity
• Environmental temperature in the OR can temporarily be set at 25 C to 26.6 C
• Warm IV and irrigating fluids
• Wet gowns and drapes are removed promptly and replace with dry materials
PREVENTING INTRAOPERATIVE POSITIONING INJURY
v The patient should be in as comfortable a position as possible, whether conscious or unconscious
v The operative field must be adequately exposed
v An awkward position, under pressure on a body part, or use of stirrups or traction should not obstruct the
vascular supply.
v Respiration should not be impeded by pressure of arms on the chest or by a gown that constricts the neck or
chest.
v Nerves must be protected from undue pressure. Improper positioning of the arms, hands, and legs, or feet can
cause serious injury or paralysis. Shoulder braces must be well padded to prevent irreparable nerve injury,
especially when the Trendelenburg position is necessary.
v Precautions for patient safety must be observed, particularly with thin, elderly, or obese patient and those with a
physical deformity.
v The patient may need light restraint before induction in case of excitement.
CLASSIFICATIONS OF INSTRUMENTS
v CUTTING AND DISECTING
• Used to dissect, incise, separate or excise tissues.
• Scalpels
ü Blades 10, 11,12 and 15 fits handle size #3 or 7
ü Blades 20,22,25 fits handle size #4
ü Blade #10 is used to open the skin
ü Blade #11 makes initial skin puncture for tiny deep incisions
ü Blade #12 is commonly used for tonsillectomy
ü Blade #15 is used for shallow short controlled incisions
ü Blade #20 same with #10but larger in size.
v SCISSORS
ü Suture scissors are used to cut sutures
ü Wire scissors are used to cut wires
ü Bandage scissors are used to cut drains and dressings and to open items such as plastic packets
ü Sharp-tipped angled scissors with short jaws used for vascular surgery
ü Mayo scissors are used for cutting heavy fascia and sutures.
ü Metzenbaum scissors are more delicate than mayo scissors and are used to cut delicate tissues.
v Curettes
• Tissue from bone is removed by scraping with the sharp edge of the loop or scoop on the end of the
curette
GRASPING AND HOLDING
v Tissues should be grasped held in position so surgeon can perform the design and the maneuver without injuring
the surrounding tissues.
• Delicate Forceps- hold fine tissues such as eye tissues
• Adson forceps- used to pick up or hold soft tissues during closure
• Smooth Forceps (thumb forceps)- used to prevent injury to the suture
• Toothed Forceps- hold on tough tissue
• Allis Forceps- used to hold tough tissue
• Babcock Forceps- end of each jaw is rounded to grasp tissue without injury (e.g. Fallopian tube)
• Lahey Forceps- has sharp point tips to grasp tough organs or tumors
• Stone Forceps- grasp calculi in kidney and gallbladder
CLAMPING AND OCCLUDING
v Instruments that apply pressure by clamping or occluding
• Hemostatic Forceps- used for occluding blood vessels
• Crushing Clamps- used to crushed tissues or clamp blood vessels
EXPOSING AND RETRACTING
v Soft tissues, muscles and other structures should be pulled aside for exposure of the surgical site
• Malleable Retractors- maybe bent to the desired angle and depth for retraction
• Hooks- commonly used to retract skin edges during a wide-flap dissection such as mastectomy
• Self-retraining- inserted to spread the edges of an incision and hold them apart. eg: Balfour
SUTURES
v Used for ligating, stitching or approximating tissues
ABSORBABLE SUTURES
• Surgical Gut- collagen derived from the submucosa of sheep’s intestine or serosa of beef’s intestine
• Plain Surgical gut- loses strength in 5-10 days and is digested within 70 days.
ü Used to ligate small vessels and sutures subcutaneous fats
• Chromic Surgical Gut- support the wound for about 14 days and loses tensile strength up to 21days
and is absorbed within 90 days. Used for ligation of larger vessels and sutures urinary/biliary tract.
• Synthetic Absorbable Polymers- are absorbed by a slow hydrolysis process in the presence of tissue
fluids
• Polydioxanone Sutures (PDS)- Useful in tissues in which wound healing is slow, as in the fascia, or
where extended wound support is desirable.
• Poliglecaprone 25 (Monocryl)- loses all tensile strength by 21 days and absorption is between 91-119
days. Used in soft tissues such as gynecologic, urologic, and plastic surgery
• Polyglactin 910 (Vicryl)- absorbs rapidly within 90days. Uncoated polyglactin 910 is used for
ophthalmic procedures
NON-ABSORBABLE SUTURES
v Surgical silk
• loses tensile strength when wet
• Used frequently in the serosa of the gastrointestinal tract and to close fascia in the absence of infection
v Surgical Cotton
• Gains tensile strength when wet
• Used in the most body tissues for ligating and suturing
v Surgical stainless steel
• Used for abdominal wall or for retention sutures to reduce the danger of wound disruption/dehiscence
SURGICAL NEEDLES
v Point of the Needle- honed to the configuration and sharpness desired for specific types of tissue
• Cutting point is used when tissue is difficult to penetrate (skin, tendon, and tough tissues in the eye)
ü Conventional cutting needles
ü Reverse-cutting needles
ü Side cutting needles
ü Trocar point
• Taper (Round) point is used when tissue such as intestines and peritoneum
• Blunt point is used for suturing friable tissues such as liver and kidney
v Body of the Needle
• Straight needles are used in readily accessible tissues
• Curved needles are used to approximately most tissues
• French eye needle has a slit from the inside of the eye to the end of the needle through which the
suture strand is drawn
• Eyeless needle is a continuous unit with the suture strand, needle is swaged onto the end of the strand
in the manufacturing process
POSTOPERATIVE NURSING
v Care of the Patient in the Post-anesthesia Care Unit
• The post-anesthesia care unit (PACU),
Also called the recovery room or post-anesthesia recovery room, is located adjacent to the operating rooms suite
v Phases of Post-anesthesia Care
• Phase I PACU: care of surgical patients immediately after surgery and for the patient whose condition
warrants close monitoring and intensive care is provided
• Phase II PACU: surgical patient’s condition no longer requires close monitoring provided in a phase I
PACU. Patient is prepared for self-care or care in the hospital or in extended care setting.
• Phase III PACU: setting in which the patient is cared for in the immediate postoperative period and
then prepared for discharge from the facility
v Determining Readiness for Discharge From the PACU
• Many hospitals use a scoring system (Aldrete score) to determine the patient’s general condition and
readiness for transfer from the PACU
• Throughout the recovery period, the patient’s physical signs are observed and evaluated by means of a
scoring system based on the set of objective criteria.
• The patient is assessed at regular intervals, and a total score is calculated and recorded
• Aldrete score is usually 8 to 10 before discharge from the PACU, patient with a score of less than 7 must
remain in the PACU until condition improves or they transferred to an intensive care area
• Area of assessment in Aldrete score includes:
ü activity
ü respiration
ü circulation
ü consciousness
ü oxygen saturation
v PRIORITY # 1: restoration of homeostasis and prevent complications
v PRIORITY # 2: maintain and promote adequate airway and respiratory function
v PRIORITY # 3: maintain adequate cardiac function and promote tissue
v PRIORITY #4: maintain adequate fluid and electrolyte balance and adequate renal function
• sufficient fluids to maintain extracellular fluids and blood volume
• prevent fluid overload with resultant
• pulmonary congestion and edema
• monitor serum electrolyte
• accurate I&O recording
• instruct and support breathing exercises
• don’t force fluid too soon
v PRIORITY # 5: promote comfort and rest
• Manage pain during variety of approaches: pharmacologic (narcotic, analgesic), comfort measures
v PRIORITY # 6: promote adequate nutrition and elimination
• normal peristalsis returns to 48 to 72 hrs post-op.
• liquid diet (broth, tea, fruit juices, jello, soup)
• early ambulation to prevent abdominal distension
v PRIORITY # 7: promote wound healing and prevention of:
• DEHISCENCE- Total or partial disruption or (separation) in wound edges but underlying subcutaneous
tissue has not parted
• EVISCERATION- Protrusion of viscera through an abnormal wound opening
NURSING MANAGEMENT IN THE PACU
v Assess patient’s airway, respiratory function, cardiovascular function, skin color, level of consciousness, and the
ability to respond to commands
v Check the surgical site for drainage or hemorrhage and make sure that all drainage tubes and monitoring lines
are connected and functioning
v Monitoring v/s every 15 mins
v Administer postoperative analgesics
v Maintaining Patent Airway
• Assess for hypopharyngeal obstruction, signs of occlusion include chocking, noisy and irregular
respirations
•Suction mucus or vomitus that is obstructing the trachea (caution with patient who has had a
tonsillectomy or other oral or laryngeal surgery)
v Maintaining Cardiovascular Activity
• Hypotension can result from blood loss, hypoventilation, position changes, pooling of the blood
extremities, or side effects of medication and anesthetics
v Shock, one of the most serious postoperative complications, can result hypovolemia and decreased intravascular
volume
• Primary intervention for hypovolemic shock is volume replacement
• Administer oxygen
• Continuously monitor patient’s condition has stabilized
• Keep the [patient warm and maintain normothermia (normal body temperature)
v Hemorrhage is copious escape of blood from blood vessel
CLASSIFICATION OF HEMORRHAGE
Time Frame
Primary Hemorrhage occurs at the time of surgery.
Intermediary Hemorrhage occurs during the few hours after surgery when the rise of blood
pressure to its normal level dislodges insecure clots from untied vessels.
Secondary Hemorrhage may occur sometime after surgery if a suture slips because of blood
vessel was not securely tied, became infected, or was eroded by a drainage tube.
Types of Vessel
Capillary Hemorrhage is characterized by a slow, general ooze.
Venous Darkly colored blood bubbles out quickly.
Arterial Blood is bright red and appears in spurts with each heartbeat.
Visibility
Evident Hemorrhage is on the surface and can be seen.
Concealed Hemorrhage is in a body cavity and cannot be seen.
v Clinical Signs/ Intervention for Hemorrhage

• Patient presents with hypotension, rapid, thready pulse, disorientation, restlessness, oliguria, cold and
pale skin.
• Feeling of apprehension, decreased cardiac output and vascular resistance and signifies that the patient
is in the early phase of shock
• Transfusing of blood or blood products and determining the cause of hemorrhage are the initial
therapeutic measures
• Inspect surgical site and incision, if bleeding is evident, a sterile gauze pad and a pressure dressing are
applied, and the site of the bleeding is elevated to heart is possible
• Place the patient in shock position (flat on back; legs are elevated at 20-degree angle; kept straight)
• If suspected for internal hemorrhage, patient is taken back to OR
v Relieving Pain and Anxiety
• Monitor the patient’s physiological status, manage pain and provides psychological support to relieve the
patients fears and concerns
• Opioid analgesics are administered mostly in the IV in the PACU, it immediately relief pain and are short
acting
v Controlling Nausea and Vomiting
• Intervene immediately in the patient’s first report of nausea to control the problem rather than the wait
for it to progress vomiting
• Administer medicine such as Phenergan and Atarax as ordered to prevent post op nausea and vomiting
• Encourage the patient to breathe deeply to facilitate elimination of anesthetics
NURSING MANAGEMENT AFTER SURGERY
PREVENTING RESPIRATORY COMPLICATIONS

v Respiratory depressive effects of opioid medications, decreased lung expansion secondary to pain and decreased
mobility, put the patient in risk for common respiratory complications such as:

• Atelectasis – alveolar collapse; incomplete expansion of lung
ü Signs and symptoms include
Decreased breath sounds over the affected area crackles and cough
• Pneumonia – characterize by chills and fever, tachycardia, and tachypnea. Cough may or may not be
present and may or may not productive.
Hypostatic pulmonary congestion, caused by a weakened cardiovascular system that permit stagnation of secretion
at lung bases, may develop.
Clinical manifestations include:
ü Slight elevation temperature, pulse, and respiratory rate, cough
ü Dullness and crackles at the base of the lungs
• Encourage the patient to turn frequently, take deep breaths, cough and use the incentive spirometer at
least every 2 hours
• Careful splinting of abdominal or thoracic incisions sites help the patient to overcome the fear that the
exertion of coughing might open the incisions
• Encouraged the patient to yawn or take sustained maximal inspirations to promote lung expansions
• Coughing is contraindicated in patients who have head injuries or who have undergone intracranial
surgery, eye surgery and plastic surgery
• Early ambulation increases metabolism and pulmonary aeration
ASSISTING POSTOPERATIVE PATIENT

IN AMBULATION
v Early ambulation has a significant effect on the recovery and the prevention of complications (eg, atelectasis,
hypostatic pneumonia, gastrointestinal discomfort and circulatory problems such as blood stasis and
thromboembolism)
• Help the patient move gradually from lying position to the sitting position by the raising the head of the
bed and encourage the patient to splint the incisions when applicable
• Position the patient completely upright (sitting) and turned so that both legs are hanging over the edge
of the bed.
• Help the patient stand beside the bed
• Nurse should be on the patient’s side to give physical support and encouragement
• Bed exercises are also encouraged to improve circulation
ü arm exercises
ü hand and finger exercises
ü foot exercises to prevent DVT, foot, drop and toe deformities and to aid in maintaining good
circulation
ü leg flexion and leg-lifting exercises to prepare patient for ambulation
ü abdominal and gluteal contraction exercises
PREVENTING DEEP VEIN THROMBOSIS

v DVT occurs in pelvic veins or in the deep veins of the lower extremities in postoperative patients. DVT is most
common after hip surgery. Venus thrombi located above the knee are considered as the major source of
pulmonary emboli.
• Homan’s sign: Calf pain upon dorsiflexion
• Painful swelling of the entire leg
• Slight fever, chills, perspiration
• Marked tenderness over the anteromedial surface of the thigh
• Intravascular clotting without marked inflammation may develop, leading to phlebothrombosis
• Circulation distal to the DVT may be compromised if sufficient swelling is present
v Nursing Interventions and Management
• Hydrate patient adequately postoperatively to prevent hemoconcentration.
• Encourage leg exercises and ambulate patient as soon as permitted by surgeon.
• Avoid restricting devices such as tight straps that can constrict and impair circulation
• Avoid rubbing or massaging calves and thighs
• Instruct to avoid standing or sitting in one place for prolonged periods and crossing legs when seated
• Assess distal peripheral pulses, capillary refill and sensation of lower extremities.
• Check the positive Homan’s sign –calf pain on dorsiflexion of the foot.
• Prevent the used of bed rolls or knee-gatch on the patients at risk because there is danger of constricting
the vessels under the knee.
• Initiate anticoagulant therapy either I.V subcutaneously or orally as prescribed.
• Prevent swelling and stagnation of venous blood by applying approximately fitting elastic stockings or
wrapping the legs from the toes or the groin with elastic bandage.
• Apply external pneumatic compression intraoperatively to patients of highest risk of DVT.
PULMONARY EMBOLISM
v Pulmonary embolism (PE) is cause by the obstruction of one or more pulmonary arterioles by the embolus
originating somewhere in the venous system or in the right side of the heart.
v Postoperatively, most emboli develop in the pelvic or in the iliofemoral veins before becoming dislodged and
travelling to the lungs
• Dyspnea is the most frequent symptom
• Chest pain is common and is usually sudden and pleuritic in origin
• Anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, and syncope.
• Most frequent sign is tachypnea
• Calm the patient
• Monitor visual signs, ECG, arterial blood gases.
• Treat for shock or heart failure as directed.
• Give analgesics or sedatives as directed to control pain or apprehension.
• Prepare for anticoagulation or thrombolytic therapy or surgical intervention. Management depends on the
severity of pulmonary embolism.
WOUND INFECTION
v Second most common nosocomial infection. The infection may be limited to the surgical site or may affect the
patient systematically.
• Redness, excessive swelling, tenderness, warmth.
• Red streaks in the skin ear the wound
• Pus or other discharge in the wound
• Tender, enlarge lymph nodes in the axillary region or groin closest to the wound
• Foul smell from the wound
• Generalized body chills or fever
• Elevated temperature and pulse
• Increasing pain from the incision site
• Keep dressing intact, reinforcing if necessary, until prescribed otherwise.
• Used strict sterile technique when dressings are changed.
• Monitor and document the amount, type, and location of the drainage. Ensure that all drains are working
properly.
• A culture is taken and sent to the laboratory for bacterial analysis.
• Wound irrigation may be done; have the aseptosyringe and saline available
• A drain may be inserted, or the wound may be packed with sterile gauze.
• Administer antibiotics as prescribed.
• If deep infection is suspected, the patient may be taken back to the operating room.

PROFESSIONAL ADJUSTMENT, LEADERSHIP AND MANAGEMENT

PROFESSIONAL ADJUSTMENT
DEFINITION OF A PROFESSION
v An occupation or calling requiring advanced training and experience in some specific or specialized body of
knowledge, which provides service to society in that special field (Webster's Dictionary).
DEFINITION OF A PROFESSIONAL NURSE

v A person who has completed a basic nursing education program and is licensed in his/ her country or state to
practice professional nursing
v The professional nurse must:
• Have a license to practice nursing in the country;
• Have a Bachelor of Science degree in Nursing; and
• Be physically and mentally fit
DEFINITION OF LICENSE
v A legal document given by the government that permits a person to offer to the public his or her skills and
knowledge in a particular jurisdiction, where such practice would otherwise be unlawful without a license.
v The primary purpose of registration is to protect the health of the people by establishing minimum standards
which qualified practitioners must meet.
v It discourages certain persons who may be tempted to misrepresent themselves as professional nurse.
v The Professional License is also called Certificate of Registration.
DEFINITION OF REGISTRATION
v Recording of names of persons who have qualified under the law to practice their respective professions.
v Under the Philippine Nursing Act of 2002, R.A. 9173, Sections 12 and 20 state that license to practice nursing
shall be issued to those who pass the licensure examination or by reciprocity.
Registration by Reciprocity
• SEC. 20. Registration by Reciprocity. A certificate of registration/ professional license may be issued without
examination to nurses registered under the laws of a foreign state or country: Provided, that the requirements for
registration or licensing of nurses in said country are substantially the same as those prescribed under this Act.
Registration by Examination
• SEC. 12. Licensure Examination. All applicants for registration as a nurse and issuance of a certificate of
registration and professional
identification card to practice nursing shall be required to pass a written examination which shall be given by the
Board in such places and dates as maybe designated by the Commission. Such examination must be in
accordance with and fully compliant with RA No. 8981.
Practice through Special/ Temporary Permit
• It may be issued by the Board to the following persons subject to the approval of the Commission and upon
payment of the prescribed fees:
• Licensed nurses from foreign countries/ states whose service are either for a fee or free if they are internationally
well-known specialists or outstanding experts in any branch or specialty of nursing
• Licensed nurses from foreign countries/ states on medical mission whose services shall be free in a particular
hospital, center or clinic; and
• Licensed nurses from foreign countries/ states employed by school/ colleges of nursing as exchange professors in
a branch or specialty of nursing.Provided, however that the special/ temporary permit shall be effective only for
the duration of the project, medical mission or employment contract.
CONTINUING PROFESSIONAL DEVELOPMENT IN NURSING

Continuing Professional Development (CPD)
v Consists of planned learning experiences beyond the basic education program
v Inculcation of advanced knowledge, skills and ethical values in a post-licensure specialization or in an inter- or
multidisciplinary field of study, for assimilation into professional practice, self-directed research and/or lifelong
learning
v According to RA 10912 (Continuing Professional Development Act of 2016):
o Required CPD credit units per year: 15 units
o Professional Identification Card (PIC) Renewal: every 3 years; 45 CPD units required
Examples
v Seminars
v Conventions
v Residency
v Distance Learning
In-Service Education
v Planned program provided by an employing agency to its employees
• The major goal is not only the improvement of professional practice but also the fullest development of nurse as
a person and as a contributing member of society focuses on and is designed to re-train people, to improve their
performance and communication ability to get them started in the never-ending continuum of education
NURSING ETHICS
v Examination of all ethical and bio-ethical issues from the perspective of nursing theory and nursing
Teleological Approach
v Telos or "goal or end"
v "The right thing to do is the good thing to do"
v The good resides in the promotion of happiness or the greatest net increase of pleasure over pain.
Deontological Approach or Duty-oriented Theory
v A person is morally good and admirable if his actions are done from a sense of duty and reason (Immanuel Kant)
Virtue Ethics Approach
v Focused primarily on the heart of the person performing the act
v Focuses on the traits and virtues of a good person
UNIVERSAL PRINCIPLES OF BIOMEDICAL ETHICS

Autonomy
v Voluntary decision-making
v Self-governance
v Involves self-determination and freedom to choose and implement one's decision
Veracity
v Truth-telling
Beneficence
v Doing good
v Refers to acts of kindness and mercy that directly benefit the patient
v These acts promote the health of the patient, prevent illness or complications, alleviate suffering, and assist
towards peaceful death if the inevitable comes
Non-maleficence
v Do no harm.
v Stated as an admonition in the negative form
Examples:
• Not assisting persons to commit suicide
• Not performing euthanasia or mercy killing
• Not willfully subjecting patients to experimental drugs whose potential harm may be greater than the expected
benefit
• Not harming a person's reputation by
revealing confidential information
Justice
v Just, fair and equal treatment
Fidelity
v Keeping one's promises; loyalty
Principle of Epikia
v "Exception to the general rule"
v It is a reasonable presumption that the authority making the law will not wish to bind a person in some particular
case, even though the case is covered by the letter of the law
Examples:
• Mental patient went berserk and the doctor could not be contacted, the patient may be restrained by virtue of
epikia
• Allowing a relative to see a seriously ill patient who expresses the desire to see a former although it is not yet
visiting hours.

Two-fold Effect
v When a nurse is faced with a situation which may have both good and bad effects, the basis of her action may be
the following:
• Action must be morally good;
• Good effect must be willed and the bad effect merely allowed;
• Good effect must not come from an evil action but from the Initial action itself directly; and
• Good effect must be greater than the bad effect
CODE OF ETHICS
v Systematic guides for developing ethical behavior. They answer normative questions of what beliefs and values
should be morally accepted.
CODE OF GOOD GOVERNANCE
v Promulgated by the Professional Regulation Commission on July 23, 2003 states that the hallmark of all
professionals is their willingness to accept a set of professional and ethical principles which they will follow in the
conduct of their daily lives
v Adopted by the PRC and the 42 Professional Regulatory Boards to cover an environment of good governance in
which all Filipino professionals shall perform their duties
LEGAL ASPECTS OF NURSING
LAW
v Sum total of rules and regulations by which society is governed
v It is man-made and regulates social conduct in a formal and binding way
v Rule of conduct pronounced by controlling authority and which may be enforced
Two Classifications of Law According to Origin
v DIVINE LAW
• Author is God (eg: 10 commandments)
v HUMAN LAW
• Author is man
Public Law
• A law that affects the general public (i.e. criminal laws — euthanasia, abortion, theft, robbery)
Private Law
• A law that affects the relationship of an individual to another individual
Functions of Law Nursing
v Provides a framework for establishing what nursing actions in the care of patients are legal
v Delineates the nurse's responsibilities from those of other health professionals
v Helps to establish the boundaries of independent nursing actions
v Assists in maintaining a standard of nursing practice by making persons accountable under the law.
RESPONSIBILITY AND ACCOUNTABILITY FOR THE PRACTICE OF PROFESSIONAL NURSING
Republic Act 9173 Nursing Law or Nursing Act of October 21, 2002
v This repeals or changes all of RA 7164
v Under this law, there is no more refresher course
v A candidate can take the board examination until he passes. This is embodied in section 15 of RA 9173
v Under this law, the upper 40% rule is no longer in effect.
Concepts
v Where do you file an appeal when the Board of Nursing revokes or suspends your nursing license?
• File your appeal with the Professional Regulatory Commission (PRC) within a period of 30 days after suspension
or revocation order has been received. This is called the reglementary period.
v The Board of Nursing is under the Professional Regulatory Commission.
v The Professional Regulatory Commission is under the Office of the President of the Philippines. The highest
agency for appealing of suspended or revoked nursing license is the Office of the President of the Philippines.
License revocation or suspension is an administrative case.
v Civil and criminal cases are appealed in court.
Revocation
v Permanent
v Invalidation of the license
v Under RA 9173, revocation of license is limited to four years in certain conditions:
o Reason for revocation must have been cured.
o Reason for revocation does no longer exist.

Suspension
v Temporary
v For a fixed period
Illegal Dismissal
v Filing of cases of illegal dismissal is with
v Department of Labor and Employment
v Done when there is lack of due process prior to dismissal
v No lawyer is needed
v If you win the case, there is back payment of salary and reinstatement. Reinstatement may be in the form of
paper reinstatement or payroll reinstatement.
PROFESSIONAL NEGLIGENCE AND MALPRACTICE

Standard
v Desired and achievable level of performance against which actual practice is compared
v Serves as benchmark against which to plan, to implement and assess quality of services
Negligence
v Refers to the commission or omission of an act, pursuant to a duty, that a reasonably prudent person in the same
or similar circumstance would or would not do, and acting or the non-acting of which is the proximate cause of
injury to another person or his property
ELEMENTS:
1. Existence of duty
2. Failure to meet the standard of due care/ Breach of duty
3. Foreseeability of harm
4. Injury to the plaintiff
SPECIFIC EXAMPLES:
1. Failure to report observations to attending physicians
2. Failure to exercise the degree of diligence which the circumstances of the particular case demands
• Mistaken identity
• Wrong medicine, wrong concentration, wrong route, wrong dose
• Defects in the equipment such as stretchers and wheelchairs may lead to falls thus injuring the patients
Res Ipsa Loquitor
v "The thing speaks for itself"
v Means that the injury could not have happened if someone was not negligent that no further proof is required
3 CONDITIONS TO ESTABLISH NEGLIGENCE WITHOUT PROVING SPECIFIC CONDUCT:
v Injury was of nature that it would not normally occur unless there was a negligent act.
v Injury was caused by an agency within control of the defendant.
v Plaintiff himself did not engage in any manner that would tend to bring about the injury.
Malpractice
v Improper or unskillful care of a patient by a nurse; also denotes stepping beyond one's authority with serious
consequences
v Term for negligence of professional personnel (professional negligence)
v Used properly only when it refers to a negligent act committed in the course of professional performance (Lesnik,
1962).
Force Majeure
v An irresistible force, one that is unforeseen or inevitable.
Respondeat Superior
v "Let the master answer for the acts of the subordinate"
v Liability is shared between the employee and employer; not a shift of liability from the subordinate to the master.
Incompetence
v Lack of ability, or legal qualifications and being unfit to discharge the required duty
CONSENT TO MEDICAL AND SURGICAL PROCEDURES

Consent
v Free and rational act that presupposes knowledge of the thing to which consent is being given by a person who is
legally capable to give consent
v Must be obtained from the patient or his authorized representative who may be his parent or guardian
v In case of emergency: consent is waived; consent does not apply

NATURE
• Nurse - secures consent of the patient upon admission
o Physician obtains the consent.
• To substantiate the patient's consent, a written consent form is needed as proof against any liability.
ELEMENTS OF AN INFORMED CONSENT
• Diagnosis and explanation of the condition
• Fair explanation of the procedures to be done and used and the consequences
• Description of alternative treatments or procedures
• Description of the benefits to be expected
• Material rights if any
• Prognosis, if the recommended care, procedure is refused
PROOF OF CONSENT
• Consent Form is signed to show that the person consents and he/she understands the nature of the procedure,
the risks involved and the possible consequences.
WHO MUST CONSENT?
• Minor
ü Parents or someone standing in their behalf
ü If the minor is married or otherwise emancipated, parental consent is not needed
• Mentally Ill
ü Parents or legal guardian
• Emergency Situation
ü No consent is necessary because inaction at such time may cause greater injury
ü Implied consent
• Consent for Sterilization
ü Husband and wife, if the operation is primarily to accomplish sterilization
ü Patient alone, if only because of medical necessity and the sterilization is an incidental result
MEDICAL RECORDS
Purposes
v Saves duplication in future cases and aids in prompt treatment
v Supplies rich material for medical and nursing research
v Serves as a legal protection for the hospital, doctor, and nurse by reflecting the disease or condition of the
patient and his management
Remember
• "If it was not charted, it was not observed or done."
Nurses' Notes
v Should be written fully, accurately, legibly and promptly
v Not only includes medications and treatments, but also physical and emotional symptoms exhibited by the patient
v Aids to medical diagnosis and in understanding the patient's behavior
Nurses' Roles
v Safeguarding the patient's record from loss or destruction or from access by persons who are not legally
authorized to read such
Medical Records in Legal Proceedings
v It is usually the medical records librarian, by virtue of a subpoena duces tecum, who testifies that the patients'
records are kept and protected from unauthorized handling and change
ADVANCE DIRECTIVES
Living Will
v Directive given by the patient as to type of treatment he wants to receive if and when he gets into respiratory
arrest
E.g. DNR (Do Not Resuscitate), DNI (Do Not Intubate)
Durable Power of Attorney or Health Care Proxy
v When the patient legally assigns a person, who will decide in his behalf for his treatment
TORTS
v Legal wrong, committed against a person or property independent of a contract which renders the person who
commits it liable for damages in a civil action

ASSAULT
v Imminent threat of harmful or offensive bodily contact
v Verbal threat
E.g. A nurse threatens to restrain patient if he will not take his medicine.
BATTERY
v Intentional, unconsented physical touching of another person
v E.g. When a patient refuses an injection and the nurse gives it anyway, he latter can be charged for battery
FALSE IMPRISONMENT OR ILLEGAL DETENTION
v Unjustifiable detention of a person without a legal warrant within boundaries fixed by the defendant by an act or
violation of duty intended to result in such confinement
v If patient is insisting on leaving the hospital, probable consequences of their action must be explained by a
competent doctor or medical staff, and then he is allowed to go home against advice.
INVASION OF RIGHT TO PRIVACY AND BREACH OF CONFIDENTIALITY

v The right to be left alone, right to be free from unwarranted publicity and exposure to public view
v Privacy relates to a person or identity. Example: Curtains are closed during physical examination
v Confidentiality relates to data/ information about an individual. Example: Patient's charts are not shared or
discussed to people that are not part of the health care team.
DEFAMATION
v Character assassination, be it written or spoken
v Slander (oral/spoken defamation)
v Libel (written defamation)
v There must be a third person who hears or reads the comment
CRIMES, MISDEMEANORS, AND FELONIES
Crime
v Defined as an act committed or omitted in violation of the law
ELEMENTS
• Criminal act
• Evil/ criminal intent
CONSPIRACY
• Principal
ü Direct part in the execution of the act
ü Directly force or induce others to commit it
ü Mastermind of a Crime: principal by inducement
• Accomplice
ü Cooperates in the execution of the offense by previous or simultaneous act
ü Had knowledge of the criminal intention of the principal
• Accessory
ü Have knowledge of the commission of the crime
ü Take part subsequent to its commission by profiting themselves or assisting the offender to profit from the
effects of the crime
ü Provides the exit strategy
Felony
v Committed with deceit and fault
v Major public offense for which a convicted person is liable to be sentenced to death or to be imprisoned in a
penitentiary or prison
ACCORDING TO DEGREE OF ACT
• Consummated
ü All the elements necessary for its execution and accomplishment are present
• Frustrated
ü When the offender performs all the acts or execution which will produce the felony.
ü Did not produce felony by reason of causes independent of the will of the perpetrator
• Attempted
ü Offender commences the commission of the same directly by overt (open or manifest) acts
ü Does not perform all the acts or execution which shall produce the felony

CIRCUMSTANCES AFFECTING CRIMINAL LIABILITY
Justifying Circumstance
v No criminal liability because the act itself is justified as reasonable.
EXAMPLES
• Self-defense
ü Elements of Self Defense:
1. Unlawful aggression
2. Necessity of the means employed
3. No sufficient provocation of the attacker
o If one of the three elements is lacking, this becomes incomplete self-defense and it becomes a mitigating-
circumstance
• Fulfillment of a lawful order or duty
• State of necessity
Exempting Circumstance
v No criminal liability because the person who committed the crime is exempted.
EXAMPLES
• Insane or Imbecile
ü Insane person lacks intelligence, the ability to determine what is right or what is wrong.
ü Imbeciles are people who have abnormalities in development who also do not possess adequate intelligence.
• Person below nine (9) years old
• Parents would pay damages
• Force majeure/Natural calamity causes injury
Lucid interval
• person has normal state of mind during a lucid interval
Mitigating Circumstance
v Decreases criminal liability
v Because of equity (equality in the law) and justice
EXAMPLES
• Voluntary surrender
• Confession of guilt
• Provoked
• Age of Convict
o Below 18 years old
o Above 70 years old
• Blind, deaf, and mute
o Because they cannot defend themselves in court
Aggravating Circumstance
v Increases criminal liability
EXAMPLES
• Abuses
1. Cruelty
2. Abuse of authority
3. Crimes in times of calamity (Looting, profiteering)
• Treachery
• Insult to authority
• Premeditation
Alternative Circumstance
v Degree of Education
v Degree of Intoxication (on alcohol or on prohibited drugs as defined by RA 9165)
v Relationship
• In the presence of relationships, cases of theft, malicious mischief, estafa and swindling are mostly mitigating
circumstances.
IMPORTANT LAWS RELATED TO NURSING PRACTICE
RA 6173
Code of Conduct and Ethical Standards for Public Officials and Employees
LOI 949
Legal basis of Primary Health Care

RA 7160
Local Government Code
RA 3573
Declared that all communicable diseases should be reported to the nearest health station, and that any person
may be inoculated, administered or injected with prophylactic preparations
RA 7305
Magna Carta for Public Health Workers
RA 2382
Philippine Medical Act nearest health station, and that any person may be inoculated, administered or injected
with prophylactic preparations
RA 9173
Philippine Nursing Act of 2002
RA 8749
Clean Air Act of 2000
PD 825
requires penalty for improper disposal of garbage and other forms of uncleanliness
PD 856
Code of Sanitation
RA 9211
Tobacco Regulation Act
RA 9211
Tobacco Regulation Act
RA 8976
Philippine Food Fortification
RA 6365
National Policy on Population
E0 2009
Family Code of the Philippines
RA 7432
Entitles the elderly to a 20% discount in all public establishments
RA 7600
Rooming-In and Breastfeeding
RA 9288
Newborn Screening Act of 2004
RA 9262
Anti-Violence Against Women and the Children
RA 7719
National Blood Service
RA 7875
National Health Insurance Act
PD 996
Compulsory Immunization of all children below 8 years of age against the six childhood immunizable diseases
RA 6675
Generics Act
RA 6425
Dangerous Drug Act
RA 4226
Hospital Licensure Act
RA 8504
Philippine AIDS Prevention and Control
NURSING LEADERSHIP AND MANAGEMENT
LEADERSHIP
v The art of developing people (Venzon, 2006)
v Achieving shared goals
v The process of influencing the behavior or actions of a person or group to attain the desired objectives.
v A dynamic, interactive process that involves three dimensions

• Leader
• Follower
• Situation
NURSING LEADERSHIP
v It is a process necessary to guide nursing personnel to a specific goal.
v Goal: Quality nursing care to the patient
LEADERSHIP THEORIES
1. Great Man Theory/Trait Theory
• Great leaders are born and not made.
• Leaders arise when there is a great need.
• This theory argues that a few people are born with necessary characteristics to be great.
Leadership Traits
• Task-oriented
• Includes planning, scheduling coordinating activities.
• Relationship-oriented
• Includes acting friendly and considerate, showing trust and confidence
• Participative Leadership
• Uses group meetings to enlist associate participation in decision making.
2. Charismatic Theory
• Leaders possess an inspirational quality and emotional commitment from followers.
3. Contingency Theory
• Leadership behavior should be flexible
• According to Fred Fiedler (1960), leader's ability to lead depends upon the situation.
Three Aspects
• Leader - member relations
ü Involves amount of confidence and loyalty the followers have with regard to their leader.
• Task structure
ü I t is high if easy to define and measure a task
ü It is low if it is difficult to define the task and to measure progress toward its completion.
• Position power
ü Authority inherent in the position
ü Power to use rewards and punishment
4. Path- Goal Theory
• Leader minimizes obstructions to facilitate accomplishment of tasks
• Focuses on motivation and productivity
6.Situational Theory
• Leader may vary differ according to varying situation.
• A person may be a leader in one situation
and a follower in another or vice-versa.
7. Transactional Theory
• Focuses on management tasks and trade - offs to meet goals.
• People are motivated by reward and punishment.
8. Transformational Theory
• Inspirational leadership that:
ü Promotes employee development
ü Attends to needs and motives of followers
ü Inspires through optimism
ü Influences changes in perception
ü Encourages follower creativity
9. Strategy Theory
• It is based on human handling skills of leaders.
Strategies:
• Attention through vision
• Meaning thru communication
• Trust thru positioning
• Deployment of self through positive self-regard
10. Leadership Styles
Authoritarian
o Strong control through commands
o Decision-making by one person
o Downward communication
• Democratic
o Control through guidance
o Decision-making by the leader and members of the group

o Upward and downward communication
• Laissez-faire
o Little or No control
o Decision-making by the members of the group
o Horizontal communication
o Requirement: Self-directed and skilled members
MANAGEMENT THEORIES
Scientific Management
1. Frederick Taylor
• Father of Scientific Management
• Through the use of stopwatch studies, he applied the principles of observation, measurement and scientific
comparison to determine the most efficient way to accomplish a task.
2. Frank Gilbreth & Lillian Gilbreth
• Time-and-motion studies
• Emphasized the benefits of job simplification and establishment of work standards as well as the effects of the
incentive wage plans and fatigue on work performance.
3.Henry Gantt
• Concerned with problems of efficiency
• Gantt Chart — depicts the relationship of the work planned or completed on the axis to the amount of time
needed or used on the other.
• He argued for a more humanitarian approach by management, placing emphasis on service rather than profit
objectives
CLASSIC ORGANIZATION
1. Henry Fayol
• Father of the Management Process School
• Studied the functions of managers and concluded that management is universal.
• Believer in the division of work
• Argued that specialization increases efficiency
• Recommended centralization through the use of a scalar chain or levels of authority
2. Max Weber
• Father of Organization Theory
• Emphasis on rules instead of individuals and on competence over favoritism as the most efficient basis for
organization.
3. Lyndall Urwick
• His conceptual framework blended scientific management and classic organization theory into the beginnings of
classic management theory.
• He described the managerial process as planning, coordinating, and controlling
• Popularized concepts such as balance of authority with responsibility, span of control unity of command, use of
general and special staff, the proper use of personnel, delegation. and departmentalization
Human Relations
1. Chester Barnard
• He said that authority depends on acceptance by the followers
• He stressed the role of informal organizations for aiding communication, meeting individuals' needs and
maintaining cohesiveness.
2. Mary Follett
• Stressed the importance of coordinating the psychological and sociological aspects of management

Behavioral Science
1. Abraham Maslow
• Hierarchy-of-Needs Theory
ü Physiological
ü Safety
ü Love and Belonging
ü Self-esteem
ü Self-actualization
2. Frederick Herzberg
• Found that job factors in situations associated with satisfaction were different from job factors in situations
associated with dissatisfaction
• Motivators or satisfiers identified were achievement, recognition, work itself, responsibility, advancement and the
potential for growth
• Hygiene factors or dissatisfiers identified were supervision; company policy; working conditions; interpersonal
relations with superiors, peers and subordinates; job security.
3. Douglas McGregor
THEORY X THEORY Y
Goal of organization Goal of individual
People dislike work and will avoid it Seek responsibility & display imagination
Workers have no ambition but desire security Workers have self-direction

Motivation by fear and threats Motivation by praise and recognition
4. Robert Blake and Jane Mouton
• Maintained that there are two critical dimensions of leadership
• Concern for the people
• Concern for production
5. Peter Drucker
• Maintains that the only way for management to justify its existence is through economic results
• Three areas of management
ü Managing a business
ü Managing managers
ü Managing workers
TYPES OF LEADERS
v Formal leader
• It is based on an occupying position in an organization.
• Appointed by the administration, and given legitimate authority to act.
v Informal leader
• It occurs when an individual demonstrates leadership outside the scope of a formal leadership role.
• Emerges as a leader when accepted by others and perceived to have influence of the many.
• Becomes a leader because of seniority, age, special proficiencies, an inviting personality or ability to
communicate with and counsel others.
SOURCES OF POWER
v Legitimate
• Power because of position
• Job title
• E.g. Director of Nursing
v Reward
• Something given in recompense for a good deed; incentives
• Sources: money, desired assignments, provision of personal space. acknowledgement of accomplishments
v Coercive
• Fear of punishment if one fails to conform.
v EXPERT
• Special abilities, skills or expertise towards the job.
v REFERENT
• Based on association with a leader and what the leader symbolizes
• Leader is admired and exerts influence because the followers desire to be like the leader

v Connection
• Comes from formal or informal coalitions and interpersonal relations
• Links to prestigious and influential people within and outside the organization.
• Eg. Son/Daughter of the Mayor; Friend of the President of the Philippines
v Information
• Information power comes from knowledge and access to information that other people don’t have.
MANAGEMENT
v Process by which a cooperative group directs actions toward common goals.
v The act of planning, organizing, directing and controlling.
v It involves techniques by which a distinguished group of people coordinates the services of people.
v MANAGER – a person who creates and maintains an internal environment in an enterprise where individuals
work together as a group.
PRINCIPLES OF MANAGEMENT
v Pareto Principle
• Also known as the 80-20 rule, the law of the vital few, and the principle of factor sparsity
• Roughly 80% of the effects comes from 20% of the causes
• Once the major cause of the problem is identified, it can be problem solved, leading to considerable impact.
v Principle of Least Effort
• Also known as the deterministic description of human behavior.
• Information-seeking client will tend to use the most convenient search method, in the least exacting mode
available
• The user will use the tools that are most familiar and easy to use that finds the results.
GENERAL MANAGEMENT ROLES

v Interpersonal Role
Manager shows as a:
• Symbol (signing of papers / documents)
• Facilitator (hires, trains, encourages, fires, remunerates, and judges)
• Liaison (link to community, suppliers and the organization)
v Informational Role
Present the manager as:
• One who monitors information
• Disseminates information from both external and internal sources
• Spokesperson or representative of the organization.
v Decisional role
The manager is:
• An entrepreneur or innovator
• A trouble shooter
• A negotiator
FUNDAMENTAL SKILLS OF MANAGERS

According to Katz:
v Technical
• Proficiency in performing an activity in the correct manner with the right technique
v Human
• Dealing with people and how get along with them
v Conceptual
• Ability to see individual matters as they relate to the total picture and to develop big problems and discarding
irrelevant facts.
According to Summer:
v Knowledge Factors
• Refer to ideas, concepts or principle
v Attitude Factors
• Beliefs, feelings, and values
v Ability Factors
• Skills, art, judgment and wisdom
MANAGEMENT LEVELS
v First Level Manager
• Concerned with specific unit's work flow.
• Deals with immediate problems in the unit's daily operations, with organizational needs, and with
personal needs of employee.
• E.g. Head nurse
v Middle Level Manager
• Coordinates the efforts of lower levels of the hierarchy
• Conduit between lower and top-level managers.
• E.g. Supervisor
v Top Level Manager
• Manages and looks at the organization as a whole
• Coordinates internal and external influences and generally makes decisions with few guidelines or
structures.
• E.g. Chief nurse
STEPS IN MANAGEMENT
P.O.L.E
P - lanning
0 - rganizing
• Staffing
L - eading (Directing)
E - valuating (Controlling)
PLANING
v It is a continuous process of assessing, establishing goals and objectives, implementing and evaluating them,
and subjecting these to changes.
v Deciding in advance what to do; who is to do it; and how, when, and where it is to be done.
Characteristics of a Good Plan
v A well-developed plan should:
• Be precise with clearly - worded objectives
• Be guided by policies and/or procedures affecting the planned action
• Indicate priorities
• Develop actions that are flexible and realistic
• Develop a logical sequence of activities
• Include the most practical methods for achieving each objective
• Pervade the whole organization
Scope of Planning
• Strategic planning
• 3-5 years in the future
• Set overall goals and policies
• Nursing Directors, Chief Nurses, Directors of Nursing
1. Vision
ü Used to describe future roles, functions, and aims of an organization.
ü Eg. The Medical Center envisions itself to become a Center of Excellenceproviding holistic approach to health
care services. As a Center of Wellness, the services provided shall enable the people to improve their health and
increase control over it.
2.. Mission
ü It is a brief statement identifying the reason why an organization exists.
ü E.g. The Medical Center, as a public, tertiary hospital is so maintained as the people's partner and improve to
provide accessible, quality, cost effective, preventive, promotive, curative, rehabilitative health care services to
the general public, especially the destitute
3. Philosophy
ü Delineates the set of values and beliefs that guide all actions of the organization
ü E.g. The Medical Center is guided by the following beliefs:
The hospital is committed to assume a vital role in health promotion, disease prevention, curative, rehabilitative
and primary health care in partnership with public health counterparts, the clients, families, and communities.
4. Goals
ü Actions for achieving the mission and philosophy

ü E.g. To provide the best possible health care services to its clients in a high-quality setting conducive to attaining
its vision as a center of wellness and a standard medical center
5. Objectives
ü Similar to goals in that they motivate people to a specific end and are explicit, measurable, observable, or
retrievable, and obtainable.
ü E.g. To establishes an organized governing body so functioning that has overall responsibility for the conduct of
hospital in a manner consonant with its philosophy, mission and objectives.
6. Standards
ü Professionally desirable norms
7. Policies
ü Broad guidelines for the managerial decisions that are necessary in organizational planning
8. Procedures
ü Are plans that establish customary or acceptable ways of
accomplishing a specific task and delineate a sequence of steps of required action.
9. Rules
ü Describe situations that allow only one choice of action.
ü Fairly inflexible
Intermediate planning
• 6 months to 2 years
• Formulation of policies, rules and regulations, methods and procedures for intermediate level planning for on-going
activities is done in coordination with the top management and those with the lower level
• Nursing Supervisors
v Operational planning
• Departmental plans, maintenance, and improvement goals.
• Daily and weeklyplans for
administration or direct patient care.
• Head nurses
Budgeting: Financial Plan

v Budget
• A financial road map that estimates future costs and a plan for utilization of resources
Components of Budget
• Operating Budget
ü Daily revenue and expenses including:
Ø Salaries
Ø Supplies
Ø Contractual services
Ø Employee benefits
Ø Laundry services drug and pharmaceuticals
Ø In-service education
ü Composed of the revenue and expense budget.
Revenue Budget — summarizes the income
Expense Budget — salaries, supplies, utilities, maintenance
• Cash Budget
ü Forecasts the amount of money received
ü It consists of the beginning cash balance, estimates of the receipts and disbursements, and the estimated
balance for a given period.
ü Prepared by estimating the amount of money to be collected from patients and allocating it to cash
disbursement required to meet obligations promptly as they come.
• Capital Expenditure Budget
ü Major expenditures
ü Consists of accumulated data for fixed assets that are expected to be acquired during the budget period.
ü Replacement, or expansion of the plant, major equipment, and
inventories.
ü E.g. MRI, X-ray, CT scan

• Flexible Budget
üComposed of budgets that adjust automatically over the course of the year depending on variables such as
volume and labor costs.
• Zero-Based Budgeting
ü Major advantage of this type of budget is that it forces managers to set priorities and justify.
ü Disadvantage: Time consuming
ORGANIZING
v It is the process of establishing formal authority that involves
• Setting up the organizational structure through identification of groupings, roles and relationships
• Determining the staff needed and
distributing them in various areas.
Elements of Organizing
1. Organization structure
2. Staffing
3. Scheduling
4. Developing job description
Authority: The right to act or make decisions without need for approval of higher administration.
Terms Used in Organizing Authority
• The right to act or make decisions without need for approval of higher administration
Accountability
• Taking full responsibility for the quality of work and behavior
Responsibility
• Obligation to perform the assigned task
v Principles of Organizing
• Unity of Command
ü There can only be one superior
• Scalar Principle / Hierarchy/ Chain of Command
ü Flow from higher to lower authority
• Departmentalization
ü Grouping of workers with similar assignments
• Span of Control
ü The number of people that reports directly to a manager
v Centralization
ü The staff all reports to one person that is higher to them
• Decentralization / Delegation
ü Transferring specified decision making to lower levels of the organization
v Organization — the structure and process which allows an agency to enact its philosophy and achieve its
goals
Types of Organization
Line Organization
ü It is the simplest and most direct type of organization
ü Each position has general authority over the lower positions in the hierarchy.
ü E.g. Clinical and Administration
ADVANTAGES DISADVANTAGES
• Maintain simplicity •Neglects special planning
• Encourages speedy action •Overworks key People
• Makes a clear division of authority • Depends upon retention of few key people
Staff Organization
v It is purely advisory to the line structure with no authority to put recommendations into action.
•E.g. Training and Research

• Frees the line executive of detailed analysis • Reduces expert power to place recommendation into
• Affords young specialist a mass training action
• Enables specialist to give expert advise • Tends towards centralization of the organization
• Continues the organization even if its functions are not
clear
Functional Organization
v It is one where each unit is responsible for a given part of the organization's workload.
• There is clear delineation of roles and responsibilities which are actually interrelated
• Relieves line executive of routine specialized • Makes relationship more complex
decision • Makes limits of authority of each specialist a difficult
• Provides frameworks for applying expert knowledge coordination
ORGANIZATIONAL CHART
It is a diagrammatic representation of the organizational structure
Five Major Characteristics
1. Division of Work
2. Chain of command
3. Type of work to be performed
4. Grouping of Work Segments
5. Levels of Management
FORMS OF ORGANIZATIONAL CHART
Vertical Chart •Also known as Tall Chart
•Depicts the Chief Executive at the top with line of authority flowing down the
hierarchy.
Horizontal Chart •Also known as Circular Chart
Depictsthe manager at the top with a wide span of control
Concentric Chart •Also known as Circular Chart
•Shows outward flows of Communication from center
STAFFING
- It is the process of determining and providing the acceptable number and mix of nursing personnel to produce a
desired level of care to meet the patient's demand.
Purpose: To provide each nursing unit with an appropriate and acceptable number of workers in each category to
perform the nursing tasks required.
Schedule — a timetable showing planned workdays and shifts for nursing personnel
Types of Scheduling
v Centralized
• Done by the Chief nurse.
• He/ She assigns the nursing personnel to the various units of the hospital.
v Decentralized
• The shift and off — duties are arranged by the Nurse Super-visors or Senior nurse of the particular unit.
v Cyclical
• Covers a designated number of weeks as one cycle, which is repeated thereon.
Advantages
• It is fair to all
• Saves time
• Enables employees to plan ahead of time
• Scheduled leaves are more stable
• Productivity is improved

The Hospital Nursing Service Administration Manual of the DOH has recommended the following nursing care hours
for patients in the various nursing units of the hospital
Cases/Pt NCH/Pt/day Prof to Non-prof ratio
General Medicine 3.5 60:40
Medical 3.4 60:40
Surgical 3.4 60:40
Obstetrics 3.0 60:40
Pediatrics 4.6 70:30
Pathologic Nursery 2.8 55:45
ER/ICU/RR 6.0 70:30
CCU 6.0 80:20
Patient Care Classification
• Method of grouping patients according to amount and complexity of nursing requirements
LEVELS OF CARE
Level 1: Minimal For discharge, non- emergency, 1.5 hours per day
Level 2: Moderate Some help with ADL, IV, VS 3x per shift, 3 hours per day
Level 3: Total / Intensive Completely dependent, VS q30 6 hours per day
Level 4: Critical Continuous observation 6- 9 hours or higher per day
PERCENTAGE OF PATIENTS IN VARIOUS LEVELS OF CARE

TYPE OF HOSPITAL MINIMAL CARE MODERATE CARE INTENSIVE CARE HIGHLY SPECIALIZED CARE
Primary 70 25 5 -----
Secondary 65 30 5 -----
Tertiary 30 45 15 10
Special Tertiary 10 25 45 20
TOTAL NUMBER OF WORKING DAYS PER YEAR
40 hours/ week 48 hours/ week
Non - working days 213 265
152 100
Working hours 1, 704 2, 120
Relievers needed 0.15 0.12
Staffing Formula
1. Categorize according to level of care needed. Multiply the total number of patients by the percentage of patients
at each level of care (whether minimal, intermediate, intensive or highly specialized).
2. Find the total number of nursing care hours needed by the patients at each category level.
a. Find the number of patients at each level by the average number of nursing care hours needed per day.
b. Get the sum of the nursing care hours needed at the various levels
3. Find the actual number of nursing care hours needed by the given number of patients. Multiply the total nursing
care hours needed per day by the total number of days in a year.
4. Find the actual number of nursing care hours rendered by each nursing personnel per year.
a. Multiply the number of hours on duty per day by the actual working days per year.
5. Find the total number of nursing personnel needed.
a. Divide the total number of nursing care needed per year by the actual number of working hours rendered
by an employee per year.
b. Find the number of relievers. Multiply the number of nursing personnel needed by 0.15 (for those
working 40 hours per week) or by 0.12 (for those working 48 hours per week)
c. Add the number of relievers to the number of nursing personnel need.
6. Categorize the nursing personnel into professionals and non-professionals. Multiply the number of nursing
personnel according to the ratio of professionals to non-professionals
7. Distribute by shifts.
Professional to Non-Professional
Type of Hospital Ratio Prof. to Non-Prof
Primary 55.45
Seconder 60. 40
Tertiary 65.35
Specialized 70.30 or 80:20
Distribution Per Shift
AM – 45%
PM - 37%
Night - 18%
DIRECTING
v Issuance of orders, assignments and instructions that enable the nursing personnel to understand what are
expected
v Involves command and coordination
Elements of Directing
• Communication
• Delegation
• Supervision
• Coordination
• Staff Development
• Decision-making
COMMUNICATION
v Transmission of information, opinions, and intentions between and among individuals
v Types
• Verbal
ü Oral
ü Written
• Non- verbal
ü Facial expression
ü Tone of Voice
ü Body Language
ü Touch
LINES OF COMMUNICATION
Downward Examples:
- From superior to subordinate • Policies
• Rules and regulations
• Memorandum
• Employee
• Handbooks
• Performance Appraisal
Upward Examples:
- From subordinates upward • Incident report
• Grievance report
Horizontal Examples:
-between peers, personnel, or departments on the • Endorsements
same level • Conferences
• Nursing Rounds
Outward Examples:
- From caregivers to patient and their relatives • Discharge teaching
Diagonal Examples:
-From individuals or departments that area not in • Nutrition department to nursing department
the same level or the hierarchy
Grapevine Examples:
- informal communication; often rapid and subject • Gossip
to much distortion • hearsay
Delegation
v Process by which a manager assigns specific tasks/duties to workers with commensurate authority to perform the job.
v Principles of Delegation
• Select the right person is to be delegated
• Delegate both interesting and uninteresting tasks
• Provide subordinates with enough time to learn
• Delegate gradually
• Delegate in advance
• Consult before delegating
• Avoid gaps and overlaps
v What Cannot Be Delegated
• Overall responsibility, authority and accountability for satisfactory completion of all activities in the unit
• Authority to sign one’s name is never delegated
• Evaluating the staff and/or taking necessary corrective or disciplinary action
• Responsibility for maintaining morale or the opportunity to say a few words of encouragement to the staff
especially to new ones
• Jobs that are too technical and those that involve trust and confidence
RESPONSIBILITIES
RN IV Medications
Health Teaching
Assessment
Evaluation
Over-all accountability Unstable/critical Patients
Licensed Medications (IM. SC, ID, Except IV)
Practical Nurse Wound cleansing
Blended Feeding
Suctioning
Nursing Routine activities
Assistant V/S
Application of pulse oximeter sensor
Post-mortem
Stable patients / ambulatory/ MGH
NURSING CARE ASSIGNMENTS

v Can also be called modalities of nursing care, systems of nursing care, or patterns of nursing care.
1. Functional Nursing
• This kind of nursing modality is task- oriented in which a particular nursing function is assigned to each
worker.
• Divides work to be done & every member is responsible for his actions
• Best system that can be used if there are many patient and professionals
- Work is done fast ü Fragmentation of nursing care; therefore,
- Workers learn to work fast holisticis not achieved
ü Patient cannot identify who their real nurse is
ü Nurse- patient relationship is not fully developed
ü Evaluation of nursing care is poor
ü Outcomes are rarely documented
ü It is hard to find a specific person to answer
relative questions
2. Total Care Nursing
• One nurse is assigned to one patient for the delivery of total care.
• Works best when there are plenty of nurses whereas patients are few.
3. Team Nursing
• One nurse leads a group of nursing personnel in providing nursing needs to a group of patients
• Decentralized system of care
ü Team effort
ü Frees patient care coordinator to manage
the unit
ü Time needed to coordinate delegated work
ü Nursing care conferences help problem
solve and develop staff
ü Nursing care plan

4. Primary Nursing
• RN is responsible for the total care of a small group of patients (4-6) from admission
to discharge.
• RN remains responsible for the care of those patients 24 hours per day.
ü Patient and family are able to develop
trusting relationship with the RN.
ü High cost because there is higher RN skill
ü Assures continuity of care
ü Proximity of patient assignment
ü Improves communication with the
ü Overlapping of staff functions
members of the health team and eliminates
ü Nurse patient ratio must be realistic
the use of nursing aides in the provision of
direct nursing care.
5. Case Method
• One is to one nurse patient ratio
• E.g. ICU nurse, private duty nurse
• Consistency of one individual caring for • The Nurse may not have the same patient the
the whole shift. nest day
• More opportunity to observe and monitor • It does not serve the purpose of
the patient decentralization
6. Modular Method
• Also termed as District Nursing
• Modification of team and primary nursing
• It is sometimes used when there are not enough RNs to practice nursing
• It differs from team nursing in that the registered nurse provides direct nursing care with the assistance of
aides.
Supervision
v It is providing guidelines for the accomplishment of a task or activity with initial direction and periodic inspection
of the actual accomplishment coordination, and synchronization of services
Principles of Good Supervision
v Good supervision requires adequate planning and organization which facilitate cooperation, coordination, and
synchronization of services
v Good supervision gives autonomy to workers depending on their competency, personality and commitment.
v Good supervision stimulates the worker's ambition to grow into effectiveness.
v Good supervision creates an atmosphere of cordiality and trust.
v Good supervision considers the strengths and weaknesses of employees
v Good supervision strives to make the unit an effective learning situation of the task or activity.
v Good supervision considers equal distribution of work considering age, physical condition, and competence.
Staff Development
v Providing structure and assistance for employees to learn more.
1. Orientation
• Done for new employees
• Refers to planned and guided activities of an employee in the organization, the work environment and in his job
2. In-Service Education
• Consists of on the job instructions that are given to enhance employee's recent job performance
3. Specialty Courses
• Offered by hospitals with trained specialist, facilities and source
• E.g. dialysis nursing, oncology nursing, cardiology nursing
4. Formal Education
• Graduate Degree: Master's Degree
Coordination
• Unites personnel and services toward a common objective
• Synchronization of activities among various services and department
• Prevents overlapping of functions
• Promotes good working relationships
• Work schedules are accomplished as targeted
Conflict Management
Conflict
v A clash between two opposing parties. It is a type of behavior involving two or more parties in opposition to each
other.
Types of Conflict
1. Intrapersonal
• From within one person
2. Interpersonal
• Between two persons
3. Intragroup
• Within the group itself
4. Intergroup
• Conflict between two groups of people in the organization
CONFLICT RESOLUTION •
Avoidance Avoid confrontation Lose-lose

Accommodation One gives way to other Win-lose
Collaboration Both work out days to solve the problem Win-win
Compromise Both will sacrifice Lose-lose
Competition One wins Win-lose
Decision Making
v The process of arriving at a course of set of that is consciously chosen from alternatives
Decision Making Process
1. Define the Problem
2. Analyze the Problem
3. Develop alternative solution
4. Select possible solutions
5. Implement follow-up
Controlling
v Also called “evaluating”
v An on-going function of management which occurs during planning, organizing and directing activities
Basic components of the control process:

• Establish Standard
• Measure actual performance
• Compare performance vs. standards
• Reinforce correct behavior
• Implement corrective action
Performance Appraisal
• A control process wherein an employee's performance is evaluated against standards
Characteristics of an Evaluation Tool
• Objectivity
• Reliability
• Validity
• Sensitivity
Performance Appraisal Tools
ü Checklists
• Compilation of all nursing performances expected of a worker.
ü Rankings
• In simple ranking, the evaluator ranks the employees according to how he or she fared with co-workers with
respect to certain aspects of performance or qualifications.
ü Rating Scales
• Includes a series of items representing the different tasks or activities in the nurse's job description
ü Anecdotal recording
• Describes the nurse's experience with a group or a person, or in validating technical skills and interpersonal
relationships.
ü Essay
• The appraiser writes a paragraph or more about the worker's strengths, weaknesses and potentials.
Informal Appraisal
• Consists of incidental observation of performance while the worker is engaged in performing nursing care.
Formal appraisal
• Collecting objective facts that can demonstrate the difference between what is expected and what was done.
Quality Assurance
• Evaluation of the health care system and the provision of healthcare services by workers.
Quality Assurance Criteria
• Structure
ü Physical setting and condition
ü Focus on the structure or management system used by the agency to deliver care
• Process
ü Steps in nursing process
• Outcome
ü Measure results of care and the desirable changes in client
Benchmarking
• A tool to assist in quality of care decision making
• A continuous process of measuring what exist against the best
Continuous Quality Improvement (CQI) or Total Quality Management (TQM)
• A way to ensure customer satisfaction by involving employees in the improvement of the quality of every
product or service
• Process of continuously improving a system by gathering data or performance
Nursing Audit
• It measures the actual performance of the nursing personnel against standards
• It is composed of a representative from all levels of the nursing staff
Patient Care Audit
ü Concurrent
• One in which patient care is observed and evaluated through:
• Review of the patients' charts while
the patients are still confined
• Observation of the staff as patient care is given
• Observation of the effects of patient care

ü Retrospective
• One in which patient care is evaluated through:
• Review of discharged patients' charts
• Questionnaires sent to interviews conducted discharged patients
Peer Review
• Audit done by peers evaluating another job performance of the employees of the same rank against accepted
standards
Discipline
• A constructive and effective means by which employees take responsibility for their own performance and
behavior
Stages of Disciplinary Action
1. Counseling and Oral Warning
ü Best given in private and in an informal atmosphere
ü Employee is given a fair chance to air his side
2. Written Warning
ü Identify the rule violated, list consequences if behavior is continued, employees commitment to take corrective
actions
3. Suspension
ü It is given after an evidence of oral and written warnings.
ü Temporary withdrawal from duties
4. Dismissal
ü Permanent removal of a person from organization

LEADERSHIP VS MANAGEMENT
Leadership Management
Motto Do the right thing I Do things right
Challenge Change Continuity
Focus Purpose Structure and I procedure
Time Frame Future Present
Methods Strategies Schedules
Questions Why? Who, What, when, where, how?
Human Potential Performance
LEADERSHIP AND CHANGE

Strategies for effecting change
ü Empirical- Rational
• Based on the assumption that people are rational and behave according to rational self-interest.
• It follows that people should be willing to adopt a change if it is justified and if the people are shown how they
can benefit from the change.
ü Normative- Reeducative
• Based on the assumption that people act according to their commitment to sociocultural norms
• Manager pays attention to changes in values, attitudes, skills and relationships in addition to providing
information.
ü Power- Coercive
• Involves compliance of less powerful people to leadership, plans and directions of more powerful people
• E.g. Use of strikes, sit-ins negotiations, conflict confrontation and rulings
Kurt Lewin's Theory of Change
ü Unfreezing
o Development through problem awareness of a need for change.
o Coercion and induction of guilt and anxiety have been used for freezing.
ü Moving
o Working toward change (identifying problem, exploring alternatives, defining goals)
ü Refreezing
o Integration of the change into one's personality and the consequent stabilization of change.
Types of Change
ü Coercive Change
o Non-mutual goal setting, imbalanced power ratio, and one-sided deliberativeness characterize coercive
change.
ü Emulative Change
o Transition is fostered through identification with and imitation of power figures.
ü Indoctrination
o Uses mutual goal setting, has an imbalanced power ratio, and is deliberative.
ü Interactional Change
o Mutual goal setting, fairly equal power, but no deliberativeness
ü Natural Change
o Includes accidents and acts of God.
o Involves no goal setting deliberativeness
ü Socialization Change
o Individual conforms to the needs of a social group.
o When there is greater deliberativeness on the power side, change becomes indoctrination.
ü Technocratic Change
o Collecting and interpreting data bring about change
o Technocrat merely reports the findings of the analysis to bring about the change.
ü Planned Change
o Involves mutual goal setting, an equal power ratio, and deliberativeness.

Theories of Motivation
ü Need Theory
• Abraham Maslow 's Hierarchy of Needs
• People are motivated to satisfy certain needs to complex psychological needs.
ü The Two — Factor Theory

• Hygiene factors (relate to the working conditions such as salary, quality of supervision, job security)
• Motivating factors (relate to job itself; "satisfiers")
• Nurse managers need to use both of these factors to recruit and retain staff.
ü McClelland's Three Basic Needs Theory

• Includes the three basic needs that people should possess in varying degrees (achievement, power, and
affiliation)
ü Expectancy Theory
• Victor Vroom's Expectancy Theory Human Motivation
ü Indicates that felt needs individuals in work settings are increased if a person perceives positive
relationship between effort and performance.
ü Operant Theory
• B.F Skinner's Operant Theory
ü Suggests that an employee's work motivation is controlled by conditions in the external environment
instead of internal needs and desires.
ü Equity Theory
• Perceptions about equity and inequity
• Found that employees assess fairness by considering their input and the psychological, social and financial
rewards in comparison with those of others.
NURSING RESEARCH
DEFINITION
ü Research
• Systematic inquiry that uses disciplined methods to answer questions or solve problems.
• Scientific method
• Solve Problems and answer questions
ü Nursing research
• Systematic inquiry designed to develop trustworthy evidence about issues of importance to the:
• Nursing profession
Ø Nursing practice
Ø Education
Ø Administration
Ø Informatics
PURPOSES OF NURSING RESEARCH
- Accountability for Nursing Practice
- Credibility to Nursing, Cost effectiveness
- Evidence-Based Nursing Practice
- Documentation of Nursing Care
TYPES OF RESEARCH ACCORDING TO PURPOSE
BASIC APPLIED
General knowledge Find solution to existing problem
Formulate/ refine a theory Focus on intervention to achieve desired goal
General principles of human behavior How principles can be used to solved problems in such nursing practice
Ex: in-depth study to be better Ex: study to determine Effectiveness of a nursing intervention to ease
understand normal grieving process grieving.

ü Basic Research
• Undertaken to extend the base of knowledge in a discipline, or to formulate or refine a theory.
Example: The Sun to the Earth And beyond: Panel Reports (2003)
ü Applied Research
• Focuses on finding solutions to existing problems and thus tends to be of greater immediate utility for evidence-
based practice.
• Designed to indicate how these principles can be used to solve problems in nursing practice.
Example: The use of breastfeeding for pain relief during neonatal immunization injections.
TYPESOF RESEARCH ACCORDING TO DESIGN

ü Quantitative Research
• Uses mechanism designed to control the study
• Information gathered in such a study is numeric information that results in some type of formal measurement
and that is analyzed with statistical procedure
• Quantitative data- information in numeric form
ü Qualitative Research
• Materials are narrative and subjective
• Takes place in the field, often over an extended period of time
• Tends to emphasize the dynamic, holistic, and individual aspects of human experience.
• Qualitative data- narrative description
VARIABLES
Variables- a characteristic or quality that takes on different values.
• Independent variable
ü The presumed cause of, antecedent to, or influence on the dependent variable.
• Dependent variable
ü The behavior, characteristic or outcome the research is interested in understanding, explaining or
affecting. It is the presumed effect.
ü Example: The relationship between the number of prenatal classes attended by pregnant women and the degree
of anxiety concerning labor and delivery
• Independent variable: number of prenatal classes
• Dependent variable: degree of anxiety
QUATITATIVE QUALITATIVE
Positive traditions Naturalistic inquiry
Scientific method Human experience
Numerical data Narrative description data
objective Subjective
Systematic/ controlled Flexible/ evolving
Empiricism (use of senses) Analytical insight
General/broad Specific/direct
Cause and effect Meaning discovery
Deductive reasoning Inductive reasoning
Theory testing Theory development
Laboratory setting Field setting
QUANTITATIVE RESEARCH
Experimental research
• Researchers actively introduce an intervention or treatment
• Example: the effect of the pressure relieving devices on prevention of heel pressure ulcers.
True Experimental Design
1. Manipulation
ü An intervention or treatment is introduced to some subjects
ü Treatment group
Ø The group who receives intervention
2. Control
ü The experimenter introduces control over the experimental situation

ü Control group
Ø Group without treatment
Ø Refers to a group of subjects whose performance on dependent variable is used to evaluate the
performance of the treatment group on the same dependent variable.
3. Randomization
ü The experimenter assigns subjects to a control or experimental condition on a random basis.
ü Random means that every subject has an equal chance of being assigned to any group.
Example: An experimental study was o ducted to determine the effects of classical music in improving the
grades of elementary school students. The students were selected through random sampling. One group was
exposed to classical music during review sessions. The other group was placed into another room without the
intervention. After the review session, a post test was given to the students.
Ø M- The classical music
Ø R- The students were randomly selected
Ø C- The presence of a control group (without intervention)
• Quasi-experimental design
Involves an intervention, however, quasi-experimental designs lack randomization, the signature of a true
experiment.
Non-Experimental Research
ü They collect data without introducing treatments or making changes.
1. Correlational Research
• Designs that examine relationships between variables.
• A correlation is an interrelationship or association between two variables, that is, a tendency for variation in one
variable to be related to variation in another.
• Eg. The relationship of nursing supervisor's perceived sense of humor staff nurses' job satisfaction.
2. Comparative Research
• Identify, analyze and explain similarities and differences across society
• Eg. Preparing Educators towards Educational Technology: Comparative, study of Students' and Educators
perception in Learning Programming languages
3. Survey Research
• Is designed to obtain information about the prevalence, distribution, and interrelation of variables with in
population.
Telephone interviews Questionnaires
• E.g. For a political or ethical survey, about which anybody can have a valid opinion, you want to try and
represent a well-balanced cross section of society
4. Methodological Research
• Studies are investigation of the ways of obtaining and organizing data and conducting rigorous research.
QUALITATIVE RESEARCH
1. Grounded Theory
ü Researchers strive to generate comprehensive explanations of phenomena that are grounded in reality
ü A research method that will.
• Develop a theory
• Offer an explanation
• Focus on the main concern of the population
• Show how the concern is resolved or processed.
2. Phenomenological Research
v Is concerned with the lived experience of humans
v Is an approach to thinking about what life experiences of people are like.
v Example: In-depth interviews to explore the experiences of women who had undergone vaginal closure surgery
to correct severe vaginal prolapse.
3. Ethnographical Research
v Is the primary research tradition within anthropology, and provides a framework for studying the patterns,
lifeway and experiences of a cultural group in a holistic fashion.
v Example: Ramon and Mei Joy conducted ethnographic fieldwork in two rural Ecuadorian communities and studied
the burdens of women's roles, the women's perceived health needs, and health care resources.

4. Historical Research
v The systematic collection and critical evaluation and interpretation data relating of historical evidence (past
occurrences)
5. Case Studies
v Are in depth investigations of a single entity or a small number of entities
v Example: Ralf and Carlo conducted in-depth case study of a patient who had had a stroke 2 years ago and is
experiencing eating difficulties.
MAJOR STEPS IN A QUANTITATIVE STUDY

Phase 1: Conceptual Phase
• Formulating and Delimiting the Problem
• Identify an interesting, significant research problem and research question
• Research problem
ü Is the situation that causes the researcher to feel apprehensive, confused and ill at ease
ü Is the demarcation of a problem area within a certain context involving the who or what, the where, the
when and the why of the problem situation.
• Problem statement
ü Articulates the problem to be addressed and indicates the need for a study through the
development of an argument.
• Research questions
ü Are the specific queries researcher wants to answer addressing the research problem?
2. Reviewing the Related Literature
• Provides a foundation on which to base new evidence and usually is conducted well before any data are
collected.
ü Primary Source
Ø Descriptions of studies written by the researchers who conducted them.
Ø Mostly recommended.
ü Secondary source- description of studies prepared by someone other than the original researcher.
3. Defining the Framework and Developing Conceptual Definition
• Framework is the overall conceptual underpinnings of a study.
ü Conceptual framework
Ø Deals with abstractions that are assembled by virtue of their relevance to a common theme.
Ø It is a study that has roots in a specified conceptual model
• Theoretical framework
Ø It is a study based on a theory.
• Conceptual definition
ü Presents the abstract or theoretical meaning of the concepts being studied
ü Eg. Weight is a measurement of gravitational force acting on an object
• Operational definition
ü Specifies the operation that researchers must perform to collect and measure the required information
ü Eg. Weight is a result of measurement of an object on a Newton spring scale.
4. Formulating Hypothesis
• Hypothesis
ü Is a statement of the researcher's expectations about relationships between study variables
ü Research hypothesis
Ø Statements of expected relationships between
variables.
Ø Non-Directional
Eg. There is a difference it the test scores of students, of clinical instructors with 5 years bedside
experience and students of clinical instructors with only 1 year of bedside experience.
Ø Directional
E.g. There is a positive relationship between fast food consumption and weight gain
ü Null hypothesis
Ø State that there is no relationship between the independent and dependent variables.
Ø E.g. There is no significant relationship between anxiety and duration of infertility

Phase 2: The Design and Planning Phase
1. Selecting a Research Design.
Cross-sectional design
ü Involves the collection of data once: the phenomena under study are captured during one period of data
collection.
Longitudinal design
ü A study in which data are collected at more than one point in time over an extended period.
ü E.g. Premature infants-evaluating development during childhood.
Retrospective design
ü Involves collecting data on an outcome occurring in the present, and then linking it retrospectively to antecedents
or determinants occurring in the past.
Prospective design
ü Information is first collected about a presumed cause or antecedent, and then subsequently the effect or
outcome is measured.
ü E.g. Framingham Heart Study; Nurses Study. Those who develop certain diseases are compared to those who
don't.
2. Identifying the Population
• People who provide information to the researchers or investigators are:
ü Subjects
ü Study participants
ü Respondents
ü Informant (Qualitative study)
• Population
ü All the individuals or objects with common, defining characteristics.
• Accessible/ Source population
ü Aggregate of cases that conform to designated criteria and that are accessible as subjects for a study.
• Target population
ü Aggregate of cases about which the researcher would like to generalize.
• Sample
ü Subset of population elements
• Element
ü Most basic unit about which information is collected. The key consideration in assessing a
sample in a quantitative study is representativeness.
• Pilot Study
ü Small-scale version or trial run designed to test the methods to be used in a larger, more rigorous study,
called parent study.
2. Designing the Sampling Plan
• Sampling
ü Process of selecting a portion of the population to represent the entire population so that inferences about
the population can be made.
• Representativeness
ü The key consideration in assessing a sample in a quantitative study.
Probability Sampling
• Involves random selection of elements.
1. Simple Random Sampling
ü Most basic probability sampling design.
2. Stratified random sampling
ü It subdivides the population into homogeneous subsets from which• an appropriate number of elements are
selected at random.
3. Cluster sampling (Multi-stage sampling)
ü Involves the successive selection of random samples from larger to smaller units by either simple random or
stratified random methods.
4. Systematic Sampling
ü Involves the selection of every nth case from a list, such as every tenth person on a patient list.
Non-probability sampling
• Elements are selected by nonrandom methods.

1. Convenience/Accidental Sampling
ü Entails using the most conveniently
available people as study participants.
2. Snowball/Network/Chain Sampling
ü Variant of convenience sampling. Early sample members are asked to refer other people who meet the eligibility
criteria.
3. Quota Sampling
ü One in which the researcher identifies population strata and determines how many participants are needed from
each stratum.
4. Purposive/Judgmental Sampling
ü Judgmental sampling is a non-probability sampling technique where the researcher selects units to be sampled
based on their knowledge and professional judgment
Phase 3: The Empirical Phase
1. Collecting the Data
v Data saturation
• Involves sampling to the point at which no new information is obtained and redundancy is achieved.
Instruments in Data Collection
v Observation
• Way of gathering data by watching behavior, events, or noting physical characteristics in their natural setting.
• Types of Observation:
ü Overt- Everyone knows they are being observed
ü Covert- No one knows they are being observed and the observer is concealed
Types of observer:
ü Non-participant, or direct, observation
Ø Is where data are collected by observing behavior without interacting with the participants.
ü Participant observation
Ø Is where data are collected by interacting with, and therefore experiencing, the phenomenon being studied.
• Advantages of Observation:
ü Collect data where and when an
event or activity is occurring.
ü Does not rely on people's willingness or ability to provide information.
ü Allows you to directly see what people do rather than relying on what people say they did.
• Disadvantages of Observation:
ü Susceptible to observer bias.
Susceptible to the 'hawthorne effect," that is, people usually perform better when they know they are being
observed, although indirect
ü By the interviewer to Observation may decrease this problem.
ü Can be expensive and time-consuming compared
ü To other data collection methods.
ü Does not increase your understanding of why people behave as they do.
v Questionnaires
• Is a research instrument consisting of a series of questions and other prompts for the purpose of gathering
information from the respondents.
• Types:
ü Closed-ended questions
Ø Is a question format that provide respondents with a list of answer choices from which they must choice to
answer the question
Ø E.g. Do you get well with your boss
ü Open-ended questions
Ø An open-ended question is designed to encourage a full, meaningful answer using the subject's own
knowledge and/or feelings
Ø E.g. Tell me about your relationship with your boss
• Advantages of Questionnaires
ü Cost- less costly, less time and energy to administer
ü Anonymity- offer the possibility of complete anonymity,
ü Interviewer bias- absence of an interviewer ensures that there will be no interviewer bias.

v Interview
• Is a conversation between two people (the interviewer and the interviewee) where questions obtain information
from the interviewee.
• Types:
ü Structured
Ø Require adherence to a very particular set of rules. Each question that is outlined should be read word for
word by the researcher without any deviation from the protocol
ü Semi-structured
Ø Semi-structured interviews are a bit more relaxed than structured interviews.
Ø While researchers using this type are still expected to cover every question in the protocol, they have some
wiggle room to explore participant responses by asking for clarification or additional information.
ü Unstructured
Ø Have the most relaxed rules of the three.
Ø In this type, researchers need only a checklist of topics to be covered during the interview.
Ø There is no order and no script.
• Advantages of Interview
ü Response rates- tends to be high in face to face interview
ü Audience- many people cannot fill up questionnaire. Interview is feasible with most of the people.
ü Clarity- interviews offer some protection against ambiguous or confusing questions.
ü Depth of questioning- open-ended questions are used mostly in interview
ü Missing information- less likely to give missing information in interview
ü Order of question- in interview, researchers have control over question ordering
v Physiological Measurements
• Weight- most objective
v Likert Scale
• Is a psychometric scale commonly involved in research that employs questionnaires
• Delphi technique
• Is a structured communication technique, originally developed as a systematic, interactive, forecasting method
which relies on a panel of experts
ü Pre-existing Data
• Preparing the Data for Analysis
Phase 4: The Analytic Phase
1. Interpreting the Results
• Interpretation is the process of studying the results and examining their implications Inferential Statistics
Parametric tests
• Are characterized by three attributes:
• They involve the estimation of a parameter
• They require measurement on at least an interval scale
• They involve several assumptions, such as the assumption that the variables are normally distributed in
the population.
Non-parametric tests
• They involve less restrictive assumptions about the shape of the variable's distribution than do parametric tests
Levels of measurement
Non-parametric:
1. Nominal
• Involves assigning numbers to classify characteristics into categories.
• E.g. gender, blood type, marital status
2. Ordinal
• Involves sorting objects based on their relative ranking on an attribute
• E.g. levels of anxiety (mild, moderate, severe and panic)
• Parametric:
3. Interval
• Occurs when researchers can specify the rank-ordering of objects on an attribute and can assume
equivalent distance between them.
• E.g. Fahrenheit temperature scale
4. Ratio
• It is the highest level of measurement.
• They have a rational, meaningful zero.
• It provides information concerning the ordering of objects on the critical attribute, the intervals between
objects, and the absolute magnitude of the attribute.
• E.g. Scores in the board examination
• Measurements:
• Chi-Square Test
ü To test hypotheses about the proportion of cases that fall into different categories, as when a
contingency table has been created.
ü For non-parametric variables
• T-test
ü Assesses whether the means of two groups are statistically different from each other.
ü This analysis is appropriate whenever you want to compare the means of two groups
• Analysis of variance (ANOVA)
ü Is the parametric procedure for testing differences between means when there are three or more groups
Descriptive Statistics
v Measure to condense
• Frequency distribution
ü A systematic arrangement of values from lowest to highest together with a count of the number of times
each value was obtained.
• Percentage
• Is a way of expressing a number, especially a ratio, as a fraction of 100.
• Graphic Presentation
• The transformation of data through visual methods like graphs, diagrams, maps and charts is called
representation of data
v Measures of Central Tendency

• Are indexes expressed as a single number that represent the average or typical value of a set of scores.
• Mode
Ø Most frequently occurring score value in a distribution
• Median
Ø Is the point in a distribution above which and below which 50% of cases fall.
• Mean
Ø Is the sum of all scores, divided by the number of scores
Ø Also referred to as the average
Measures of Variability
v It shows how spread out the data
• Range
• Simply the highest score minus the lowest score in a distribution
• Standard deviation
• Indicates the average amount of deviation of values from the mean.
• Variance
• Is equal to the standard deviation squared.
v Percentile
• Is the value of a variable below which a certain percent of observations fall
Measures of relationship
v Pearson's r- This coefficient is computed with variables measured on either an interval or ratio scale
v Spearman's rho (p)- the correlation index usually used for ordinal-level measures.
v Correlation coefficient
• Indicates the magnitude and direction of a relationship between two variables
• It can range from -1.00 (a perfect negative relationship) through zero to +1.00 (a perfect positive relationship).

Hypothesis testing
True False
True (null is accepted Correct decision Type II error (False negative)
False (null is rejected) Type I error (False positive) Correct decision
Phase 5: Dissemination Phase

1. Communicating the Findings
• Final task of the research project is the preparation of a research report that can be shared with others.
2. Utilizing the Findings in Practice
CRITERIA IN ASSESSING QUALITY OF RESEARCH

v Reliability
• Refers to the accuracy and consistency of information obtained in a study
v Validity
• Is a more complex concept that broadly concerns the soundness of the study's evidence- that is whether the
findings are unbiased, cogent, and well grounded.
v Dependability
• Refers to evidence that is consistent and stable.
v Conformability
• Is similar to objectivity
• It is the degree to which study results are derived from characteristics of participants and the study context, not
from researcher biases.
v Credibility
• An especially important aspects of trustworthiness, is achieved to the extent that the research methods engender
confidence in the truth of the data and in the researchers
interpretation of the data.
v Triangulation
• Is the use of multiple source or referents to draw conclusions about what constitutes the truth.
ETHICS IN RESEARCH
v Nuremburg code
• Developed after the Nazi atrocities were made public in the Nuremburg trials.
• The commission established by the National Research Act, issued a report in 1978 that is referred to as the
Belmont Report, which provided a model for many of the guidelines adopted by disciplinary organizations in
The United States.
v Declaration of Helsinki
• Allowed for the inclusion of vulnerable populations in research: (1) minors (2) indigenous peoples
Ethical Principles for Protecting Study Participants
v Beneficence
• Imposes a duty on researchers to minimize harm and to maximize benefits
v The Right to Freedom from Harm and Discomfort
v The Right to Protection from Exploitation
v The Right to Self-determination
• The principle of self-determination means that prospective participants have the right to decide
voluntarily whether to participate in a study, without risking any penalty or prejudicial
treatment.
v The Right to Full Disclosure
• Full disclosure means that the
researcher has fully described the nature of the study,the person's right to refuse participation, the
researchers responsibilities and likely risks and benefits.
• Concealment
• The collection of information
without the participants' knowledge or consent
• Deception
• Either withholding information from participants or providing false information.
v The Right to Fair Treatment
• Justice
• Connotes fairness and equity, and so one aspect of the justice principle concerns the equitable
distribution of benefits and burdens of research.
v The Right to Privacy
• Researchers should ensure that their research is not more intrusive than it needs to be and that
participant's privacy is maintained throughout the study.
• Anonymity
ü The most secure means of protecting confidentiality occurs when even the researcher cannot link
participants to their data.

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NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH

LET*PSYCHOMET*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM

NURSING THEORIESAND CONCEPTUAL FRAMEWORK

SCOPE OF NURSING PRACTICE

STANDARD OF NURSING PRACTICE

4 TOPRANK REVIEW ACADEMY- NURSING MODULE

EXPANDED CAREER ROLES FOR NURSES

PATRICIA BENNER’S STAGES OF NURSING EXPERTISE

GENERAL GUIDELINES FOR RECORDING

8 TOPRANK REVIEW ACADEMY- NURSING MODULE

CHARACTERISTICS OR NURSING CARE

COMPONENTS OF THE NURSING PROCESS (ADPIE)

v Activities during assessment

CONCEPTS OF HEALTH AND ILLNESS

MODELS OF HEALTH AND ILLNESS

LEAVELL AND CLARK'S AGENT-HOST- ENVIRONMENTAL MODEL (ECOLOGIC MODEL)

LEAVELL AND CLARK'S THREE LEVEL OF PREVENTION

PHYSIOLOGIC RESPONSES TO STRESS AND ILLNESS

ASSESSING VITAL SIGNS / CARDINAL SIGNS

ASSESSING BODY TEMPERATURE

TEPIDSPONGE BATH (TSB)

RESPIRATIONS (The Act of Breathing)

19 TOPRANK REVIEW ACADEMY- NURSING MODULE

BLOOD PRESSURE (BP)

Normal <120 and <80

ASSESSING BLOOD PRESSURE

CHARACTERISTICS OF PAIN (PQRST)

21 TOPRANK REVIEW ACADEMY- NURSING MODULE

v Faces Pain Scale •

o Suitable for children to describe pain

PHYSICAL HEALTH EXAMINATION

Percussion Sounds and Tones

Normal Breath Sounds

TYPES OF SKIN LESION

24 TOPRANK REVIEW ACADEMY- NURSING MODULE

25 TOPRANK REVIEW ACADEMY- NURSING MODULE

TYPES OF MEDICATION ORDER:

ROUTES OF DRUG ADMINISTRATION

26 TOPRANK REVIEW ACADEMY- NURSING MODULE

27 TOPRANK REVIEW ACADEMY- NURSING MODULE

• Oral/ parenteral Medication: liquids

PREPARING MEDICATIONS FROM AMPULES

PREPARING MEDICATIONS FROM VIAL

MIXING MEDICATIONS USING ONE SYRINGE

v Mixing medication from two vials

PARENTAL FLUID AND ELECTROLYTE REPLACEMENT

30 TOPRANK REVIEW ACADEMY- NURSING MODULE

Milliliters per minute

INITIATING, MAINTAINING AND TERMINATING BLOOD TRANSFUSION

Termination of the Transfusion

33 TOPRANK REVIEW ACADEMY- NURSING MODULE

ASEPSIS AND INFECTION CONTROL

DISINFECTING AND STERILIZING

COMMONLY USED ANTISEPTICS AND DISINFECTANTS

CDC (COMMUNICABLE DISEASE CONTROL), HICPAC (HOSPITAL INFECION CONTROL PRACTICES

35 TOPRANK REVIEW ACADEMY- NURSING MODULE

DISPOSAL OF SOILED EQUIPMENT AND SUPPLIES

ALTERATIONS IN RESPIRATORY FUNCTIONS

CLIENT TEACHING ON ABDOMINAL (DIAPHRAGMATIC) AND PURSED-LIP BREATHING

37 TOPRANK REVIEW ACADEMY- NURSING MODULE

NURSINGRADTECHDENTISTRYCRIMINOLOGYMIDWIFERY*MEDTECH

LETPSYCHOMETRESPIRATORY THERAPYCIVIL SERVICENAPOLCOM