Medical Nursing 1 Updated

CYBER SCHOOL
EXPERIENCE
MEDICAL NURSING 1
This pamphlet contains

different simplified topics of
Medical Nursing 1 for CN.
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KAWALYA GERMAINE NELSON
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CYBER SCHOOL EXPERIENCE MEDICAL NURSING 1
Copy right @ 2023 by Kawalya Germaine Nelson
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First Edition 2023
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1 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

TABLE OF CONTENTS
TABLE OF CONTENTS __________________________________________________________ 2
INTRODUCTION TO MEDICINE ___________________________________________________ 5
DEFINITION OF MEDICINE ____________________________________________________________ 5
TERMS USED IN MEDICINE ___________________________________________________________ 5
INTRODUCTION TO DISEASES _________________________________________________________ 7
CIRCULATORY DISORDERS _____________________________________________________ 21

INFLAMMATORY DISEASES OF THE HEART ______________________________________________ 22
PERICARDITIS ____________________________________________________________________________ 22
MYOCARDITIS ____________________________________________________________________________ 27
ENDOCARDITIS ___________________________________________________________________________ 31
CONGESTIVE CARDIAC FAILURE ______________________________________________________ 34

RHEUMATIC FEVER & RHEUMATIC HEART DISEASE _______________________________________ 38
ARTERIOSCLEROSIS & ATHEROSCLEROSIS ______________________________________________ 43
ARTERIOSCLEROSIS _______________________________________________________________________ 43
ATHEROSCLEROSIS ________________________________________________________________________ 45
THROMBUS AND EMBOLUS _________________________________________________________ 48

THROMBUS ______________________________________________________________________________ 49
EMBOLUS _______________________________________________________________________________ 49
HYPERTENSION ___________________________________________________________________ 51
HYPERTENSIVE CRISIS ______________________________________________________________ 60
HEMATOLOGIC DISORDERS ____________________________________________________ 62

ANEMIA _________________________________________________________________________ 62
COAGULATION DISORDERS __________________________________________________________ 70
LEUKEMIA _______________________________________________________________________ 76
RESPIRATORY TRACT DISORDERS _______________________________________________ 82

UPPER RESPIRATORY TRACT DISORDERS _________________________________________ 83
COMMON COLD/CORYZA ___________________________________________________________ 83
TONSILITIS _______________________________________________________________________ 86
SINUSITIS/RHINOSINUSITIS __________________________________________________________ 90
PHARYNGITIS_____________________________________________________________________ 94
LARYNGITIS ______________________________________________________________________ 97

INFLUENZA _____________________________________________________________________ 102
LOWER RESPIRATORY TRACT DISORDERS ________________________________________ 108

PNEUMONIA ____________________________________________________________________ 108
TUBERCULOSIS __________________________________________________________________ 115
BRONCHITIS ____________________________________________________________________ 125
ASTHMA _______________________________________________________________________ 133
STATUS ASTHMATICUS ____________________________________________________________ 139
EMPHYSEMA /PULMONARY EMPHYSEMA _____________________________________________ 141

PREFACE
The organization presents a new epic series of textbooks for Certificate students doing Nursing
and Midwifery in the 2.1 semester and students. These books also include textbooks for
certificate students in 2.1.
These books are written by Kawalya Germaine Nelson “The Professor” include the following
No. Textbook Price

1. Medical Nursing 1 & Pharmacology 1 25,000/=@
Question and Answer Booklet
2. Surgical Nursing 1 and Gynaecology 1 25,000/=@
3. Palliative Care Nursing and Pediatrics 1 25,000/=@
Question & Answer Booklet
4. Midwifery 1 & Pharmacology 1 25,000/=@
5. Obstetric Anatomy and Physiology 25,000/=@
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Sr. Ruth
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INTRODUCTION TO MEDICINE
DEFINITION OF MEDICINE
This is the study or science of treating diseases especially by means of internal remedies (drugs)
as distinct from mechanical and operative procedures which is the domain of surgery.
TERMS USED IN MEDICINE
1. Health: is a state of complete physical, social, mental and spiritual wellbeing of an
individual and not merely the absence of diseases or infirmity.
2. Aetiology: is the study of the causes of diseases and the facts that influence their
occurrence. The causes are divided into 2; the exciting cause (the micro-organism
responsible for that particular disease) and predisposing causes/factors (these are factors
encouraging/promoting/influencing/aggravating/precipitating the occurrence of that
particular disease.
3. Pathology: is the study of the disease process/developing or study of changes which occur
in the diseased organs so as to produce signs and symptoms.
4. Signs: are the abnormal things that we can see in a patient with our naked eyes, e.g. a
rash, swelling, diarrhea, ulcer, scar, etc.
5. Symptom: the abnormal things that we can not see in a patient with our naked eyes, e.g.
pain, nausea, musclé ache, etc..
6. Physical sign: is what is found on examination of the patient, e.g. an enlarged spleen,
liver, full urinary bladder, a pregnant uterus, anaemia seen from the pale tongue and
mucous membrane, fracture, sore, etc.
7. Inspection: is the general observation of the patient by use of eyes only and this reveals
many abnormalities such as deformity, diminished movements on the affected side of the
body, etc.
8. Palpation: this is feeling a patient by use of the palms of the hands for swellings (whether
painful, hot, cold, smooth, fluctuant, fixed/mobile, round/irregular). It is a manual
examination of the patient by placing the hands on the chest/abdomen and trying to feel
the nature of underlying organs.
9. Percussion: this is the tapping of the chest or abdominal wall using flat hands and fingers,
then striking over them with fingers from the opposite hands. This is to detect normal
sounds and abnormal ones from the underlying cavities or hollow organs as the tapping
sounds are transmitted through the skin, muscles and into the cavities/organs. A dull
sound in the chest indicates fluid filled cavities or consolidated hollow organ (filled and
without any space), and a loud sound is heard over the normal area where the air is freely
entering into the free space. The same to the abdomen and the organs contained there
in.

10. Auscultation: this is listening with the stethoscope on the chest wall/abdominal wall to
enable the clinician/doctor/nurse to hear the normal breathe/abdominal sounds and the
abnormal ones or for peristaltic movements in the abdomen in post-operative
abdominally operated patients. Those with intestinal obstruction or abdominal post-
operative patients who have taken 2 days may have no sounds at all.
11. Complications: this is a lesion/damage/symptom which results from the original disease
and not necessarily part of that disease, e.g., a complication of gonorrhea is urethral
stricture, or meningitis results in paralysis if the brain was involved.
12. Sequeale: is a symptom persisting after the original disease has subsided. It is a
permanent complication that remains with the patient for life. The sequale of meningitis
is permanent mental retardation.
13. Diagnosis: is the recognition of a particular disease. It is arrived at through good history
taking, physical examination and laboratory findings.
14. Laboratory diagnosis, this is through identification of micro-organisms under the
microscope in the laboratory to confirm the clinical diagnosis. In urgent situations, the
patient should be treated according to the clinical diagnosis and not to wait for
confirmation from the laboratory.
15. Differential diagnosis; this is the knowledge of other diseases which resemble the disease
in question and it points the difference which will help in performing a final diagnosis, e.g.
malaria +meningitis are all fever causing diseases unless blood slide and lumbar puncture
are done to differentiate btn the 2.
16. Prognosis: is the act of foretelling how the disease will end judging from the
course/progress/worsening reduction in the progress of the disease. E.g. the disease
started like this, it later changed like this and it might end this way.
17. Prophylaxis: this is the prevention of a disease by vaccination, giving treatment before
the disease starts. It may be for an individual, or for the whole community.
18. Path gnomic sign: this is a sign occurring in one disease only and not found n any other
condition. When present, it affords the establishment of a certain disease. E.g., koplick’s
spots in measles, polyarthritis in rheumatic fever which is shifting in nature.
19. Syndrome: is a collection of signs and symptoms which constitute a special disease, e.g.
Aids.
20. Epidemiology: is the study of the diseases by reference to its incidence in the population,
e.g., during which season, in which geographical areas, which group of people are more
affected.
21. Geriatric: is a branch of medicine which is concerned with the prevention of social neglect
in the elderly. It is the health care given to the elderly.
22. Infection: is a successful invasion of the body tissues by micro-organisms without showing
any sign and symptoms.

23. Inflammation: is the body’s reaction/response to infection (by developing fever in order
to make the temperature unsuitable for the survival of microbes; swelling to take more
cells-soldiers to the invaded area in much blood supply; pain is caused by the
overstretching of a part due to swelling, due to destruction of tissues and nerves; loss of
function in order for the affected part to rest and to heal without being disturbed. The
inflammation can be acute or chronic.
INTRODUCTION TO DISEASES
Disease: is any alteration in the structure and function of an organ.
Types of diseases
 Communicable/infectious diseases
 Non communicable/infectious diseases
Communicable/infectious diseases
Definition; Communicable disease is an illness due to specific infectious agents in its toxic
products, which under certain conditions tends to spread among individuals in a community.
Period of communicability or communicable period refers to the time during which an infectious
agent may be transferred directly or indirectly from an infected person to a susceptible person.
This period is usually equal to the maximum known incubation period for that disease.
Examples of Communicable / infectious Diseases
 Tuberculosis
 Cholera
 Malaria
 Meningococcal meningitis and Niral meningitis
 Plague
 HIV
 Ebola virus and Marburg virus
 Hepatitis A, B, C and E
Modes of Transmission of communicable diseases
The modes of transmission may be classified into two broad categories direct and indirect
Direct Transmission
1. Direct contact: e.g. sexual contact, kissing etc and continued close contact. Diseases
transmitted here include STI/HIV, Leprosy and Scabies
2. Droplet infection. Through Coughs, Sneezing diseases, common cld, TB, measles,
whooping cough, meningitis etc.
3. Contact with infected soil e.g. Tetanus infective hookworm larvae
4. Inoculation into skin or mucosa e.g. animal bites (dog bites -rabies and HIV or Hepatitis B
virus from contaminated needle pricks.
5. Trans placental or vertical transmission e.g. toxoplasmosis, HIV, rubella virus, syphilis.

Indirect transmission
1. Vehicle - borne transmission; the common vehicle of transmission is water, milk or food
others vehicles may be blood, serum, plasma and other biological products. This group
include water-borne, milk-borne, food-borne and blood borne infections, examples-
enteric fever, cholera, dysentery, diarrhoea, hepatitis A,B,E, food poisoning.
2. Vector-borne transmission: e.g. malaria, filarial, kala-azar and plague are transmitted by
insects. The mode of transmission is vector transmission.
3. Air-borne transmission: e.g. Droplet nuclei - (very small infective particles which float in
the air e.g. TB, infected dust; due to sweeping or dusty a infected settled droplet on the
ground.
4. Formite-bome transmission. Fomites are articles that convey infection to others because
they have been contaminated e.g. handkerchief, drinking glasses, door geckoes, clothings
etc. highly infectious diseases e.g. Ebola can be easily transmitted by formites
Other terms used in communicable diseases
1. Zoonoses: An infectious disease transmissible under natural conditions from vertebrate
animals to man is called a zoonoses. There are over 150 disease common to man and
animals.
2. These include anthrax, liver fluke, bovine TB, salmonellosis, brucellosis, rabies, plague,
typhus, and yellow fever
3. Nosocomial infections: An infection occurring in a patient in a hospital or other health-
care facility and in whom it was not present or incubating at the time of admission or
arrival at a healthcare facility is called a nosocomial infection.
4. It refers to diseases transmitted from a hospital. Usually such infections are more difficult
to manage as they are generally resistant to most of the common antibiotics. Nosocomial
infections also include those infections, which were contacted in the hospital but
manifested after discharge, and also infections suffered by staff members if they
contacted the infection from the hospitalized patients.
5. Herd Immunity: The immune status of a group of people/community is called herd
immunity as it is the immune status of the 'herd' of people. For many communicable
diseases, an outbreak of disease is only possible if the level of immunity is sufficiently low
and there are a large number of susceptible individuals in the population. In diseases like
poliomyelitis, diphtheria, measles etc., herd immunity plays an important role. However,
in a disease like tetanus or rabies where every individual is at risk unless specifically
protected, herd immunity plays no role.
Factors responsible for the increased risk of infectious diseases are;
 Failure to control vectors especially mosquitoes
 Break down of the water and sanitation system.
 Failure to detect the disease early.
 Lack of immunization programmes

 High risk human behavior.
Control of communicable diseases

Methods/ approaches of prevention and control of communicable diseases
 This refers to the reduction of the incidence and prevalence of communicable diseases to
a level where it cannot be a major public health problem.
 There are three main methods of controlling communicable diseases.
 Eliminating the reservoir (attacking the source)
 Interrupting transmission
 Primordial prevention
Eliminating the reservoir (attacking the source)

1. Detection and adequate treatment of cases: This arrests the communicability of the
disease e.g. control of tuberculosis and leprosy and most sexually transmitted diseases.
2. Isolation: This means that the person with the disease is not allowed to come into close
contact with other people except those who are providing care, therefore the organism
cannot spread. It is used to control highly infectious diseases such as hemorrhagic viral
fevers.
3. Quarantine: Limitation of the movement of apparently well person or animal who has
been exposed to the infectious disease for duration of the maximum incubation period of
the disease.
4. Reservoir control: In those diseases that have their main reservoir in animals, mass
treatment or chemoprophylaxis or Immunization of the animals con be carried out e.g. in
brucellosis. Other ways include separating humans from animals or killing the animals and
so destroying the reservoir e.g. plague rabies and hydatid disease.
5. Notification: Means immediately informing the local health authorities (e.g. the District
Medical officer) that you suspect a patient is suffering from an infectious disease.
Interrupting transmission
This involves the control of the modes of transmission from the reservoir to the potential new
host through;
 Environmental sanitation
 Personal hygiene and behavior change.
 Vector control e.g. mosquitoes
 Disinfection and sterilization
 Protection of susceptible host

1. Immunization; This increases host resistance by strengthening internal defenses. It is one

of the most effective controls of communicable diseases in Africa. To be more effective,
immunization has to be given to a high proportion of the people (At least 80%).
2. Chemoprophylaxis: Drugs that protect the host may be used for suppressing malaria, and
for preventing infection with such diseases as plague, meningitis and tuberculosis.
3. Personal protection: The spread of some diseases may be limited by the use of barriers
against infection, e.g. shoes to prevent entry of hook worms from the soil, bed nets and
insect repellants to prevent mosquitoes.
4. Better nutrition: Malnourished children get infections more easily and suffer more severe,
complications, Prevention and actions aimed at eradicating, eliminating or minimizing the
impact of disease and disability.
Primordial prevention
This consists of actions and measures that inhibit the emergence of risk factors in a country or
population. it begins with the change in the social and environmental conditions. Examples of
primordial prevention actions
 National policies and programs on nutrition involving agricultural sector, the food
industry.
 Comprehensive policies to discourage smoking
 Programs to promote regular physical activity
1. Primary prevention: This is action prior to the onset of disease which removes the
possibility that the disease will occur. Its objectives are to promote health, prevent
exposure and prevent disease.
2. Secondary prevention: This is the action which halts the progress of a disease and limit
permanent damage through early detection and treatment of disease.
3. Tertiary prevention: this is to limit disabilities and to promote the patients adjustments
to irremediable conditions interventions include disability limitation and rehabilitation.
Non communicable diseases
These are types of diseases which cannot be transmitted from one person to another
Types of non-communicable diseases
1. Congenital disease: it is a disease or an abnormality somebody is born with, e.g. syphilis,
aids, extra digits, or an imperforate anus. These abnormalities may be caused by drugs,
viral infections, radiations and genetic factors like sickle cell disease (the passage of a gene
of abnormal red blood cell shape to the offspring from the parents).
2. Inherited disease: this is a disease which is hereditary and runs in families, such as SCD,
diabetes mellitus (type one), or haemophilia a condition of blood clotting abnormalities.
3. Traumatic disease: is a disease due to injury by mechanical means, e.g., fractures, burns,
wounds, ruptured organs, etc.

4. Inflammatory disease: is a disease caused by an infection with pathogenic organisms.

This can be acute or chronic. Acute disease occurs suddenly but chronic disease occurs
slowly.
5. Circulatory disease: this is a disease which affects the circulatory system like blood
vessels; blood itself, the heart and so on.
6. Neoplasm/new growths: these are swellings or ulcers which result from overgrowth of
new tissues from abnormal cells.
7. Degenerative diseases/miscellaneous diseases: degeneration means wearing out of cells
and the gradual replacement of tissues by fats, fibrous tissues or some other material. It
may occur as a result of action of toxic metabolic changes or diminished blood supply.
The diseases of degeneration may occur because of disease or old age. Examples of these
diseases are diabetic and other metabolic disorders, blood vessel diseases or brain
deterioration due to old age.
8. Allergic diseases: allergy means that an abnormal reaction or response of an individual
to a normal allergen which would not cause any reaction to another individual. These
abnormal allergens lead to the formation of antibodies (immunoglobulin Igb) and a high
concentration of these in blood suggests an allergic reaction. The examples of allergic
diseases are bronchial asthma, anaphylactic shock and other minor ones which provoke
characteristic symptoms whenever they are consequently encountered.
Etiology of diseases
Introduction
 There are 3 elements that determine the etiology of health problems in population, these
are; Agent, the Host and Environment.
 They are referred to as an epidemiological triad
 Epidemiology is a study of distribution and determinants of the diseases and health related
events in human population
 Disease or disorder occurs when the agent is more powerful than the host and cause the host
to becomes weaker and the environment becomes favorable for growth, multiplication and
survival of the agent.
 This is possible when the host becomes stronger and the agent is moved and the environment
becomes unfavorable to the agent.
Agent
It is a factor whose presence or absence causes a disease.
It is a specific factor without that a disease cannot occur.
A disease agent is defined as a substance living or non-living or a force; tangible or non-tangible,
the excessive presence or relative lack of that is the immediate cause of a particular disease.
The disease agent is classified as follows:-

1. Physical Agents: Various mechanical forces of frictions that may produce injury as well as
atmospheric abnormalities such as extremes of heat ,cold, humidity, pressure, radiation,
electricity, sound etc,
2. Biological Agent: Include all living organisms e.g. Viruses, Bacteria, Rickettsia, Chlamydia,
Protozoa, Fungi, Helminthes, among others.
3. Chemical Agents:
a) Endogenous: Some of the chemicals may be produced in the body as a result of
decayed function e.g. Urea (uraemia), Ketones, Ketosis, Sodium, Bilirubin (Jaundice),
uric acid (Gout), CaCo3 (Kidney stones) among others.
b) Exogenous Agents:
These arise from outside of human host, allergens, Metals, fumes, insect ides etc, they
may be acquired by inhalation, ingestion or inoculation.
4. Genetic Agents: Transmitted from parent to a child through the genes.
5. Mechanical Agent: Chronic friction and after mechanical forces resulting in injuries,
trauma, fractures, sprain, dislocation and even death.
6. Nutrient Agents: Dietary components, we need to survive e.g. proteins, fats,
Carbohydrates, vitamins, minerals and H2O.
 The excessive or deficient intake of nutrients leads to Malnutrition etc, which in
twin leads to susceptibility to disease.
 Absence, Insufficiency or Excess of factor:
 Chemical hormones e.g. insulin, oestrogen etc,
 Nutrients
 Lack of structure e.g. congenital defects of the heart.
 Chromosomes e.g. Mongolism, Mental retardation.
Host
This refers to humans or animals that come in contact with the agent.
Host factors influence the interaction with the agent and the environment as follows:-
1. Age: Certain diseases are more frequent in certain age groups than others e.g.
 Childhood age; Measles, whooping cough
 Advanced age e.g. diabetes, hypertension, cardiovascular
2. Sex: There are certain anatomical and hormonal differences between the two sexes e.g.
disorders associated with pregnancy in females; Prostatic hypertrophy in males.
3. Race: Some races also suffer from particular disease e.g. Negroes suffer from sickle cell
Anaemia (SCA).
4. Genetical factors: Behavioral disorders and diseases of blood run in the family due to
chromosomal factors.

5. Habits: Living habits or life styles such as dietary patterns, Use of tobacco, alcohol,
narcotics and drugs are the factors that influence on susceptibility of disease e.g.
Malnutrition, drug dependence, sexual excesses.
6. Nutrition; The effects of poor nutrition lead to susceptibility to various infections.
7. Customs; Certain traditional systems like superstition lead to diseases e.g. fixed belief in
gods of disease in Hindu society makes people not to believe in immunization that leads
to childhood diseases.
8. Human Mobility: Frequent disease’s in place may cause e.g. malaria, chlolera, AIDS,
syphilis etc,
9. Immunity: The reaction of human host to infection depends upon his previous
immunological experience e.g. infection, immunization. Those who acquired natural
immunity will not be easily susceptible to disease.
10. Social Status: Certain diseases occur according to social class e.g. low social classes are
susceptible to Bronchitis, TB. Usually upper classes have lower mortality and morbidity
than lower classes.
11. Economic status: Person’s occupation itself may be the cause of certain occupational
hazards and infections e.g. Brucellosis, Dermatitis etc, and unemployment also leads to
diseases.
12. Educational status: Diseases can be easily controlled and managed in the educated class
whereas of will be difficult in the case of uneducated class.
Environment
This refers to the aggregate of all external conditions and influences affecting the life and
development of an organisms, human behaviour and society.
1. Physical Environment: It includes non- living things and physical factors like H2O, Air, Soil,
Heat, Light, Radiation, Noise, Housing, Climate etc, Alteration or disease in this
environment due to various causes leads to H2O pollution, Air pollution, soil pollution,
Noise pollution that is too may cause diseases e.g. heavy flooding in the village or town
can cause the like hood that the area H2O sources will be contaminated with waste
products.
2. Biological Environment: Includes all the living things created in the world. Man lives
around the living things that include bacteria, Viruses, and other various Microorganisms
which may cause diseases and mal-adjustment in the ecological system leading to
causative factor of the disease.
3. Social Environment: Man has to live in society and should follow the accepted patterns of
particular society such as cultural values, customs, habits, beliefs, attitudes and morals,
religion and other psychological factors. Any alteration in these factors may lead to

conflicts and tensions that may cause behavioral diseases. Habits like smoking, alcohol,
drug dependence are well known to cause diseases.
Levels of disease prevention
Primary (1o) prevention
1. Is prevention that proceeds disease or days function and is applied to patients considered
physically and emotionally healthy.
2. It is aimed at intervention before pathological diseases have begun during the stage of
susceptibility.
3. It includes activities that are directed at using the probability of specific illness or body
function.
4. 1o prevention includes both general health promotions and specific protection
General health promotions include e.g.
 Health education
 Good standard of nutrition adjusted to developmental stages of life.
 Attention to personality development.
 Provision of adequate housing and recreation and agreeable working conditions.
 Genetic screening
 Marriage and sex education
 Periodic selective examination.
Specific Protection refers to measures aimed at protecting individual against specific
agents e.g. immunization,
 Vaccination
 Attention to personal hygiene for self-care.
 Use of environment sanitation e.g. chlorination of well
 Protection from accidents e.g. Wearing helmets.
 Use of specific nutrients
 Protection or avoidance of allergens
 Protection from carcinogens.
Any particular disease or health problem is a result of intervention between a number of
specific or associated risk that can be classified as Agent; Host and Environmental factors.
The interaction can be understood by visualizing the concepts or positive health and
disease.
Secondary prevention (2o)
Focuses on the individuals who are experiencing health problem or illness and who are @ risk for
developing conditions or worsening conditions.
Its efforts seek to detect disease early and treat if promptly.

The goal is to cure the disease at the earliest stage when cure is impossible to slow its progression
as well as prevent conditions of limit disability.
The activities directed at;-
 Early Diagnosis and Treatment:-
 Case finding measures, individual and mass
 screening surveys
 Selective Exam
 Cure and prevention of disease process to prevent spread of communicable disease,
prevent conditions and short the period of disability.
2. Disability Limitations
 Adequate TX to arrest disease process with prevents conditions.
 Provision of facilities to limit disability and prevent death.
Tertiary (3o) prevention
Occurs when the defect or disability is permanent.
It includes limitations of rehabilitation for those persons who have already experienced residual
damage.
Tertiary prevention activities focus on the middle to latter phases of clinical disease.
When irreversible pathological damage produces disability (e.g. smoke exercise). Here the
activities of restoration and rehabilitation will include:-
 Provision of hospital and community facilities for training and education to maximize use
of remaining capacities.
 Education of the public and industries to use rehabilitated –
 Mother and father Meoble extent.
 Selective placement
 Work therapy and hospital
In 3o prevention, mainly the activities are directed at rehabilitation rather than diagnoses and
treatment
Case at this level aims to help the patient to achieve a high level of functioning as possible despite
the limitation caused by illness or impaired functions.
Management of diseases
Clinical diagnostic principles and treatment:
1. History taking and recording
2. Physical examination
3. Tests and studies
4. Treatment which involves first aid, nursing care, medical treatment, surgical treatment,
preventive treatment/health education/discharge advice.
History taking and recording

This is the process of gathering information concerning the patient’s health problem as he arrives
from home to the hospital.
Factors to be considered before history taking are commenced:
1. The clinician/nurse taking history should be understood by the patient in order for a good
problem account to be taken and recorded.
2. The language to be used in history taking should be simple, clear and understandable to
the patient.
3. Where the interpreter is involved, the patient should be given time to express him or
herself.
4. The interviewer should not as far as possible ask questions which do not have definite
answers and the questions should be related to the suspected disease which may lead to
the diagnosis but not off topic questions.
5. The interviewer should not just stop at presenting complaint and assumes that that is all
for the history but should go deeper than that since the presenting complaint may just be
only a small part of the problem.
6. The history should be taken from the right source, i.e., the patient her self, close family
member who has been with the patient since the illness started or a mother in case of a
child, or from the incident report from the first aider/health centre/ those who found the
patient and helped him to reach the hospital.
7. Allow the patient to present the complaints in the way he/she feels it and only fill in the
necessary information which should include whatever has been disclosed concerning the
patient and his/her attitudes.
8. There must be privacy during history collection to avoid concealing more otherwise vital
information that could have helped in the diagnosis.
9. The history should be detailed, clear and chronological with significant information. It
should include the interpretation of the present situation and should indicate the result
they expect from consultation.
10. History taking should be done is such a way that the patient/attendant learns from the
interview so that he is made to discover what could have gone wrong such that the illness
has occurred .
Physical examination
Introduction
Physical examination can be done through inspection, palpation, percussion and auscultation and
this may need a stretcher or just the laps of the mother for the case of a small child/a baby.
1. Inspection: this is the act of visually observing the patient to note any significant physical
change.
2. Palpation: this is the use of sense of touch to assess factors such as texture, crepitance,
temperature, moisture, vibration or pulsation, swelling, rigidity or spasticity, organ

location and size, presence of lumps or masses, and presence of tenderness or pain.
Different parts of the hands are used for palpation.
3. Percussion: this is striking the patient’s skin to determine the density, size and location of
the underlying structure. A tap on the skin sets the body wall in motion: and the quality
of sound produced describes the organ below, i.e. the density of air versus solid matter
of the different structures. The sounds of the different notes on the percussed areas may
either be of normal clear, hollow quality, low pitched one, or much lower & louder in the
lung areas where there is much air, or it may be dull: soft, high-pitched, muffled thud over
the spleen and liver. The sound may be absolutely dull/flat sound where there is no air
especially over the thigh muscles or large tumours.
4. Auscultation: this is used to assess sounds produced by the heart, lungs, and bowel.
Abnormalities can be detected as different sounds are interpreted and compared to the
normal sounds produced by the above organs.
General principles of Inspection
1. Approaching the patient: whenever possible, ample time is allowed for the examiner and
the patient to become acquainted. Patient should be treated as an individual with respect
and dignity. The beliefs and other values should be considered. Encourage a good
examiner-client relationship.
2. Observations/inspection: this starts at the time the patient is entering the examination
room/screen/hospital ward. The purpose is to note any significant physical
characteristics. It is the point-specific scrutiny of the patient as a whole/system by system.
It must be purposeful, focused, and unhurried.
3. First observe the movement/gait and the way he/she is coming or being brought in, i.e.,
walking straight/limping/supported/rolled on a wheel chair/or on a stretcher. This tells
you about how weak the patient is/how severe his condition is and the type of
treatment/action he/she needs.
4. Observe general appearance: is the face sad/sick looking, crying in deep pain/grimacing
or vise versa.
5. Carry out ABC plan of assessment: but you should be careful for your own safety before
starting the assessment.
6. Respiration: check if the breathing is normal/dyspnoiec and respiratory characteristics
7. Dehydration, malnutrition and anemia: skin turgor/wrinkles, hollow cheek and jutting
prominences, thirst, presence of secretions-saliva, urine, history of
vomiting/diarrhea/bleeding/not eating and drinking for sometimes?
8. Check for mental outlook: consciousness, confusion and hallucinations, alertness,
orientation or unconsciousness. Observe the head for injuries, bleeding, and swelling. Do
the same for the eyes, nose and ears, also the pupils for the size and their reaction to
light.

9. Smell for: breathe incase of alcohol/poisonous intake/acetone smell especially in patients

who are unconscious.
10. Take the vital signs: temperature, pulse, respiration, blood pressure and weight
11. Look for muscle: for weakness, paralysis and spasms.
Process of examination
1. Undressing: the majority of patients resent the removal of clothes even for examination
purposes, i.e., the bras, pants and knickers. Most females look shy. The reason for clothe
removal must be explained to the patient and confidentiality be ensured. The patient
should then be told to lie on the stretcher in an anatomical position.
2. Examination: usually it is better to start with an area unlikely to be having pain or a site
of a patient’s complaints. The ears, eyes throat should be last in children. Before
performing a disagreeable painful or embarrassing examination, tell the patient what is
likely to happen and how the patient can assist, tell him that the examination is necessary
and it will be performed as fast as possible and that during examination, some specimen
has to be taken like vaginal smears.
Order of examination
Head
1. Check the hair for quantity, thickness, texture, distribution, infestation. The texture is very
important when conditions like hyper/hypothyroidism, or HIV/AIDS/chronic wasting diseases
that cause protein loss, drugs, or alopecia are implicated.
2. Check the scalp for scaliness, parasites, lumps, lesions, and nits. Note also the skin color,
cyanosis, pallor in the face, jaundice, and mucous membrane, and edema.
3. Observe the general size and contour of the skull and note any deformity, lumps and
tenderness especially when checking for hydrocephalus, microcephalus or acromegally.
Check for facial expression, symmetry of the facial structures (stroke and hypertension).
4. Eyes: ask if patient is able to see/has blurred vision esp. in hypertension and diabetes
mellitus. Also look for photophobia, visual acuity (for long/short sightedness), any swelling,
discharge, wounds, eye size, check pupil size and their reaction to light esp. in unconscious
patients or those with injuries on the head.
5. Ears: for size, skin lesions, swelling, tenderness and pain on the pinna. Look for redness,
wounds in the middle ear and discharge (note the color whether bloody, purulent, serous,
etc) for they have different indications.
6. Nose: check for any deformity, asymmetry, inflammation, wounds, discharge, patency of
each nostril, smelling test.
7. Mouth and throat: inspect the lips for color, moisture, lumps, ulcers, cracking. Certain
diseases affect the lips including dehydration. Note the color of the mucous membrane in the
tongue, smoothness (for the dorsal surface of the tongue is normally roughened from the
presence of papillae), check for rashes and fungal infections, sores and wounds. Check the

gum for swelling; bleeding, discoloration, retraction, etc. check the throat for the swellings of
thyroid glands, salivary glands, range of movement and strength of cervical bones and
muscles.
Thoracic cavity
1. On inspection, look for shape (barrel chest-horizontal ribs+ large antero-posterior
diameter or scoliosis-an S-shaped curvature, lordosis/sway-back=an anterior curvature of
the lumbar spine, and kyphosis-an exaggerated posterior curvature of the thoracic spine=
hump back).
2. Observe the skin and muscles to determine the level of nutrition.
3. Check for any respiratory movement, wounds and penetrations.
4. Note respiratory abnormalities such as dyspnoea, tachypnoeic, bradypnea, irregular,
shallow, slow breathing, apnea, cheyne stoke’s breathing.
5. Look for chest sounds by use of percussion and auscultation ( decreased and absent
sounds occur in bronchial obstruction by foreign bodies, secretions, mucus plug), and
percussion notes( resonance = normal, hyperresonace = emphysema, dull = abnormal
density in the lungs caused by pneumonia, pleural effusion, Atelectasis or tumor).
6. Do breast examination for size, dimples, nodules, sores, swelling, etc. Do also
cardiovascular examination.
Abdomen by use of inspection, auscultation, percussion and palpation:
1. Check the abdomen for distension, scars, rigidity, tenderness and pain, enlargement of
the organs, ascites, skin turgor and folding. Nb: the abdomen is auscultated first after
inspection and before percussion and palpation so that the auscultatory findings are not
altered by increased or decreased peristalsis
2. Pelvis: check it for position, size and proportion to detect any abnormality.
3. Extremities ( both lower and upper extremities): note the color, presence of clubbing of
the fingers and toes in chronic illnesses, hair distribution, venous pattern, swellings,
ulcers, temperature, palpate the blood supply to the extremities, check for range of
movement abilities at the joints and observe for muscle strength, any deformity and
inequality.
4. Skin: check for color, texture, rashes, scales, desquamation, scars, swollen nodes, edema,
sensation, temperature, wounds, etc.
Neurological examination
This involves assessing for the level of consciousness by calling him/her, shaking, shouting in the
ears, pressing a nail bed for pain stimuli and see how he/she is responding, checking for papillary
reaction to light and size, or by use of Glasgow coma scale, check for the senses of smell, taste,
site, touch, muscle weakness, paralysis, reflexes, etc.
Investigations/tests & studies

Tests are procedures carried out from the laboratory to identify the pathogenic microbes while
studies are investigations which need interpretation.
The types of tests that can be done in the laboratory include:
1. Urine: this may be collected either in a sterile way to identify the microbes such as; E.coli,
enterococci, staphylococci, hemolytic streptococci, mycobacterium tubercle, parasites
such as schistosoma haematobium, trichomonas vaginalis, urea, Creatinine, etc. clean
urine may also be collected to check for amount, color, consistency, specific gravity,
glucose, albumin, pH, acetone, etc.
2. Blood: this may be removed for various tests such as complete blood count, erythro-
segmentation rate, Hb, grouping and cross-match, smears, urea, renal and liver function
tests, glucose, etc.
3. Stool: this is removed to identify the ova, cysts, occult blood, mucus, microbes, worms,
etc.
4. Discharges: vaginal, urethral, cervical, pus, sputum, skin smears are taken for gram
staining, etc.
5. Punctures: this is when cavities are gone into and their secretions are aspirated and taken
to the laboratories for analysis; e.g. thoracentesis, paracentesis, lumbar punctures, knee
aspirations, etc.
Studies done to diagnose diseases include:
1. Biopsies: this depends on the disease suspected and pieces of affected tissues are
removed and taken for histological studies to identify the different cell types found in the
tissue questioned especially if cancerous cells are suspected.
2. Radiography: use of x-rays to detect any deformity/breakage in the bones; find abnormal
lungs, distended loops of the gut, to show the size and shape of the heart.
3. Ultra sound scan: use of sound waves emitted by the machine to produce an image of an
anatomical structure which may either be normal/abnormal in size or structure.
4. Endoscopies: this involves the insertion of tubes with light source at their tips and a
viewing lens at the other side, into the tubular structures to view their walls for wounds,
swellings, inflammations. These include: bronchoscopy, cystoscopy, endoscopy, etc.
5. Use of radiopaque dyes: this is when radiopaque substances are injected into the tubular
structures to coat up the walls of these organs so that when their radiograph is taken,
blocked tubes, narrow ones are identified and actions are taken appropriately. These
include: angiography, urography, venography, etc.
6. Computerized tomography: a much more expensive method of imaging than the ultra
sound scanning that can be used for more finely and diagnostic procedures for tumors
especially in the brain where ultra sound scanning may not give any information that may
be of help.

7. Magnetic resonance imaging (MRI): use of magnetic waves to provide information about
kidney masses that can not be obtained by other methods. Here solid masses look
different from cystic/hollow masses which contain fluid in them.
Treatment of diseases
Principles of treatment of diseases
1. First aid treatment: this is the kind of treatment offered especially for the patients who
come to the hospital/health centers when they are badly off and their condition is
deteriorating to the dying point within minutes. Assess for your own safety, carry out
ABCDE plan of resuscitation and assessment, and refer the patient for further
management.
2. Nursing care: This care given to the patient without the use of drugs and it depends on
the condition of the patient on arrival. Airway care is catered for first, then circulation
(shock, anaemia, dehydration), and then others may follow. Nursing care involves
preparing the patient, your self and equipment, doing the procedure, clearing and making
the patient comfortable including records and patient follow up and continuous
assessment and monitoring of the patient.
3. Medical treatment: is the treatment of diseases using drugs. This may have been given
during emergency before the doctor’s arrival and those that the doctor may prescribe
before or after laboratory results.
4. Surgical treatment: the use of mechanical means of operation to cure diseases in
situations that drugs may not cure the patient.
5. Preventive treatment: this involves prevention of infections through notification,
isolation, health education and giving prophylactic drugs. Screening of contacts may be
done and drugs given to the infected ones and you protect the health workers and other
contacts.
CIRCULATORY DISORDERS
These are diseases affecting the blood vessels and the heart.

We shall look at the following

1. Inflammatory disorders of the heart
2. Congestive cardiac failure
3. Rheumatic heart disease
4. Arteriosclerosis and atherosclerosis
5. Thrombus and embolus
6. Hypertension
7. Hypertensive crisis
INFLAMMATORY DISEASES OF THE HEART
Introduction
Inflammatory diseases of the heart refers to the group of diseases that cause the muscles of the
heart to inflame.
The inflammation of the heart muscles, such as myocarditis, the membrane sac which surrounds
the heart called as pericarditis, and the inner lining of the heart or the myocardium, heart muscle
as endocarditis are known as the inflammatory heart diseases.
Types of inflammatory diseases
1. Pericarditis: refers to the inflammation of the pericardium
2. Myocarditis: refers to the inflammation of the myocardium
3. Endocarditis: refers to the inflammation of the endocardium
General clinical manifestation of inflammatory diseases of the heart
1. Chest pain
2. Trouble breathing when lean back or in a relaxed position,
3. Pulse and BP difference in upper extremities,
4. Palpitations,
5. Weakness,
6. Coughing,
7. Hoarseness, voice weakness or complete aphonia,
8. Dysphagia,
9. Cyanosis,
10. Distended neck veins,
11. Anxiety and fatigue,
12. Low-grade fever,
13. Abdominal or leg swelling for long term pericarditis.
PERICARDITIS
Introduction
Pericarditis refers to inflammation of the pericardium, which is a thin, fibro-elastic sac that
surrounds the heart and the roots of the great vessels, cushioning them, and preventing friction
during each heartbeat.
Clinical manifestation
14. Chest pain
a. Sharp, Stabbing Chest pain over the center or left side of the chest: chest pain is a
common symptom associated with pericarditis.
b. It may be described as sharp and stabbing pain although some reported dull and
pressure-like pain.
c. It is typically felt under the breastbone or sometimes towards the left side of the
chest. It may radiate to the left arm and sitting up and leaning forward eases the pain.
15. Trouble breathing when lean back or in a relaxed position,
16. Pulse and BP difference in upper extremities,
17. Palpitations,
18. Weakness,
19. Coughing,
20. Hoarseness, voice weakness or complete aphonia,
21. Dysphagia,
22. Cyanosis,
23. Distended neck veins,
24. Anxiety and fatigue,
25. Low-grade fever,
26. Abdominal or leg swelling for long term pericarditis.
Cardinal signs and symptoms of pericarditis

Remember “Friction”
*Friction rub pericardial (sounds like a grating, scratching sound), Fever
Radiating substernal pain to left shoulder, neck or back
*Increased pain when in supine position (leaning forward relieves pain)
*Chest pain that is stabbing (will feel like a heart attack)
Trouble breathing when lying down (supine position)
*Inspiration or coughing makes pain worse
Overall feels very sick and weak
Noticeable ST segment elevation
Types of pericarditis
1. Acute pericarditis has a sudden onset, and it resolves within 3 weeks. It may settle
completely and recur in the future.
2. Sub-acute pericarditis lasts about 4-6 weeks but not exceeding 3 months and with
continuous presence of symptoms.
3. Chronic pericarditis develops slowly and can last up to more than 3 months and can lead
to constrictive pericarditis: where thick tissue forms around the pericardium and this
compresses the heart (the heart can’t expand to fill with blood properly).
Causes of pericarditis
Infectious Pericarditis
1. Viral (Coxsackievirus B, A, Adenovirus, Mumps),
2. Bacterial (Pneumococci, Staphylococci, Streptococci, Septicemia),
3. Fungal (Histoplasma, Candida Species, Infections such as toxoplasmosis,
4. Lung disease (Tuberculosis),
5. HIV (Human Immunodeficiency Virus).
Non-Infectious Pericarditis
1. Uremia,
2. Radiation-Induced,
3. Myxedema,
4. Acute MI,
5. Dissection of Aortic Aneurysm,
6. Trauma to the heart (Thoracic Surgery pacemaker),
7. Delayed post-myocardial- pericardial Injury,
8. Post cardiac syndrome,
9. Post myocardial infarction syndrome,
10. Side-affects some medication such as Isoniazid, cyclosporine, Tetracycline,
11. Malignancy,
12. Scleroderma,

13. Ankylosing spondylitis,

14. Inflammatory bowel disease,
15. Rheumatic fever,
16. Immunologic (Systemic lupus very tomatoes, Rheumatic fever),
17. Cancer (including leukemia).
Investigation
There are different test and diagnosis systems for pericarditis disease, which are in the following:
1. Medical history and physical exam,
2. ECG,
3. Echocardiography,
4. Cardiac CT scan/ MRI,
5. Blood test- C-reactive protein (CRP), Blood Urea Nitrogen (BUN), Troponin-I, CK-MB,
Myoglobin, ESR.
6. Radionuclide scanning.
Nursing interventions/management
Mild pericarditis
1. Assess patient’s pain (very painful)
2. Keep patient in high Fowler’s position (avoid supine) because this relieves pain
3. Monitor for Cardiac Tamponade (fluid compressing the heart):
a. Pulsus paradoxus (during the inspiratory phase that is a 10 or greater mmHg drop in
the systolic blood pressure)
b. Jugular venous distention with clear lungs
c. Heart sounds are muffled (fluid buildup on the heart
d. Tachycardia
e. Hypotension
4. Administer medications as prescribed by physician:
a. Aspirin OR
b. NSAIDS (nonsteroidal anti-inflammatory medications) Ibuprofen…watch for GI
bleeding, take with a full glass of water
c. Colchicine: decreases the inflammation (used in gout) don’t take with grapefruit juice
because this increases toxicity (nausea vomiting, abdominal pain, (can take it with or
without food)
d. Corticosteroids: used if patient not responding to other treatments…Prednisone:
decreases the inflammation
e. IV antibiotics for infection
Moderate to severe pericarditis

1. Establish a good rapport with the patient

2. Carrying out history taking i.e. patient’s history of smoking, anginal pain and other
presenting symptoms.
3. Carrying out observations i.e. TPR/BP, general examination
a. Pulsus paradoxus (during the inspiratory phase that is a 10 or greater mmHg drop
in the systolic blood pressure)
d. Tachycardia Hypotension
6. Monitor patient pain level and evaluate pain within 30 minutes.
7. Administer prescribed pain medication such as morphine to relieve pain.
8. Monitor the patient pain level and effectiveness of analgesics.
9. Provide a comfortable position (sit up and lean forward).
10. Check vital signs and record them continuously.
11. Discuss disease process and signs and symptoms expanding aneurysm or impending
aneurysm.
12. If surgical intervention is needed, provide psychological support, and prepare for surgery.
13. For post-surgical patients, discuss warning signs of postoperative complications such as
fever, inflammation in the surgical site, bleeding, and swelling.
14. Daily check of weight.
15. Closely monitor and notify a physician about persistent cough, vomiting, or systolic blood
pressure above 180mmhg because of the increased risk for hemorrhage.
16. Ensure bed rest until fever, chest pain and friction rub disappear.
17. Administer O2 and keep SPO2 ˃90%.
18. Administer medication as order-such as NSAIDs and steroids with food.
19. Ensure administer of antibiotic timely.
20. Continue I.V antihypertensive medication if persistent blood pressure high.
21. Carefully maintain fluid intake and output.
22. Reassure the patient that chest pain is not a Myocardial Infarction.
23. Check signs and symptoms for cardiac tamponade at least 8 hourly and PRN.
24. Assist the patient with bathing if necessary.
25. Provide a bedside commode to reduce stress on the heart.
26. Tell the patient to resume his daily activities slowly.
27. Build a rapport relationship with the patient to reduce anxiety.
Complications of pericarditis
1. Pericardial effusion,

2. Constrictive pericarditis,
3. Cardiac tamponade,
4. Fatal hemorrhage,
5. Myocardial ischemia,
6. Stroke,
7. Paraplegia due to interruption of the anterior spinal artery,
8. Abdominal ischemia.
MYOCARDITIS
Introduction
Myocarditis refers to the inflammation of the heart muscle, called the myocardium.
Okay, but first, a bit of anatomy and physiology. The heart wall is made of three layers: the outer
layer is the epicardium, the middle layer is the myocardium, and the inner layer is the
endocardium.
So, the myocardium is a muscular layer that consists of cells called cardiomyocytes, which relax
so that the heart can be filled with blood during diastole, and then contract to pump the blood
out of the heart during systole.
Contraction of the cardiomyocytes is controlled by the pacemaker cells in the sinoatrial or SA
node, which generates electrical signals that get sent out through the conduction system in the
heart.

Types of myocarditis
1. Infectious Myocarditis: the cause is a pathogen e.g. commonly viruses, bacteria and fungi
in people with weak immunity
2. Non-infectious Myocarditis: Caused by non-pathogens include cardiotoxins, certain
drugs, and some systemic disorders. Myocarditis caused by drugs is termed
hypersensitivity myocarditis..
Clinical manifestations
1. Chest pain: The pain may be described as a dull or sharp precordial or sub-sternal pain
which may radiate to the neck, left trapezius ridge, or shoulders. Pain may also be eased
by sitting up and leaning forward.
2. Shortness of breath during exercise,
3. Fatigue,
4. Palpitations lightheadedness,
5. Irregular heartbeat,
6. Sudden loss of consciousness,
7. Fever,
8. Bluish or Grayish discoloration of the skin,
9. Fluid retention with swelling of legs, ankles, and feet,
10. Headache,
11. Body aches,
12. Sudden breath.
13. Dyspnea
14. Edema Signs of fluid overload
15. Crackles
16. Elevated jugular venous pulses
17. Presence of 3rd and 4th Heart sounds
18. Systolic murmurs
19. Arrhythmias or abnormal heart rhythm
Causes
Infectious Myocarditis
1. Viruses: Coxsackie virus-B, Parvo-Virus-B19, Rubella, adenoviruses, hepatitis B and C.
2. Bacteria: Staphylococcus, Streptococcus.
3. Parasites: Trypanosoma, Cruz.
4. Fungi: fungi can easily infect people with weak immunity e.g. Candida Molds, aspergillus,
and histoplasmosis
Non-Infectious Myocarditis
1. Medications or Illegal Drugs: Allergic, Toxic reaction),
2. Connective tissue disorders (Scleroderma, Systemic lupus erythematosus),
3. Wegener’s granulomatosis
4. Electric shock
5. Radiation induces
6. Hyperpyrexia.
Investigations
There are different test and diagnosis ways for myocarditis, which are mentioned below:
1. ECG,
2. Chest X-Ray,
3. Echocardiogram,
4. Holter monitor,
5. Blood test (CBC, CRP),
6. MRI,
7. Cardiac catheterization and endomyocardial biopsy,
8. Rheumatologic screening,
9. Viral genome testing in an endomyocardial biopsy,
10. Cardiac angiography,
11. Cardiac enzyme levels (eg, creatine kinase or cardiac troponins)
12. Serum viral antibody titers.

Medical management
Various treatment options for myocarditis disease are in the following:
Medication:
1. ACE Inhibitors (Enalapril, Captopril) to relax the blood vessels and increase cardiac output.
2. Angiotensin-2 receptor blockers (Losartan, Valsartan) to relax the blood vessels in the
heart and help blood flow more easily.
3. Beta-Blockers (Metoprolol, Bisoprolol) to control irregular or fast heart rhythms.
4. Diuretics (Furosemide) to reduce fluid overload and sodium retention.
5. Antibiotics (To treat bacterial infection).
6. Non Steroidal Anti-inflammatory Drugs (To relieve pain and inflammation).
7. Anticoagulant (Aspirin) to prevent blood clots.
8. Inatrops (Dobutamine, Dopamine) may be necessary for severe decompensation.
Supportive:
1. Oxygen Supplement,
2. Fluid management,
3. Low Sodium Diet,
4. Hemodynamic and cardiac monitoring,
5. Reduced activity.
Surgical:
1. Temporary Transvenous pacing.
2. A temporary artificial heart,
3. Intra-aortic balloon pump.
4. Ventricular assist device or percutaneous circulatory support; left ventricular assistive
devices (LVADs) and extracorporeal membrane oxygenation (ECMO) [5].
1. Carrying out history of the patient about the signs and symptoms
2. Carry out vital observations i.e. TPR/BP
3. Give a comfortable position (semi-fowler position).
4. Monitor pain characteristics and administer analgesics as needed and use salicylates
around the clock.
5. Give O2 supplement and ensure saturation ˃90%.
6. Give drugs as indicated (Aspirin, Steroids).
7. Give antipyretic drug if fever present.
8. Provide a calm and quiet environment and give emotional support while the patient is
confined to a hospital or home with restrictive intravenous therapy.
9. Check vital signs and record them carefully.
10. Carefully monitor intake output.

11. Closely monitor signs for cardiac tamponade.

12. Ensure bed rest to reduce myocardial oxygen requirements and reduce heart rate.
13. Ensure rest and activity according to the degree of tolerance.
14. Ensure a high protein, high carbohydrate, and low sodium diet to meet adequate
nutrition.
15. Explain all procedures to patients that improve patient confidence.
16. Prepare patient for surgery if needed
17. If the patient received surgical treatment, provide post-surgical care and instruction.
18. After surgery, monitor the patient’s temperature, fever may be present for weeks.
19. Provide 4 hourly mouth cares and serve attractive meals that stimulate the appetite.
20. Instruct to avoid people who have an upper respiratory tract infection.
21. Monitor for signs and symptoms of organ damage such as stroke (CVA, brain attack),
meningitis, heart failure, myocardial infarction, glomerulonephritis, and splenomegaly.
22. Instruct patient and family about activity restrictions, medications, and signs and
symptoms of infection.
ENDOCARDITIS
Introduction
Endocarditis disease is an inflammation of the inner lining of the heart chambers and heart valves
(Endocardium).

Types of endocarditis
1. Infective endocarditis: This type of endocarditis caused by pathogens e.g. staphylococcus
and streptococcal bacteria. This is the most common type of endocarditis.
2. Non infective Endocarditis: It develops when sterile fibrous vegetations form on the heart
valves hence causing inflammation of the endocardium.
1. Flue like symptoms such as fever chills, sweating at night,
2. Fatigue, weakness, and muscles ache,
3. Shortness of breath,
4. Persistent cough,
5. Weight loss,
6. Blood in urine,
7. Petechiae (tiny red spots on the skin, eye, and inside of mouth),
8. Bleeding under the nails,
9. Red, painless skin spots on the palms and soles,
10. Swelling of feet and legs,
11. Tenderness in the spleen.
Causes of endocarditis
There are different causes of endocarditis, which are mentioned below:
1. Infection (Bacterial, fungal, Viral),
2. History of endocarditis,
3. Implanted heart device such as a pacemaker, Implantable cardioverter-defibrillator),
4. Central venous catheter,
5. Congenital heart defect,
6. Hypertension,
7. Abnormal or damaged heart valves,
8. Artificial heart valve,
9. Certain dental procedures,
10. Contaminated needles used to inject the illegal drug,
11. Rheumatic fever,
12. Immune suppression,
13. Prolonged I/V antibiotic therapy.
Investigations
There are different diagnosis types for endothermic, which are in the below:
1. Medical history and physical exam (Heart murmur, enlarged spleen, Bleeding under nails),
2. Blood culture, CBC, CRP,

3. ECG,
5. Chest X-Ray,
6. CT scan or MRI of the chest.
Management
Medical management
1. Antibiotics,
2. Antipyretics,
3. Surgery (Repair or replacement of a heart valve).
1. Carry out history taking of the patients presenting complaint
2. Carrying out vital observations i.e. TPR/BP
3. Alert the doctor who will assess the patient, order for investigations and admit the patient
4. The patient will be nursed in the sit-up position
5. Monitor vital signs hourly if Patient condition unstable.
6. Monitor central venous pressure if the central line present.
7. Monitor fluid intake and output hourly.
8. Monitor weight daily.
9. Assess neurological status hourly.
10. Keep skin warm and regularly monitor nails for color and capillary refill.
11. Provide O2 supplement and keep saturation ˃90%.
12. Ensure a calm and quiet environment with adequate rest.
13. Draw blood for cultures to evaluate the effectiveness of therapy.
14. Administer antibiotics and antipyretic timely as indicated.
15. Monitor the patient’s renal status including blood urea nitrogen levels, creatinine
clearance levels, and urine output.
16. Carefully monitoring signs and symptoms of complications and report it such as cerebral
vascular complications, and valve stenosis or regurgitation.
17. Provide psychological support and reduce anxiety.
18. Prepare Patient for surgery if indicated such as valve replacement.
19. After surgery monitor Patient temperature, fever may be present for weeks.
20. Provide education teaching needs antibiotics after dental procedures, childbirth,
genitourinary, GI, or gynecologic procedures.
21. If the patient received surgical treatment, provide post-surgical care and instruction.
22. After surgery, monitor the patient’s temperature; a fever may be present for weeks.
23. Instruct patient and family about activity restrictions, medications, and signs and
symptoms of infection.
Complications

There are different complications of endocarditis, those are in the below:

1. Heart failure,
2. Abbess in the heart/brain,
3. Spread infection to lung, brain, kidney, liver,
4. Stroke,
5. Heart rhythm problems.
CONGESTIVE CARDIAC FAILURE

Introduction
Congestive cardiac failure is recognized as a clinical syndrome in heart failure characterized by
signs and symptoms of fluid overload or of inadequate tissue perfusion.
Congestive Heart Failure or CHF is a severe circulatory congestion due to decreased myocardial
contractility, which results in the heart’s inability to pump sufficient blood to meet the body’s
needs.

Systemic circulation symptoms
1. Abdominal pain, bloating
2. Anorexia, nausea
3. Ascites from portal hypertension
4. Distended neck veins
5. Fatigue
6. Nocturnal diuresis
7. Pitting, dependent edema in the feet, legs, sacrum, back, and buttocks
8. Pulsus alternans (regular alteration of weak and strong beats noted in the pulse)
9. Tenderness of right upper quadrant, organomegaly
10. Weight gain
Pulmonary/Lung symptoms
1. Cough, which may become productive with frothy sputum
2. Dyspnea on exertion
3. Orthopnea
4. Paroxysmal nocturnal dyspnea
5. Presence of crackles on auscultation
6. Tachycardia
7. Pulsus alternans
8. Fatigue
9. Pallor
10. Cyanosis
11. Confusion and disorientation
12. Signs of cerebral anoxia
Causes of CCF
1. Coronary artery disease: Atherosclerosis of the coronary arteries is the primary cause of
HF, and coronary artery disease is found in more than 60% of the patients with HF.
2. Ischemia: Ischemia deprives heart cells of oxygen and leads to acidosis from the
accumulation of lactic acid.
3. Cardiomyopathy: HF due to cardiomyopathy is usually chronic and progressive.
4. Systemic or pulmonary hypertension: Increase in afterload results from hypertension,
which increases the workload of the heart and leads to hypertrophy of myocardial muscle
fibers.
5. Valvular heart disease: Blood has increasing difficulty moving forward, increasing
pressure within the heart and increasing cardiac workload.

6. Hypertension
7. Obesity
8. Diabetes mellitus
9. Atrial fibrillation
10. Hyperlipidemia
11. Hypertrophic obstructive cardiomyopathy
12. Restrictive cardiomyopathy
13. HIV,
14. Hyperthyroidism or Hypothyroidism,
15. Smoking,
16. Obesity,
1. Carry out history taking about patient’s symptoms and signs.
2. Carry out the following assessments of the patient.
3. Assess for abnormal heart and lung sounds.
4. Monitor blood pressure and pulse.
5. Assess mental status and level of consciousness to detect confusion as a result of low
oxygen
6. Assess patient’s skin temperature and peripheral pulses to detect abnormalities
7. Monitor results of laboratory and diagnostic tests to know status of the disease and
response to treatments.
8. Monitor oxygen saturation and ABGs
9. Inspect thorax for symmetry of respiratory movement to determine adequacy of
breathing
10. Observe breathing pattern for SOB, nasal flaring, pursed-lip breathing or prolonged
expiratory phase and use of accessory muscles
11. To increase cardiac activity since the heart is failing
a. Encourage periods of rest and assist with all activities to reduce cardiac workload.
b. Assist the patient in assuming a sit up position to allows for better chest expansion,
thereby improving pulmonary capacity.
c. Administration of prescribed drugs to help strengthening the heart
d. Reposition patient every 2 hours to prevent occurrence of bed sores
e. Instruct patient to get adequate bed rest and sleep to promote relaxation to the body
12. To manage the oedema of the patient.
a. Establish rapport to gain patient’s trust and cooperation
b. Monitor and record VS
c. Assess patient’s general condition to determine what approach to use in treatment

d. Monitor fluid input and output every 4 hours using the fluid balance chart to reflect
fluid status
e. Weigh patient daily and compare to previous weights to detect fluid volume excess
f. Auscultate breath sounds q 2hr and pm for the presence of crackles and monitor for
frothy sputum production to detect pink-tinged sputum which is an indicator that the
client is developing pulmonary edema
g. Assess for presence of peripheral edema and do not elevate legs if the client is
dyspneic.
h. Follow low-sodium diet and/or fluid restriction
i. Encourage or provide oral care q2
j. Obtain patient history to ascertain the probable cause of the fluid disturbance.
k. Monitor for distended neck veins and ascites
l. Evaluate urine output in response to diuretic therapy using a fluid balance charts
m. Assess the need for an indwelling urinary catheter.
n. Institute/instruct patient regarding fluid restrictions as appropriate.
13. To relieve acute pain (chest pain, restlessness)
a. Assess patient pain for intensity using a pain rating scale, for location and for
precipitating factors.
b. Administer or assist with self-administration of vasodilators, as ordered to enhances
blood flow to the myocardium.
c. Assess the response to medications every 5 minutes
d. Provide comfort measures (non-pharmacological pain management)
e. Establish a quiet environment to reduce the energy demands on the patient.
f. Elevate head of bed to improve chest expansion and oxygenation.
g. Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain
subsides.
h. Teach patient relaxation techniques and how to use them to reduce stress.
14. To enhance patient’s level of activity
a. Adjust client’s daily activities and reduce intensity of level. Discontinue activities that
cause undesired psychological changes
b. Instruct client in unfamiliar activities and in alternate ways of conserve energy
c. Encourage patient to have adequate bed rest and sleep
d. Provide the patient with a calm and quiet environment
e. Assist the client in ambulation to prevent risk for falls that could lead to injury
f. Note presence of factors that could contribute to fatigue
g. Give client information that provides evidence of daily or weekly progress
h. Encourage the client to maintain a positive attitude
i. Assist the client in a semi-fowlers position to promote easy breathing

j. Minimizing powerlessness: Encourage the patient to verbalize their concerns and

provide the patient with decision-making opportunities.
15. Discharge advice
The nurse should provide education and involve the patient in the therapeutic regimen.
a. Patient education: Teach the patient and their families about medication
management, low-sodium diets, activity and exercise recommendations, smoking
cessation, and learning to recognize the signs and symptoms of worsening HF.
b. Encourage the patient and their families to ask questions so that information can be
clarified and understanding enhanced.
Complications
1. Hepatomegaly,
2. Splenomegaly,
3. Pleural effusion,
4. Kidney damage or failure,
5. Cardiogenic shock,
6. Arrhythmia,
7. Left ventricular thrombus and embolism,
8. Hypokalemia. Excessive and repeated dieresis can lead to hypokalemia.
9. Hyperkalemia. Hyperkalemia may occur with the use of ACE inhibitors, ARBs, or
spironolactone.
10. Prolonged diuretic therapy might lead to hyponatremia and result in disorientation,
fatigue, apprehension, weakness, and muscle cramps.
11. Dehydration and hypotension. Volume depletion from excessive fluid loss may lead to
dehydration and hypotension.
RHEUMATIC FEVER & RHEUMATIC HEART DISEASE

Introduction
Rheumatic fever (ARF) results from the body’s autoimmune response to a throat infection caused
by Streptococcus pyogenes, also known as the group A Streptococcus bacteria.
Rheumatic fever is an inflammatory disease that results from an improperly treated strep throat
or scarlet fever due to an infection caused by Streptococcus bacteria.
Rheumatic fever is an inflammatory disease that can develop as a complication of inadequately
treated strep throat or scarlet fever.
RHEUMATIC HEART DISEASE
Introduction
Rheumatic heart disease (RHD) refers to the long-term cardiac damage caused by either a single
severe episode or multiple recurrent episodes of Acute Rheumatic Fever.

OR: Rheumatic heart disease is a medical disease results then from the inflammation and scarring
of heart valves caused by rheumatic fever.
Rheumatic heart disease and claims over 288 348 lives each year - the large majority in low- or
middle-income countries.
The disease results from damage to heart valves caused by one or several episodes of rheumatic
fever, an autoimmune inflammatory reaction to throat infection with group A streptococci
(streptococcal pharyngitis or strep throat). It most commonly occurs in childhood, and can lead
to death or life-long disability.
Rheumatic heart disease can be prevented by preventing streptococcal infections, or treating
them with antibiotics when they do occur.
Rheumatic fever: is an auto-immune reaction of the body towards untreated or poorly treated
group A streptococcal throat.
Pathophysiology
1. Rheumatic fever is the primary cause of acquired heart disease in children and young
adults worldwide. Rheumatic fever occurs 2 to 3 weeks after a group A beta-hemolytic
streptococcal pharyngeal infection.
2. Rheumatic heart disease is the result of valvular damage caused by an abnormal immune
response to Streptococcus pyogenes infection, which is classified as a group A
streptococcus that causes acute rheumatic fever.
3. Acute rheumatic fever occurs around three weeks after group A streptococcal pharyngitis
and can affect joints, skin, brain, and heart. After multiple episodes of rheumatic fever,
progressive fibrosis of heart valves can occur, which can lead to rheumatic valvular heart
disease.
4. If valvular heart disease remains untreated, then heart failure or death may occur. The
precise pathophysiology is not well known. Rheumatic carditis is characterized by Aschoff
nodules and MacCallum plaques.
5. Aschoff bodies are seen in nodules in the hearts affected with rheumatic fever. They
result from inflammation in the heart muscle. MacCallum plaques are seen on the valves
and the subendocardium in the left atrium.
Causes of RHD
Rheumatic heart disease results from either a single or repeated attacks of rheumatic fever that
results in rigidity and deformity of valve cusps, the fusion of the commissures, or shortening and
fusion of the chordae tendineae. Over 2 to 3 decades, valvular stenosis and/or regurgitation
results. In chronic rheumatic heart disease, the mitral valve alone is the most commonly affected
valve in an estimated 50% to 60% of cases. Combined lesions of both the aortic and mitral valves
occur in 20% of cases. Involvement of the tricuspid valve occurs in about 10% of cases but only
in association with mitral or aortic disease. Tricuspid valve cases are thought to be more common
when recurrent infections have occurred. The pulmonary valve is rarely affected.

Rheumatic fever symptoms can include:

1. Fever
2. Painful joints especially knees ankles, elbows and wrists
3. Pain that moves between different joints
4. Fatigue
5. Jerky uncontrollable body movements called ‘chorea’
6. Painless nodules under the skin near joints and/or a rash consisting of pink rings with a
clear centre (both rare)
7. Heart murmur
Symptoms of rheumatic heart disease depend on the degree of valve damage and may include
1. Chest pain or discomfort
2. Shortness of breath
3. Swelling of the stomach, hands or feet
4. Fatigue
5. Rapid or irregular heart beat
Test and Diagnosis
There are different test and diagnosis systems for pericarditis disease, which are in the following:
2. ECG
4. cardiac MRI,
5. Chest x-ray
Management
Medical Management

Therapy is directed towards eliminating the GABHS pharyngitis (if still present), suppressing
inflammation from the autoimmune response, and providing supportive treatment of congestive
heart failure (CHF).
1. Anti-inflammatory: Treatment of the acute inflammatory manifestations of acute
rheumatic fever consists of salicylates and steroids; aspirin in anti-inflammatory doses
effectively reduces all manifestations of the disease except chorea, and the response
typically is dramatic.
2. Corticosteroids: If moderate to severe carditis is present as indicated by cardiomegaly,
third-degree heart block, or CHF, add PO prednisone to salicylate therapy.
3. Anticonvulsant medications: For severe involuntary movements caused by Sydenham
chorea, your doctor might prescribe an anticonvulsant, such as valproic acid (Depakene)
or carbamazepine (Carbatrol, Tegretol, others).
4. Antibiotics: prescription of penicillin or another antibiotic to eliminate remaining strep
bacteria.
5. Surgical care: When heart failure persists or worsens after aggressive medical therapy for
acute RHD, surgery to decrease valve insufficiency may be lifesaving; approximately 40%
of patients with acute rheumatic fever subsequently develop mitral stenosis as adults.
6. Diet: Advise nutritious diet without restrictions except in patients with CHF, who should
follow a fluid-restricted and sodium-restricted diet; potassium supplementation may be
necessary because of the mineralocorticoid effect of corticosteroid and the diuretics if
used.
7. Activity: Initially, place patients on bed rest, followed by a period of indoor activity before
they are permitted to return to school; do not allow full activity until the APRs have
returned to normal; patients with chorea may require a wheelchair and should be on
homebound instruction until the abnormal movements resolve.
Nursing management
1. Carry out history taking about the signs and symptoms
2. Carryout observation i.e. TPR/BP.
4. Continue I.V antihypertensive medication if persistent blood pressure high.
5. Carefully maintain fluid intake and output.
6. Daily check of weight.
7. Closely monitor and notify a physician about persistent cough, vomiting, or systolic blood
pressure above 180mmhg because of the increased risk for hemorrhage.
8. Check signs and symptoms for cardiac tamponade at least 8 hourly and PRN.

a. Pulsus paradoxus (during the inspiratory phase that is a 10 or greater mmHg drop in
the systolic blood pressure)
d. Tachycardia Hypotension
10. To manage fevers
a. Assess temperature, heart rate, and blood pressure frequently.
b. Ensure bed rest until fever, chest pain and friction rub disappear.
c. Administer prescribed O2 and keep SPO2 ˃90%.
d. Administer prescribed medication as order-such as NSAIDs and steroids with food.
e. Ensure administer of prescribed antibiotic timely.
f. Provide a tepid sponge bath.
g. Modify the child’s environment such as room temperature and bed linens as
indicated.
h. Eliminate excess clothing and covers.
i. Maintain bed rest especially during the acute febrile phase.
11. To relieve pain
a. Monitor patient pain level and evaluate pain within 30 minutes.
b. Administer prescribed pain medication such as morphine to relieve pain.
c. Monitor the patient pain level and effectiveness of analgesics.
d. Provide a comfortable position (sit up and lean forward).
e. Check vital signs and record them continuously.
f. Reassure the patient that chest pain is not a Myocardial Infarction.
12. To increase activity tolerance of the patient
a. Maintain bed rest especially during the acute febrile phase.
b. Assess the child’s mobility and physical activity level.
c. Assess and evaluate nutritional health status of the client.
d. Monitor pulse rate, blood pressure; observe for dyspnea, use of accessory muscles,
and skin color before and after activity.
e. Provide emotional support and positive attitude regarding abilities.
f. Encourage adequate rest periods in between activity.
g. Assist with activities of daily living as needed such as eating, bathing, dressing,
elimination.
h. Encourage and teach the child with active range-of-motion exercises.
i. Instruct child to resume activity gradually once asymptomatic at rest and indicators
of acute inflammation have resolved.
13. To allay anxiety

a. Discuss disease process and signs and symptoms expanding aneurysm or impending
aneurysm.
b. If surgical intervention is needed, provide psychological support, and prepare for
surgery.
c. For post-surgical patients, discuss warning signs of postoperative complications such
as fever, inflammation in the surgical site, bleeding, and swelling.
14. Assist the patient with bathing if necessary.
15. Provide a bedside commode to reduce stress on the heart.
16. Tell the patient to resume his daily activities slowly.
17. Build a rapport relationship with the patient to reduce anxiety.
Complications
1. Heart failure: This can occur from either a severely narrowed or leaking heart valve.
2. Bacterial endocarditis: This is an infection of the inner lining of the heart, and may occur
when rheumatic fever has damaged the heart valves.
3. Complications of pregnancy and delivery due to heart damage: Women with rheumatic
heart disease should discuss their condition with their healthcare provider before getting
pregnant.
4. Ruptured heart valve: This is a medical emergency that must be treated with surgery to
replace or repair the heart valve.
ARTERIOSCLEROSIS & ATHEROSCLEROSIS

ARTERIOSCLEROSIS
Introduction
Arteriosclerosis is the thickening, hardening, and loss of elasticity of the walls of arteries.
Arteriosclerosis is the most common disease of the arteries; the term means hardening of the
arteries. It is a diffuse process whereby the muscle fibers and the endothelial lining of the walls
of small arteries and arterioles become thickened. This process gradually restricts the blood flow
to one's organs and tissues and can lead to severe health risks brought on by atherosclerosis,
which is a specific form of arteriosclerosis caused by the buildup of fatty plaques, cholesterol,
and some other substances in and on the artery walls.
Pathophysiology
The lesions of arteriosclerosis begin as the intima (innermost layer of blood vessel wall) of the
arterial wall start to fill up with the deposition of cellular wastes. As these start to mature, they
can take different forms of arteriosclerosis. All are linked through common features such as the
stiffening of arterial vessels, thickening of arterial walls and degenerative nature of the disease.
Arteriolosclerosis, unlike atherosclerosis, is a sclerosis that only affects small arteries and
arterioles, which carry nutrients and blood to the cells.
Types of Arteriosclerosis
1. Monckeberg's arteriosclerosis or medial calcific sclerosis is seen mostly in the elderly,
commonly in arteries of the extremities.
2. Hyperplastic: Hyperplastic arteriosclerosis refers to the type of arteriosclerosis that
affects large and medium-sized arteries.
3. Hyaline type: Hyaline arteriosclerosis, also referred to as arterial hyalinosis and arteriolar
hyalinosis, refers to lesions that are caused by the deposition of homogenous hyaline in
the small arteries and arterioles.
Diagnostic procedures
1. Measuring the lipid profile (LDL-cholesterol), plasma glucose, and high-sensitivity C-
reactive protein (hscrp) (in certain instances) is reasonable.
2. Ultrasound of the abdomen to screen for an abdominal aneurysm is indicated in the
elderly especially with other ASCVD risk factors. In screening for peripheral artery disease
(PAD), a Doppler device is used to obtain the ankle-brachial index (normal 1.0 to 1.40)
and is a very useful, cost-effective test to rule out PAD. It needs to be emphasized that
PAD is a marker for
3. Stress ECG. To confirm ASCVD, a reasonable test is the calcium score by electron beam
computed tomography (EBCT). It needs to be interpreted according to age. It establishes
plaque burden.
4. Computed tomography (CT)
5. Cardiac MRI
Management
Treatment is often in the form of preventive measures of prophylaxis.
Medical Management
1. It is often prescribed to help prevent arteriosclerosis for underlying conditions, such as
medications for the treatment of high cholesterol, medications to treat high blood
pressure (e.g., ACE inhibitors), and antiplatelet medications.
2. Lifestyle changes are also advised, such as increasing exercise, stopping smoking, and
moderating alcohol intake.
Surgical Management
1. There are a variety of types of surgery:
2. Angioplasty and stent placement: A catheter is first inserted into the blocked or narrowed
part of the artery, followed by a second one with a deflated balloon that is passed through
the catheter into the narrowed area. The balloon is then inflated, pushing the deposits
back against the arterial walls, and then a mesh tube is usually left behind to prevent the
artery from retightening.

3. Coronary artery bypass surgery: This surgery creates a new pathway for blood to flow to
the heart. The surgeon attaches a healthy piece of vein to the coronary artery, just above
and below the blockage to allow bypass.
4. Endarterectomy: This is the general procedure for the surgical removal of plaque from
the artery that has become narrowed or blocked.
5. Thrombolytic therapy: This is a treatment used to break up masses of plaque inside the
arteries via intravenous clot-dissolving medicine.
ATHEROSCLEROSIS
Introduction
Definition: Atherosclerosis is the buildup of fatty material called plaque or atheroma, in the lining
of the artery walls.
It is a specific type of arteriosclerosis.
This buildup causes the narrowing of the affected arteries. When the arteries are narrowed,
blood cannot go through it easily. This can lead to reduced delivery of oxygen and nutrients to
the cells of the body.
Causes of atherosclerosis
The exact cause of atherosclerosis isn’t known. However, studies show that atherosclerosis is a
slow, complex disease that may start in childhood. It develops faster as you age.
Atherosclerosis may start when certain factors damage the inner layers of the arteries.
1. Hypercholesterolemia (LDL-cholesterol)
2. Hypertension
3. Diabetes mellitus
4. Cigarette smoking
5. Age (male older than 45 years and female older than 55 years)
6. Male gender
7. Strong family history (male relative younger than 55 years and female relative younger
than 65 years
8. Also, a sedentary lifestyle
9. Obesity
10. Diets high in saturated and trans-fatty acids, and certain genetic mutations contribute to
risk.
11. While a low level of high-density lipoprotein (HDL)-cholesterol is considered a risk factor
12. High levels of C-reactive protein (CRP), a marker of inflammation
13. Sleep apnea
Signs and symptoms will depend on which arteries are affected.
Coronary arteries

1. Pain – can be on the chest (if coronary artery is affected) or the limbs (if peripheral arteries
are affected) especially the legs
3. Tachycardia
4. Hypertension
5. Tachypnea
6. Palpitations
7. Fatigue
8. Weakness or myalgia
Carotid Arteries
The carotid arteries supply oxygen-rich blood to brain. If plaque narrows or blocks these arteries
(a disease called carotid artery disease), one may have symptoms of stroke. These symptoms
may include:
1. Sudden weakness
2. Paralysis (an inability to move) or numbness of the face, arms, or legs, especially on one
side of the body
3. Confusion
4. Trouble speaking or understanding speech
5. Trouble seeing in one or both eyes
6. Difficulty in breathing
7. Dizziness, trouble walking, loss of balance or coordination, and unexplained falls
8. Loss of consciousness
9. Sudden and severe headache
Peripheral Arteries
1. Plaque also can build up in the major arteries that supply oxygen-rich blood to the legs,
arms, and pelvis (a disease called peripheral artery disease).
2. If these major arteries are narrowed or blocked, you may have numbness, pain, and
sometimes dangerous infections.
Renal Arteries
1. 1. The renal arteries supply oxygen-rich blood to kidneys. If plaque builds up in these
arteries, one may develop chronic kidney disease. Over time, chronic kidney disease
causes a slow loss of kidney function.
2. Early kidney disease often has no signs or symptoms. As the disease gets worse, it can
cause tiredness, changes in how you urinate (more often or less often), loss of appetite,
nausea (feeling sick to the stomach), swelling in the hands or feet, itchiness or numbness
and trouble concentrating.
Complications
1. Coronary artery disease(CAD)

2. Myocardial Infarction
3. Acute coronary syndrome (ACS), or heart attack
4. Atherosclerosis may cause total blockage of a coronary artery, which may result to the
lack of blood flow to the cardiac muscle.
5. Heart Failure: Since the coronary arteries supply the heart with oxygen- and nutrient-rich
blood, blockage in them may weaken the heart. This eventually leads to failure of the
heart to supply blood to the rest of the body tissues.
6. Peripheral vascular disease (PVD): Blockage of a peripheral artery may lead to reduced
blood flow to the limbs, usually the legs. This can manifest as leg weakness and pain and
can affect the mobility of the patient.
7. Arrythmias: Abnormal heart rhythms such as atrial fibrillation may result from the
decreased blood supply in the heart. Irregular heartbeats may result to formation of more
blood clots. These thrombi can travel to other parts of the body and become embolus/
emboli. When the embolus reaches the brain, the patient may suffer from transient
ischemic attack(TIA) or
8. Stroke
Diagnostic Tests
1. Vital signs – decreased blood pressure on the affected limb; whooshing sound or bruit
over the arteries upon auscultation
2. Blood tests – to measure cholesterol levels by total lipid profile (fasting for 10 to 12
hours), lipoprotein blood test (non-fasting), and glucose testing
3. Doppler Ultrasound – to measure the blood pressure on different sites of the arm or leg
in order to check for the speed of the arterial blood flow, and any blockage
4. Ankle-brachial index – to compare the blood pressure level in the arm versus that in the
ankle
5. Electrocardiogram (ECG)
6. Echocardiogram – utilizes sound waves to create images of the heart
7. Exercise stress test – use of ECG while the patient is on a treadmill or a stationary bike
8. Cardiac catheterization and angiogram
9. Cardiac CT scan
Management
1. Blood thinning agents such as Aspirin – to reduce the ability of the blood to clot, so that
the blood flows easier through the narrowed arteries.
2. Nitrates – to relax the blood vessels.
3. Beta blockers – to decrease the cardiac demand for oxygen by means of lowering the
heart rate and blood pressure levels
4. Calcium channel blockers – used in combination with beta blockers
5. Diuretics to reduce blood pressure

6. Ranolazine – to treat angina

7. Surgery. Surgical interventions are required if the medical team believes that an urgent,
more aggressive treatment for the complications of atherosclerosis (such as CAD and
PVD) is needed. These surgeries include:
8. Coronary artery bypass surgery – creation of a graft to reroute the blood flow away from
the diseased artery
9. Fibrinolytic therapy – usage of a clot-dissolving drug to dissolve the atheroma
10. Endarterectomy – surgical removal of atheroma from the narrowed arteries
11. Lifestyle changes. A low cholesterol, low sugar diet to control cholesterol and blood
glucose levels is needed for a patient with atherosclerosis. Foods rich in omega-3 fatty
acids such as fish, soybeans, and flaxseeds are recommended, Smoking is another risk
factor of atherosclerosis and CAD. Increased physical activity by doing at least 150
minutes of moderate aerobic exercises will help promote an active lifestyle.
Nursing interventions of arteriosclerosis and atherosclerosis
1. Assess the patient’s vital signs and characteristics of heart beat at least every 4 hours.
Assess heart sounds via auscultation. Observe for signs of decreasing peripheral tissue
perfusion such as slow capillary refill, facial pallor, cyanosis, and cool, clammy skin.
2. Administer prescribed medications for atherosclerosis.
3. Administer supplemental oxygen, as prescribed.
4. Discontinue if SpO2 level is above the target range, or as ordered by the physician.
5. Educate patient on stress management, deep breathing exercises, and relaxation
techniques.
6. Administer prescribed medications that alleviate the symptoms of pain (chest pain or
angina, or leg/limb pain)
7. Assess the patient’s vital signs and characteristics of pain at least 30 minutes after
administration of medication.
8. Elevate the head of the bed if the patient is short of breath and administer supplemental
oxygen, as prescribed.
9. Discontinue if SpO2 level is above the target range, or as ordered by the physician.
10. Place the patient in complete bed rest when in severe pain.
11. Educate patient on stress management, deep breathing exercises, and relaxation
techniques.
THROMBUS AND EMBOLUS

Introduction
The circulatory system is composed of blood vessels and the heart. Blood vessels (arteries and
veins) facilitate the passage of blood throughout the body. Blood cells suspended in the plasma
travel through blood vessels.
Blood clots are solid masses that travels through the vessels along the blood. They are made up
of either platelets, fibrin, fat, amniotic fluid, a tumor or air.
Foreign substances such as iodine, cotton, talc or a piece of catheter tube can serve as blood
clots. Thrombus and embolus are two terms used interchangeably to describe blood clots.
The main difference between thrombus and embolus is that thrombus refers to a firm mass of
blood clot developed within the circulatory system whereas embolus refers to a piece of
thrombus that travels through the blood vessels. An embolus travels until it reaches the tiny
blood vessels that are too small to pass through it.
THROMBUS
Definition
Thrombus refers to a blood clot formed inside the circulatory system that can impend blood flow.
Pathophysiology
Generally, it stays attached to the site of the blood vessel where it is formed.
A blood clot can be formed as a result of injury to a blood vessel or tissue. Aggregation of platelets
forms a quick plug to prevent bleeding.
Causes of a thrombus
The formation of blood clots is induced by certain conditions such as
1. High cholesterol
2. Tobacco smoking
3. Diabetes
4. Cancer
5. Being obese or overweight
6. Stress
7. Sedentary lifestyle.
Types of a Thrombus
Depending on the location, several types of thrombosis can be identified:
1. Arterial thrombosis
2. Venous thrombosis
3. Deep vein thrombosis (DVT)
The symptoms occur when the thrombus restricts the blood flow through the lumen
1. The arterial thrombosis may cause unstable angina, peripheral arterial limb ischemia,
ischemic stroke, and heart attack.
2. The venous thrombosis may cause swelling, pain, and tenderness in the calf, red skin at
the back of the leg, and aches and warm sensations in the skin.
EMBOLUS
Definition

Embolus refers to a blood clot, fatty deposit or air bubble carried by the bloodstream until it
lodges in a blood vessel. It may travel either through arteries or veins.
Pathology
As embolus is a piece of blood clot detached from a thrombus, it is also called a thrombo embolus.
The lodging of the embolus occurs when the diameter of the blood vessel is too small for it to
pass through. Since it blocks the blood flow, the tissue that receives blood from the vessel may
starve of oxygen (ischemia) and eventually die. This clinical condition is called the embolism.
Types of embolism
Several types of embolism can be observed depending on its location. They are
1. Pulmonary embolism
2. Brain embolism
3. Retinal embolism
Similarities Between thrombus and Embolus

1. Both thrombus and embolus refer to blood clots.
2. Both thrombus and embolus occur inside the circulatory system.
3. Both thrombus and embolus are made up of platelets, fibrin, fat, amniotic fluid, a tumor,
air or foreign substances.
4. Both thrombus and embolus can block the lumen of the blood vessels.
No. Variable Thrombus Embolus

Definition Thrombus refers to a blood Embolus refers to a blood clot, fatty
clot formed inside the deposit or air bubble carried by the
1. circulatory system that can bloodstream until it lodges in a
impend blood flow blood vessel.
Size Thrombus: Thrombus is Embolus: Embolus is a piece of

large. thrombus.
2.
Source Thrombus is always caused 99% of embolus are originated

by blood constituents such from thrombus. Others may occur
3. as platelets, fibrin, and due to air, infectious particles or
cellular elements. fat.

Significance Thrombus is a blood clot Embolus is a blood clot that travels

that develops inside the through the blood vessels.
4. circulatory system.
Phase Thrombus is a stationary Embolus is a freely floating mass.

mass.
5.
Obstruction Thrombus obstructs the site Embolus obstructs a site that is

of origination. distant from the site of origination.
6.
Types Arterial thrombosis, venous Pulmonary embolism, brain

thrombosis, and DVT are the embolism, and retinal embolism
7. types of are some of the several types of
Conclusion
Thrombus and embolus are two types of particles that can block the blood vessels in the
circulation system. Most thrombus and embolus are blood clots. Thrombus is located in the site
of origination while embolus can be a piece of thrombus that breaks off from a thrombus.
Thrombus impedes the blood vessels at its site of origination. However, embolus blocks the blood
vessels located away from the site of origination. Embolus causes severe clinical complications
compared to thrombus. The main difference between thrombus and embolus is their role in the
circulation.
HYPERTENSION
Introduction
Definition: Hypertension, or high blood pressure (BP), is defined as a persistent systolic blood
pressure (SBP) greater than or equal to 140 mm Hg, diastolic blood pressure (DBP) greater than
or equal to 90 mm Hg.
This is based on the average of two or more accurate blood pressure measurements during two
or more consultations with the healthcare provider.
The definition is taken from the Seventh Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure.
Types of Hypertension

1. Primary (essential or idiopathic) hypertension: elevated BP without an identified cause;

accounts for 90% to 95% of all cases of hypertension.
2. Secondary hypertension: elevated BP with a specific cause; accounts for 5% to 10% of
hypertension in adults.
Stages of Hypertension
1. Normal: The normal range for blood pressure is between, less than 120 mmHg and less
than 80 mmHg.
2. Elevated: Elevated stage starts from 120 mmHg to 129 mmHg for systolic blood pressure
and less than 80 mmHg for diastolic pressure.
3. Stage 1 hypertension: Stage 1 starts when the patient has a systolic pressure of 130 to
139 mmHg and a diastolic pressure of 80 to 89 mmHg.
4. Stage 2 hypertension: Stage 2 starts when the systolic pressure is already more than or
equal than 140 mmHg and the diastolic is more than or equal than 90 mmHg.
5. Hypertensive crisis: BP that is greater than 180mm/hg systolic and 120mm/hg diastolic
Pathophysiology
There are various mechanisms described for the development of hypertension which includes
increased salt absorption resulting in volume expansion, an impaired response of the renin-
angiotensin-aldosterone system (RAAS), increased activation of the sympathetic nervous system.
These changes lead to the development of increased total peripheral resistance and increased
afterload which in turn leads to the development of hypertension.
Causes of Hypertension
Hypertension has a lot of causes just like how fever has many causes. The factors that are
implicated as causes of hypertension are:
1. Increased sympathetic nervous system activity: Sympathetic nervous system activity
increases because there is dysfunction in the autonomic nervous system.
2. Increase renal reabsorption: There is an increase reabsorption of sodium, chloride, and

water which is related to a genetic variation in the pathways by which the kidneys handle
sodium.
3. Increased RAAS activity: The renin-angiotensin-aldosterone system increases its activity
leading to the expansion of extracellular fluid volume and increased systemic vascular
resistance.
4. Decreased vasodilation of the arterioles: The vascular endothelium is damaged because
of the decrease in the vasodilation of the arterioles.
Risk factors of Hypertension
1. Age: Increasing age increases the risk of development of hypertension

2. Family History of the disease increases the risk

3. Lack of exercise
4. Obesity
5. Stress and depression
6. Vitamin D deficiency
7. Smoking
8. Drug abuse and alcoholism
9. Cushing syndrome
10. Diabetes
11. Sedentary lifestyle
12. Intake of extra salt
13. Insufficient calcium, magnesium, and potassium intake
14. Chronic kidney disease
15. Adrenal and thyroid problems
16. Adrenal gland tumors
17. Thyroid problems
18. Certain medications such as birth control pills, cough, and cold remedies and over-the-
counter pain relievers( NSAIDs)
19. Obstructive sleep apnea
Often called the “silent killer” because it is frequently asymptomatic until it becomes severe and
target organ disease occurs.
1. Headache: The red blood cells carrying oxygen is having a hard time reaching the brain
because of constricted vessels, causing headache.
2. Dizziness occurs due to the low concentration of oxygen that reaches the brain.
3. Chest pain: Chest pain occurs also due to decreased oxygen levels.
4. Blurred vision: Blurred vision may occur later on because of too much constriction in the
blood vessels of the eye that red blood cells carrying oxygen cannot pass through.
5. Fatigue or confusion,
6. Lightheadedness,
7. Vertigo,
8. Tinnitus,
9. Fainting,
10. Irregular heartbeat,
11. Blood in the urine.
Test and Diagnosis for Hypertension
1. History exam
2. Physical exam: Manual checking of blood pressure by a sphygmomanometer.

3. Urinalysis is performed to check the concentration of sodium in the urine though the
specific gravity.
4. Blood chemistry (e.g. analysis of sodium, potassium, creatinine, fasting glucose, and total
and high density lipoprotein cholesterol levels). These tests are done to determine the
level of sodium and fat in the body.
5. Renin level. Renin level should be assessed to determine how RAAS is coping.
6. Urinalysis: May show blood, protein, or white blood cells; or glucose suggests renal
dysfunction and/or presence of diabetes.
7. Renin: Elevated in renovascular and malignant hypertension, salt-wasting disorders.
8. Urine steroids: Elevation may indicate hyperadrenalism, pheochromocytoma, pituitary
dysfunction, Cushing’s syndrome.
9. Intravenous pyelogram (IVP): May identify cause of secondary hypertension, e.g., renal
parenchymal disease, renal/ureteral -calculi.
10. Kidney and renography nuclear scan: Evaluates renal status (TOD).
11. Excretory urography: May reveal renal atrophy, indicating chronic renal disease.
Management
Medical Management
1. The medications used for treating hypertension decrease peripheral resistance, blood
volume, or the strength and rate of myocardial contraction.
2. For uncomplicated hypertension, the initial medications recommended are diuretics and
beta blockers.
3. Only low doses are given, but if blood pressure still exceeds 140/90 mmHg, the dose is
increased gradually.
4. Thiazide diuretics decrease blood volume, renal blood flow, and cardiac output.
5. ARBs are competitive inhibitors of aldosterone binding.
6. Beta blockers block the sympathetic nervous system to produce a slower heart rate and
a lower blood pressure.
7. ACE inhibitors inhibit the conversion of angiotensin I to angiotensin II and lowers
peripheral resistance.

Drug therapy
1. ACE Inhibitors (Captopril, Enalapril, Perindopril, Quinapril). an ACE inhibitor is particularly.
2. Useful if heart failure and diabetes present.
3. Beta-blockers (Acebutolol, Atenolol, Bisoprolol, Propranolol, Timolol). Slowing the heart
rate and reducing the force of the heart.
4. Calcium channel blockers (Amlodipine, DIltiazem, Felodipine, Nifedipine, Verapamil).
Relaxing blood vessels and control blood pressure.
5. Diuretics (Bendroflumethiazide, Chlortalidone, Cyclopenthiazide and Indapamide).
a. Stage 1 Hypertension: Thiazide diuretic is recommended for most and angiotensin-converting
enzyme-1, aldosterone receptor blocker, beta blocker, or calcium channel blocker is considered.
b. Stage 2 Hypertension: Two-drug combination is followed, usually including thiazide diuretic
and angiotensin-converting enzyme-1, or beta-blocker, or calcium channel blocker.

Lifestyle modification
Lifestyle modifications are indicated for all patients with prehypertension and hypertension and
include the following:
1. Weight reduction: A weight loss of 10 kg (22 lb) may decrease SBP by approximately 5 to
20 mm Hg.
2. Dietary Approaches to Stop Hypertension (DASH) eating plan. Involves eating several
servings of fish each week, eating plenty of fruits and vegetables, increasing fiber intake,
and drinking a lot of water. The DASH diet significantly lowers BP.
3. Restriction of dietary sodium to less than 6 g of salt (NaCl) or less than 2.4 g of sodium per
day.
4. This involves avoiding foods known to be high in sodium (e.g., canned soups) and not
adding salt in the preparation of foods or at meals.
5. Restriction of alcohol

6. Regular aerobic physical activity (e.g., brisk walking) at least 30 minutes a day most days
of the week. Moderately intense activity such as brisk walking, jogging, and swimming can
lower BP, promote relaxation, and decrease or control body weight.
7. It is strongly recommended that tobacco use be avoided.
8. Stress can raise BP on a short-term basis and has been implicated in the development of
hypertension. Relaxation therapy, guided imagery, and biofeedback may be useful in
helping patients manage stress, thus decreasing BP.
Nursing management
1. Assessment of the patient
a. Carrying out history of the presenting signs and symptoms e.g. fever, headaches
among others.
b. Taking vital observation e.g. TPR/BP and general examination to exclude other
diseases
c. Alerting the doctor who will order for investigations and admission, there the
nurse will assist the patient throughout the process
2. To prevent the heart failure as a result of BP > 140 systolic
a. Monitor bp. Measure in both arms/thighs three times, 3–5 min apart while patient
is at rest, then sitting, then standing for initial evaluation. Use correct cuff size and
accurate technique.
b. Monitor and measure blood pressure in both hands, using a cuff and proper
techniques four hourly and compare with normal range and previous parameter
of the patient.
c. Note presence, quality of central and peripheral pulses because pulses in the
legs/feet may be diminished, reflecting effects of vasoconstriction increased
systemic vascular resistance and venous congestion.
d. Auscultate heart tones and breath sounds to detect pulmonary congestion
secondary to developing or chronic heart failure.
e. Observe skin color, moisture, temperature, and capillary refill time to detect or
exclude peripheral vasoconstriction.
f. Note dependent/general edema because there presence may indicate heart
failure, renal or vascular impairment.
g. Provide calm, restful surroundings, minimize environmental activity/noise. Limit
the number of visitors and length of stay to promote relaxation.
h. Maintain activity restrictions, e.g., bed rest/chair rest; schedule periods of
uninterrupted rest; assist patient with self-care activities as needed to reduce
physical stress and tension that affect blood pressure and the course of
hypertension.
i. Provide comfort measures, e.g., back and neck massage, elevation of head.

j. Instruct in relaxation techniques, guided imagery, distractions to reduce stressful

stimuli, produce calming effect, thereby reducing bp.
k. Monitor response to medications to control blood pressure.
l. Administer medications as indicated: Thiazide diuretics, e.g., chlorothiazide
(diuril); hydrochlorothiazide (esidrix/hydrodiuril); bendroflumethiazide
(naturetin); indapamide (lozol); metolazone (diulo); quinethazone (hydromox);
3. To relieve pain (head ache among others)
a. Determine specifics of pain, e.g., location, characteristics, intensity (0–10 scale),
onset/duration and note nonverbal cues to identify the pain
b. Encourage/maintain bed rest during acute phase to minimizes stimulation/promotes
relaxation.
c. Provide/recommend non-pharmacological measures for relief of headache, e.g., cool
cloth to forehead; back and neck rubs; quiet, dimly lit room; relaxation techniques
(guided imagery, distraction); and diversional activities to reduce cerebral vascular
pressure.
d. Eliminate/minimize vaso-constricting activities that may aggravate headache, e.g.,
straining at stool, prolonged coughing, bending over.
e. Assist patient with ambulation as needed.
f. Provide liquids, soft foods, frequent mouth care if nosebleeds occur or nasal packing
has been done to stop bleeding.
g. Administer medications as indicated: Analgesics; Antianxiety agents, e.g., lorazepam
(ativan), alprazolam (xanax), diazepam (valium).
4. Diet
a. Establish a realistic weight reduction plan with the patient, e.g., 1 lb weight
loss/wk.
b. Provide low calorie, salt-restricted, and potassium, calcium, magnesium-rich diet,
and explain the need for such type of diet.
c. Instruct and assist in appropriate food selections, such as a (DASH diet) diet rich
in fruits, vegetables, and low-fat dairy foods referred to as the dash dietary
approaches to stop hypertension) diet and avoiding foods high in saturated fat
(butter, cheese, eggs, ice cream, meat) and cholesterol (fatty meat, egg yolks,
whole dairy products, shrimp, organ meats).
d. Encourage patient to maintain a diary of food intake, including when and where
eating takes place and the circumstances and feelings around which the food was
eaten.
e. Encourage patient to avoid constipation and ensure intake of fiber diet.
f. Maintain fluid intake output carefully using a fluid balance chart
g. Encourage and discuss the importance of controlling weight.

h. Encourage the patient to establish an individual exercise program incorporating

aerobic exercise.
i. Encourage the patient to quit alcohol and illicit drug use.
5. To promote patient’s knowledge:
a. Instruct patient and family about the cause of pneumonia, management of
symptoms, signs, and symptoms, and the need for follow-up.
b. Instruct patient about the factors that may have contributed to the development
of the disease.
6. Discharge and Home Care Guidelines
a. The nurse can help the patient achieve blood pressure control through education
about managing blood pressure.
b. Assist the patient in setting goal blood pressures.
c. Provide assistance with social support.
d. Encourage the involvement of family members in the education program to
support the patient’s efforts to control hypertension.
e. Provide written information about expected effects and side effects.
f. Encourage and teach patients to measure their blood pressures at home.
g. Emphasize strict compliance of follow-up checkup.
Prevention
1. Weight reduction: Maintenance of normal body weight can help prevent hypertension.
2. Adopt DASH: DASH or the Dietary Approaches to Stop Hypertension includes
consummation of a diet rich in fruits, vegetable, and low-fat dairy.
3. Dietary sodium retention: Sodium contributes to an elevated blood pressure, so reducing
the dietary intake to no more than 2.4 g sodium per day can be really helpful.
4. Physical activity: Engage in regular aerobic physical activity for 30 minutes thrice every
week.
5. Moderation of alcohol consumption. Limit alcohol consumption to no more than 2 drinks
per day in men and one drink for women and people who are lighter in weight.
6. Control of normal body weight (e.g. body mass index 20 - 25 kg/m2.
7. Reduce intake of dietary sodium.
8. Quit alcoholism and drug abuse.
9. Avoid stress and anxiety.
Complications
1. Heart attack or stroke,
2. Aneurysm,
3. Weakened and narrowed blood vessels of the kidney,

4. Heart failure,
5. Thickened narrowed or torn blood vessels of eyes ( Blindness),
6. Metabolic syndrome.
HYPERTENSIVE CRISIS
Introduction
Hypertensive crisis is an emergent situation in which a marked elevation in diastolic blood
pressure can cause end-organ damage.
Severe hypertension, usually a diastolic reading >120 mm Hg can cause irreversible injury to the
brain, heart, and kidneys that can rapidly lead to death.
Hypertensive crisis can occur in patients with either essential hypertension (unknown) or
secondary hypertension which can be a result of renal or endocrine disease.
Types of hypertensive crisis
1. Hypertensive emergency: It is an acute, marked elevation in blood pressure of 180/110
mm that is associated with signs of target-organ damage. These can include pulmonary
edema, cardiac ischemia, neurologic deficits, acute renal failure, aortic dissection, and
eclampsia.
2. Hypertensive urgency: It is an acute, marked elevation in blood pressure of 180/110 mm
that is not associated with signs of target-organ damage.
Causes of hypertensive crisis
Hypertensive urgency
1. Noncompliance with anti-hypertensive therapy
2. Use of sympathomimetics
3. Thyroid dysfunction
4. Anxiety
5. Pain
6. Falsely elevated blood pressure due to poor equipment or technique is another potential
etiology of elevated blood pressure readings that should be evaluated and remedied.
7. Pseudo-hypertension, a falsely elevated blood pressure reading due to sclerotic or
calcified arteries that do not collapse during inflation of a blood pressure cuff, is another
possible cause of elevated blood pressure readings. Pseudo-hypertension should be
considered in patients presenting without symptoms suggestive of end-organ dysfunction
but with markedly elevated blood pressure despite seemingly aggressive management
Hypertensive emergency
1. Non-compliance with antihypertensive medications
2. use of sympathomimetics
3. Anxiety
4. Pain
5. Hypertensive urgency: It is a marked elevation in blood pressure greater than systolic
180mg/hg and greater than diastolic 110mg/hg without evidence of target organ damage,
such as pulmonary edema, cardiac ischemia, neurologic deficits, or acute renal failure.
Signs and symptoms of hypertensive crisis
1. Headache
2. Dizziness
4. Chest pain
5. Vomiting
6. Changes in vision.
1. Headache
2. Dizziness
3. Altered mental status
5. Chest pain
6. Decreased urine output
7. Vomiting
8. Changes in vision
9. Jugular venous distention
10. Peripheral edema may be noted, and
11. Extra heart sounds
12. Altered mental status
13. Blurry vision
14. Ataxia or other cerebellar dysfunction, aphasia, or unilateral numbness or weakness. The
eyes may present with papilledema as well as exudates and flame-shaped hemorrhages.
15. Acute renal failure may also result in signs of pulmonary edema or peripheral edema.
Management of a hypertensive crisis
1. Admit
2. Treat with combination of oral antihypertensive therapy (ace inhibitor + calcium channel
blocker ± diuretics)
3. Aim at lowering blood pressure over the next 48- 72 hours
1. Admit and give prescribed parenteral medicines. Aim at lowering the blood pressure over
24 hours (not too rapidly except if absolutely necessary)

2. Continuous assessment of the vital observations TPR/BP

3. Monitor of cyanosis and measure the pulsoximetry
4. Treatment depends also on the presenting complications
5. In acute ischaemic stroke, do not lower below 220/120 mmHg
6. In acute aortic dissection, lower BP rapidly
7. In pulmonary oedema, AMI: treat the complication
8. Administer prescribed IV furosemide 40-80 mg, If aggressive BP lowering is needed, use
IV Hydralazine 5-10 mg slowly over 20 minutes.
9. Encourage verbalization of patients pain
10. Check blood pressure regularly, repeat dose after 20-30 minutes if necessary.
11. Reassure the patient to allay anxiety
12. Provide oxygen at 2 to 4 liters/min to maintain or improve oxygenation.
13. Minimize oxygen demand by maintaining the patient at bed rest.
14. Help the patient decrease anxiety, and keep the patient NPO or provide a liquid diet in
the acute phase.
15. Monitor arterial BP continuously and note sudden increases or decrease in readings. A
precipitous drop in BP can cause reflex ischemia to the heart, brain, kidneys, and/or GI
tract. Note trends in mean arterial pressure and the patient’s response to therapy.
16. Monitor hourly urine output using a fluid balance chart and note any presence of blood
in the urine.
17. Prepare the patient and family for surgical intervention to correct the underlying cause,
if this is indicated.
HEMATOLOGIC DISORDERS
These are diseases that affect the blood and its compositions.
1. Anemia
2. Coagulation disorders
3. Leukemia
ANEMIA
Introduction
Definition: Anemia is a condition in which the hemoglobin concentration is lower than normal.
OR: Anemia is described as a reduction in the proportion of the red blood cells.
Anemia is not a diagnosis, but a presentation of an underlying condition. Whether or not a patient
becomes symptomatic depends on the etiology of anemia, the acuity of onset, and the presence
of other comorbidities, especially the presence of cardiovascular disease.

Most patients experience some symptoms related to anemia when the hemoglobin drops below
7.0 g/dL.
Normal Hemoglobin (Hgb)

Normal Hemoglobin (Hgb)-specific laboratory cut-offs will differ slightly, but in general, the
normal ranges are as follows:
1. to 18.0 g/dL in men
2. to 15.0 g/dL in women
3. to 16.0 g/dL in children
Varied in pregnancy depending on the trimester, but generally greater than 10.0 g/dL
Types of Anemia
Anemia can be classified according to size of the red blood cell
1. Microcytic anemia: It is a type of anemia are characterized by the production of RBCs that
are smaller than normal (mean corpuscular volume of less than 80 fl)due to decreased
production of hemoglobin as a result of reduced iron availability, disorders of heme
synthesis, or reduced globin production.
2. Normocytic anemia: It can characterised by normal red blood cells (80 – 100fL) occurring
classified as resulting from hemolysis, blood loss, or decreased bone marrow red cell
production.
3. Macrocytic anemia: Is defined as the insufficient concentration of hemoglobin in which
the red blood cells (RBCs) (erythrocytes) are larger than their normal volume (mean
corpuscular volume (MCV) greater than 100 fL). It is divided into two forms, megaloblastic
(hyper segmented neutrophils) and non-megaloblastic. The megaloblastic form is due to
impaired DNA synthesis from folate and/or vitamin B12 deficiencies, while the non-
megaloblastic moiety occurs from multiple mechanisms e.g. liver disease and kidney
failure
Anemia can be classified according to hemoglobin concertation
Grading of Anemia, according to the National Cancer Institute, is as follows:
1. Mild anemia: Hemoglobin 10.0 g/dL to lower limit of normal
2. Moderate anemia: Hemoglobin 8.0 to 10.0 g/dL
3. Severe anemia: Hemoglobin 6.5 to 7.9 g/dL[1]
4. Life-threatening anemia: Hemoglobin less than 6.5 g/dL
Anemia classified according to duration.
1. Acute anemia is predominantly due to acute blood loss or acute hemolysis.
2. Chronic anemia is more common and is secondary to multiple causes.
Anemia can be classified according to the cause.
1. Hemolytic anemia: Hemolysis is the premature destruction of erythrocytes. A hemolytic
anemia will develop if bone marrow activity cannot compensate for the erythrocyte loss.

The severity of the anemia depends on whether the onset of hemolysis is gradual or
abrupt and on the extent of erythrocyte destruction e.g. Sickle cell anemia and
thalassemia.
2. Aplastic anemia: Aplastic anemia is a class of anemia characterised by bone marrow
failure to manufacture red blood cells (erythrocytes) with or without failure in the
manufacture of white blood cells and platelets. The term aplastic anemia is used to refer
to anemia that occurs when production of all types of blood cells is suppressed. If
production of only red blood cells is suppressed, the disorder is called pure red blood cell
aplasia. This type of anemia presents with anemia, low white blood cell count
(leukopenia), and low platelet count (thrombocytopenia).
3. Nutritional deficiency anemia: It is the type of anemia caused by a lack of iron, protein,
vitamin B12, and other vitamins and minerals that needed for the formation of
hemoglobin in the body e.g. Iron deficiency anemia commonest, vitamin B12 deficiency
anemia and folic acid deficiency anemia
4. Blood loss anemia: resulting from serious loss of red blood cells through excessive
bleeding.
Pathophysiology
Hemolytic anemia
Hemolysis is the premature destruction of erythrocytes. A hemolytic anemia will develop if bone
marrow activity cannot compensate for the erythrocyte loss. The severity of the anemia depends
on whether the onset of hemolysis is gradual or abrupt and on the extent of erythrocyte
destruction. Mild hemolysis can be asymptomatic while the anemia in severe hemolysis can be
life threatening and cause angina and cardiopulmonary decompensation.
Aplastic anemia
During aplastic anemia the cells in the bone marrow responsible for blood cell production fail or
do not manufacture enough blood cells i.e. leucocytes, platelets and erythrocytes leading to low
total blood cell count a condition called pancytopenia.
Nutritional anemia
When there is lack of inadequate nutrients such as iron, folic acid and cobalamin low red blood
cells are manufactured leading to a low erythrocyte count.
Causes of Anemia
Hemolytic anemia
Hereditary disorders include the following:
1. Glucose-6-phosphate dehydrogenase (G6PD) deficiency
2. Hereditary spherocytosis
3. Sickle cell anemia
Acquired causes of hemolysis include the following:

1. Autoimmune disorders, such as lupus, rheumatoid arthritis, or ulcerative colitis

2. Toxic chemicals and drugs e.g. lead poisoning
3. Drugs e.g. anti-viral i.e. ribavirin, antibiotics e.g. penicillin, antimalarial medicines, sulfa
medicines, or acetaminophen
4. Physical damage
5. Infections e.g. malaria
6. Genetic disorders e.g. thalassemia, Sickle cell disease etc.
7. Hypersplenism
8. Mechanical heart valves that may damage red blood cells as they leave the heart
9. A severe reaction to a blood transfusion
10. Blood cancers e.g. leukemia
Aplastic anemia
When the cause of aplastic anemia cannot be diagnosed (called idiopathic aplastic anemia), the
cause is likely an autoimmune disorder e.g., in which the immune system suppresses bone
marrow stem cells.
Other causes include
1. Infection with viruses such as parvovirus, Epstein Barr virus, and cytomegalovirus
2. Radiation exposure
3. Toxins (such as benzene)
4. Chemotherapy drugs and other drugs (such as chloramphenicol)
5. Pregnancy
6. Hepatitis
7. Exposure to ionizing radiation
8. Exposure to toxic chemicals, such as benzene or pesticides [39]
9. Transfusional graft versus host disease (GVHD)
10. Orthotopic liver transplantation for fulminant hepatitis
11. Pregnancy
12. Eosinophilic fasciitis
13. Anorexia
14. Severe nutritional deficiencies (vitamin B12, folate)
15. Paroxysmal nocturnal hemoglobinuria (PNH)
16. Acute lymphoblastic leukemia (ALL)(rarely)
Nutritional deficiency anemia
1. Digestive Disorders that interfere with the absorption of iron, Vitamin B12 and folic acid
e.g. malabsorption syndrome e.t.c
2. Pregnancy commonly causing folic acid deficiency and iron deficiency anemia
3. Low consumption of foods containing iron, vitamin B12 and folic acid
4. Intestinal worms e.g. hook worms commonly causing iron deficiency anemia

5. Malnutrition
Blood loss anemia
Excessive bleeding i.e. externally or internally
General
A patient with anemia may present with
2. Weakness
3. Fatigue
4. Arrhythmias such as tachycardia
5. Progressive weakness
6. Pallor
Aplastic anemia
1. Neutropenia
2. Frequent and persistent minor infections, or sudden onset febrile illness;
3. Thrombocytopenia
4. Ecchymoses
5. Mucosal bleeding
6. Petechiae
7. Lab demonstrate macrocytic normochromic anemia with reticulopodia, neutropenia, and
thrombocytopenia.
Hemolytic anemia
1. Jaundice
2. Hematuria
3. If symptoms have been going on for longer periods, lymphadenopathy, hepato-
splenomegaly, cholestasis may even be seen.
Nutritional anemia
1. Parathesia
2. Glossitis
3. Mouth ulcers
4. Visual disturbances
5. Depression
6. Confusion and other problems with concentration, thinking, and memory
Test and Diagnosis
2. Complete blood count (CBC): Includes hemoglobin, hematocrit, mean corpuscular volume
(MCV), mean corpuscular hemoglobin (MCH) and mean corpuscular hemoglobin
concentration (MCHC).

3. Reticulocyte count: Serves as an estimate of bone marrow red blood cell output.
4. Iron profile: Includes serum iron, ferritin and total iron-binding content (TIBC).
5. Peripheral blood smear: Microscopic evaluation of red blood cell morphology.
6. Serum creatinine: Serves to assist in the evaluation of renal function.
7. Thyroid function tests: Includes thyroxine (T4) and thyroid-stimulating hormone level
(TSH).
8. Coagulation screen: Includes activated partial thromboplastin time (APTT), prothrombin
time/international normalized ratio (PT/INR), and thrombin time (TT).
9. Liver function tests (LFT): LFT panels may vary but should include calcium, transaminases,
total protein, bilirubin, albumin, and alkaline phosphatase.
10. Additional tests that may provide information about the liver function include lactate
dehydrogenase (LDH), gamma-glutamyl transferase (GGT), 5'- nucleotidase.
11. Hemolysis profile: The profile contains haptoglobin, lactate dehydrogenase (LDH), and
indirect bilirubin.
12. Macrocytosis profile: The profile contains vitamin B-12, folate, methylmalonic acid, and
homocysteine.
13. Hemoglobin electrophoresis: Evaluates the hemoglobin amino acid chains.
14. Abdominal sonogram: Evaluates the size of the spleen size
15. Bone marrow analysis: Hematology consult is required to obtain this.
Management
Medical Management
Management depends primarily on treating the underlying cause of anemia.
1. Anemia due to acute blood loss- Treat with IV fluids, cross-matched packed red blood
cells, oxygen. Always remember to obtain at least two large-bore IV lines for the
administration of fluid and blood products. Maintain hemoglobin of > 7 g/dL in a majority
of patients. Those with cardiovascular disease require a higher hemoglobin goal of > 8
g/dL.
2. Anemia due to nutritional deficiencies: Oral/IV iron, vitamin B12, and folate.
a. Oral supplementation of iron is by far the most common method of iron repletion.
The dose of iron administered depends on the patient's age, calculated iron
deficit, the rate of correction required, and the ability to tolerate side effects. The
most common side effects include metallic taste and gastrointestinal side effects
such as constipation and black tarry stools. For such individuals, they are advised
to take oral iron every other day, in order to aid in improved GI absorption. The
hemoglobin will usually normalize in 6-8 weeks, with an increase in reticulocyte
count in just 7-10 days.

b. IV iron may be beneficial in patients requiring a rapid increase in levels. Patients

with acute and ongoing blood loss or patients with intolerable side effects are
candidates for IV iron.
3. Anemia due to defects in the bone marrow and stem cells: Conditions such as aplastic
anemia require bone marrow transplantation.
4. Anemia due to chronic disease: Anemia in the setting of renal failure, responds to
erythropoietin. Autoimmune and rheumatological conditions causing anemia require
treatment of the underlying disease.
5. Anemia due to increased red blood cell destruction:
a. Hemolytic anemia caused by faulty mechanical valves will need replacement.
b. Hemolytic anemia due to medications requires the removal of the offending drug.
c. Persistent hemolytic anemia requires splenectomy.
d. Hemoglobinopathies such as sickle anemia require blood transfusions, exchange
transfusions, and even hydroxyurea to decrease the incidence of sickling.
e. DIC, which is characterized by uncontrolled coagulation and thrombosis, requires
the removal of the offending stimulus. Patients with life-threatening bleeding
require the use of anti-fibrinolytic agents.
Nursing interventions/managment
a. Carrying out history of the presenting signs and symptoms e.g. fever, chronic
fatigue, bleeding disorders among others.
diseases
nurse will assist the patient throughout the process.
2. To manage patient’s fatigue
a. Assess the specific cause of fatigue.
b. Assess the client’s ability to perform activities of daily living (ADLs) and the
demands of daily living because fatigue can limit the client’s ability to participate
in self-care.
c. Prioritize activities: Assist the patient in prioritizing activities and establishing
balance between activity and rest that would be acceptable to the patient.
d. Educate energy-conservation techniques i.e. Clients and caregivers may need to
learn skills for delegating tasks to others, setting priorities to complete desired
activities.
e. Administer prescribed drugs that stimulate erythrocyte production

f. Provide prescribed supplemental oxygen therapy as needed i.e. Oxygen saturation

should be kept at 90% or greater.
g. Allow time for the patient to have undisturbed rest.
h. Administer prescribe blood transfusion
i. Blood transfusion monitoring: The nurse should monitor the patient’s vital signs
and pulse oximeter readings closely.
j. Encourage deep breathing techniques because these methods boost oxygen
delivery to the tissues.
3. To a manage and prevent bleeding
a. Assess for any frank bleeding from the nose, gums, vagina, or urinary or
gastrointestinal tract.
b. Monitor stool (guaiac) and urine (Hemastix) for occult blood.
c. Instruct the client in dietary modifications to reduce constipation because eating
a diet high in fiber and drinking a lot of fluids to avoid constipation
d. Instruct the client about bleeding precautions: Instruct the client to use an electric
shaver, not a razor, Use a soft toothbrush when brushing the teeth.
4. To maintain adequate nutrition:
a. Diet: The nurse should encourage a healthy diet that is packed with essential
nutrients containing cobalamin, folic acid and iron.
b. Alcohol intake: The nurse should inform the patient that alcohol interferes with
the utilization of essential nutrients and should advise the patient to avoid or limit
his or her intake of alcoholic beverages.
c. Dietary teaching Sessions should be individualized and involve the family
members and include cultural aspects related to food preference and preparation.
5. To prevent infection
a. Assess for local or systemic signs of infection, such as fever, chills, swelling, pain,
and body malaise because opportunistic infections can easily develop, especially
in immunocompromised clients.
b. Instruct the client to avoid contact with people with existing infections.
c. If the client is hospitalized, provide a private room for protective isolation.
d. Instruct the client to avoid eating raw fruits and vegetables and uncooked meat
because these food items can harbor bacteria. A low-bacterial diet protects the
client from exposure to pathogens.
e. Stress the importance of daily hygiene, mouth care, and perineal care.
f. Teach the client and visitors proper hand washing.
6. To educate the patient
a. About the disease itself
b. About investigations

c. About complications
7. Discharge Planning
a. Encouraging patients to eat a healthy and balanced diet is important to prevent
anemia from nutritional deficiencies.
b. Follow up with a clinician
COAGULATION DISORDERS
Introduction
A coagulation disorder is a medical condition characterised by excessive bleeding occurring as a
result of deficiency of any of the essential clotting factors.
Coagulations disorders are conditions that affect the blood’s clotting activities. Hemophilia, Von
Willebrand disease, clotting factor deficiencies, hypercoagulable states and deep venous
thrombosis are all coagulations disorders. Hemophilia and Von Willebrand disease are among the
best known.
Normal mechanism of blood clotting
1. Damage or injury to the endothelium will initiate a cascade of events in an attempt to
control bleeding.
2. Disruption of the endothelium will first cause local vasoconstriction to occur, limiting
blood flow to the area.
3. Primary hemostasis initiates by platelets with the release of von Willebrand factor (vWF),
a large plasma glycoprotein made and stored in endothelial cells and megakaryocytes.
4. Platelets and vWF will combine to form a plug at the site of injury. Circulating vWF
continues to bind with collagen and Factor VIII as well as other endothelial substances,
allowing the platelet plug to adhere to the area of injury.
5. Through activation of the clotting cascade (see image) and secondary hemostasis, this
initial platelet plug will get reinforced to a sturdy fibrin clot.
6. The clotting cascade operates through a dual process system in which the various clotting
factors become activated with the result being the formation of a fibrin strand or clot at
the site of tissue injury.
NB: A deficiency of any of the essential clotting factors will result in difficulty forming a fibrin clot,
and excessive bleeding can occur.
Types of coagulation disorders
Bleeding disorders fall into two main categories:
1. Inherited coagulation disorders: Hereditary bleeding disorders are due to the absence or
deficiency of specific clotting proteins which act as pro-coagulants through precise
interactions in the clotting cascade. The three most common are:

a. Hemophilia A (Factor VIII deficiency) : Hemophilia A is an X-linked recessive

genetic disorder affecting 1 in 5000 males making it the most common congenital
coagulopathy.
b. Hemophilia B (Factor IX deficiency): Hemophilia B is an X-linked genetic
coagulopathy affecting 1 in 30000 male births.
c. Von Willebrand disease: It is characterised by excessive bleeding as a result of
deficiency of von-Willebrand factor hence causing failure of platelet plug
formation.
2. Acquired coagulation disorders: Acquired bleeding disorders can be caused by conditions
that an individual may develop at any point during their lifetime. These can be broader
in range and dependent on comorbid conditions.
a. Liver disease
b. Vitamin k deficiency
c. Disseminated intravascular coagulation
Causes of Coagulation disorders
The major causes of acquired coagulation disorders are
1. Vitamin K deficiency
2. Liver disease
3. Disseminated intravascular coagulation (DIC)
4. Development of circulating anticoagulants
5. Severe liver disease (e.g. cirrhosis, fulminant hepatitis, acute fatty liver of pregnancy) may
disturb hemostasis by impairing clotting factor synthesis. Because all coagulation factors
are made in the liver (by hepatocytes and endothelial cells), both the prothrombin time
(PT) and partial thromboplastin time (PTT) are prolonged in severe liver disorders. (PT
results are typically reported as INR [international normalized ratio].)
6. The most common hereditary disorder of hemostasis is
a. Von Willebrand disease (VWD)
b. The hemophilias
Hemophilia:
1. While mild hemophilia may only present after a traumatic injury or surgery.
2. Those with a moderate to severe form of the disease may exhibit hallmark characteristics such
as
a) Mucosal or gingival bleeding
b) Easy bruising
c) Hematoma formation
d) Hemarthrosis: is bleeding into joints, particularly in the ankles.
e) Bleeding into muscle tissue from minor traumas can result in anemia and

f) Compression of vital structures and nerves leading to compartment syndrome.

g) Intracranial bleeds
3. Hemophilia can present in infancy with cephalohematoma formation after vaginal birth and
with significant bleeding after circumcisions.
Von Willebrand Disease
1. Von Willebrand disease can exhibit clinical signs and symptoms starting in childhood with a
history of easy bruising and bleeding.
2. While patients with a very mild version of the disease may not have clinical symptoms at all,
patients with vWF that is qualitative or quantitatively low may present with a predisposition to
mucosal bleeding and episodic epistaxis.
3. Women with von Willebrand disease may have significant menorrhagia which is often a
presenting sign of the illness, precipitating a workup and eventual diagnosis.
4. These patients can also go unrecognized until undergoing major surgery or experiencing a
traumatic injury.
Test and Diagnosis for coagulation disorders
Hemophilia
1. Chromogenic assay: This assay is considered by some to be more accurate, as it measures
the level of plasma factor VIII activity but it is less widely available in clinical laboratories
in the United States.
2. Laboratory studies: Laboratory studies for suspected hemophilia include a complete
blood cell count, coagulation studies, and a factor VIII (FVIII) assay.
3. CT scans: Head CT scans without contrast are used to assess for spontaneous or traumatic
intracranial hemorrhage.
4. MRI: Perform magnetic resonance imaging (MRI) on the head and spinal column for
further assessment of spontaneous or traumatic hemorrhage; MRI is also useful in the
evaluation of the cartilage, synovium, and joint space.
5. Ultrasonography: Ultrasonography is useful in the evaluation of joints affected by acute
or chronic effusions.
6. Testing for inhibitors: Laboratory confirmation of a FVIII inhibitor is clinically important
when a bleeding episode is not controlled despite infusion of adequate amounts of factor
concentrate.
7. Carrier testing: Screening for carrier status can be performed by measuring the ratio of
FVIII coagulant activity to the concentration of von Willebrand factor (vWF) antigen; a
ratio that is less than 0.7 suggests carrier status.
8. Radiography: Radiography for joint assessment is of limited value in acute hemarthrosis;
evidence of chronic degenerative joint disease may be visible on radiographs in patients
who have been untreated or inadequately treated or in those with recurrent joint
hemorrhages.

Management
Medical Management
Hemophilia
The treatment of hemophilia may involve prophylaxis, management of bleeding episodes,
treatment of factor VIII (FVIII) inhibitors, and treatment and rehabilitation of hemophilia
synovitis.
Pre-hospital care
1. Rapid transport to definitive care is the mainstay of prehospital care; prehospital care
providers should apply aggressive hemostatic techniques, assist patients capable of self-
administered factor therapy, and gather focused historical data if the patient is unable to
communicate.
2. Emergency department care. Use aggressive hemostatic techniques; correct
coagulopathy immediately; include a diagnostic workup for hemorrhage, but never delay
indicated coagulation correction pending diagnostic testing; acute joint bleeding and
expanding, large hematomas require adequate factor replacement for a prolonged period
until the bleed begins to resolve, as evidenced by clinical and/or objective methods; life-
threatening bleeding episodes are generally initially treated with FVIII levels of
approximately 100%, until the clinical situation warrants a gradual reduction in dosage.
3. Factor VIII and FIX concentrates. Various FVIII and FIX concentrates are available to treat
hemophilia A and B; besides improved hemostasis, continuous infusion decreases the
amount of factor used, which can result in significant savings; obtain factor level assays
daily before each infusion to establish a stable pattern of replacement regarding the dose
and frequency of administration.
4. Desmopressin. Desmopressin vasopressin analog, or 1-deamino-8-D-arginine vasopressin
(DDAVP), is considered the treatment of choice for mild and moderate hemophilia A;
DDAVP stimulates a transient increase in plasma FVIII levels; DDAVP may result in
sufficient hemostasis to stop a bleeding episode or to prepare patients for dental and
minor surgical procedures.
5. Management of bleeding. Immobilization of the affected limb and the application of ice
packs are helpful in diminishing swelling and pain; early infusion upon the recognition of
initial symptoms of a joint bleed may often eliminate the need for a second infusion by
preventing the inflammatory reaction in the joint; prompt and adequate replacement
therapy is the key to preventing long-term complications.
6. Treatment of patients with inhibitors. Inhibitors are antibodies that neutralize factor VIII
(FVIII) and can render replacement therapy ineffective; the treatment of patients with
inhibitors of FVIII is difficult; assuming no anamnestic response, low-titer inhibitors (ie,
concentrations below 5 Bethesda units [BU]) occasionally can be overcome with high

doses of factor VIII; there is no established treatment for bleeding episodes in patients
with high-titer inhibitors.
7. Prophylactic factor infusions. The main goal of prophylactic treatment is to prevent
bleeding symptoms and organ damage, in particular to joints; in December 2013, the US
Food and Drug Administration (FDA) expanded the indication for anti-inhibitor coagulant
complex (Feiba NF) to include routine prophylaxis in patients with hemophilia A or B who
have developed inhibitors; approval was based on data from a pivotal phase III study in
which a prophylactic regimen resulted in a 72% reduction in median annual bleed rate
compared with on-demand treatment.
8. Pain management. Hemophilic chronic arthropathy is associated with pain; narcotic
agents have been used, but frequent use of these drugs may result in addiction;
nonsteroidal anti-inflammatory drugs may be used instead because their effects on
platelet function are reversible and because these drugs can be effective in managing
acute and chronic arthritic pain; avoid aspirin because of its irreversible effect on platelet
function.
9. Activity. Generally, individuals with severe hemophilia should avoid high-impact contact
sports and other activities with a significant risk of trauma; however, mounting evidence
suggests that appropriate physical activity improves overall conditioning, reduces injury
rate and severity, and improves psychosocial functioning.
10. Gene therapy. With the cloning of FVIII and advances in molecular technologies, the
possibility of a cure for hemophilia with gene therapy was conceived; ex vivo gene
therapy, in which cells to be transplanted are genetically modified to secrete factor VIII
and then are reimplanted into the recipient; in vivo gene therapy, in which a vector
(typically a virus altered to include FVIII DNA) is directly injected into the patient; and
nonautologous gene therapy, in which cells modified to secrete FVIII are packaged in
immunoprotected devices and implanted into recipients.
11. Radio-synovectomy. In patients who develop synovitis from joint bleeds, intra-articular
injection of radioisotopes to ablate the synovium (radiosynovectomy) can be used to
decrease bleeding, slow progression of cartilage and bone damage, and prevent
arthropathy.
Pharmacologic Management
Medications of choice for patients with hemophilia are:
1. Factor VIII. Factor VIII (FVIII) is the treatment of choice for acute or potential hemorrhage
in hemophilia A; recombinant FVIII concentrate is generally the preferred source of factor
VIII; prophylactic administration of FVIII is often recommended for pediatric patients with
severe disease.
2. Anti-fibrinolytic agents. Antifibrinolytic agents, such as aminocaproic acid and tranexamic
acid, are especially useful for oral mucosal bleeds but are contraindicated as initial

therapies for hemophilia-related hematuria originating from the upper urinary tract
because they can cause obstructive uropathy or anuria.
3. Factor IX. Factor IX is the treatment of choice for acute hemorrhage or presumed acute
hemorrhage in hemophilia B. Recombinant factor IX is the preferred source for
replacement therapy.
4. Coagulation factor VIIa. These agents can activate coagulation factor X to factor Xa as well
as coagulation factor IX to IXa.
5. Coagulation factors. FVIII concentrates replace deficient FVIII in patients with hemophilia
A, with the goal of achieving a normal hematologic response to hemorrhage or preventing
hemorrhage; recombinant products should be used initially and subsequently in all newly
diagnosed cases of hemophilia that require factor replacement; agents that bypass FVIII
activity in the clotting cascade (eg, activated FVII) are used in patients with FVIII inhibitors.
6. Anti-hemophilic agents. These agents are used to control bleeding in hemophilia B or FIX
deficiency and to prevent and/or control bleeding in patients with hemophilia A and
inhibitors to FVIII.
7. Monoclonal antibodies. Monoclonal antibodies are used to bind to one specific substance
in the body (eg, molecules, antigens); this binding is very versatile and can mimic, block,
or cause changes to enact precise mechanisms (eg, bridging molecules, replacing or
activating enzymes or cofactors, immune system stimulation).
8. Vasopressin-related. Desmopressin transiently increases the FVIII plasma level in patients
with mild hemophilia A.
Von Willebrand disease
Treatment depends on the type of VWD and should be decided by a hematologist. Options
include the following:
1. Hormonal treatments such as oral contraceptives and some intrauterine devices are
highly effective in controlling menorrhagia. In fact, 88% of women with VWD report
improvement in bleeding symptoms when treated only with oral contraceptives.
2. Desmopressin (DDAVP) is effective in most patients with type 1 VWD and some patients
with type 2. Recovery testing must be done to determine its effectiveness. During a
recovery test, a blood sample is obtained before the medication is given and 30 to 60
minutes after administration. This test helps determine if the medication increases the
patient’s factor levels enough to prevent or stop bleeding.
3. Replacement factor made from plasma-derived concentrates can be used in any patient
with VWD, but must be used in all patients with type 3 and in some patients with type 2.
Replacement factor is also used when patients don’t respond to DDAVP.
4. Anti-fibrinolytics such as aminocaproic acid and tranexamic acid are used in conjunction
with factor or DDAVP to treat bleeding. Anti-fibrinolytics stabilize a clot by preventing it

from breaking down too early, which would cause bleeding. Without anti-fibrinolytics,
bleeding may occur several days or weeks after a procedure involving mucosal tissue.
Antifibrinolytics are effective in treating mucosal bleeding such as with dental surgery,
menstrual bleeding, nosebleeds, and gastrointestinal bleeding.
Nursing intervention/management
1. Relieve pain. Immobilize joints and apply elastic bandages to the affected joint if
indicated; elevate affected and apply a cold compress to active bleeding sites, but must
be used cautiously in young children to prevent skin breakdown.
2. Maintain optimal physical mobility. Provide gentle, passive ROM exercise when the child’s
condition is stable; educate on preventive measures, such as the application of protective
gear and the administration of factor products; and refer for physical therapy,
occupational therapy, and orthopedic consultations, as required.
3. Assist in the coping of the family. Encourage family members to verbalize problem areas
and develop solutions on their own; encourage family members to express feelings, such
as how they deal with the chronic needs of a family member and coping patterns that
help or hinder adjustment to the problems.
4. Prevent bleeding. Monitor hemoglobin and hematocrit levels; assess for inhibitor
antibody to factor VIII; anticipate or instruct in the need for prophylactic treatment before
high-risk situations, such as invasive diagnostic or surgical procedures, or dental work;
and provide replacement therapy of deficient clotting factors.
5. Prevent injury. Utilize appropriate toys (soft, not pointed or small sharp objects); for
infants, may need to use padded bed rail sides on crib; avoid rectal temperatures; provide
appropriate oral hygiene (use of a water irrigating device; use of a soft toothbrush or
softening the toothbrush with warm water before brushing; use of sponge-tipped
toothbrush); and avoid contact sports such as football, soccer, ice hockey, karate.
Complications
1. Anemia
2. Arthritis
LEUKEMIA
Introduction
Definition: Leukemias are a group of hematologic disorders characterized by the dysfunctional
proliferation and development of leukocytes.
Leukemias are cancers of white blood cells or of cells that develop into white blood cells.
White blood cells develop from stem cells in the bone marrow. Sometimes the development goes
awry, and pieces of chromosomes get rearranged. The resulting abnormal chromosomes

interfere with normal control of cell division, so that affected cells multiply uncontrollably or are
resistant to normal cell death, resulting in leukemia.
Types of Leukemia
As such, the four major subtypes of leukemia are:
1. Acute lymphoblastic leukemia (ALL): ALL occurs when primitive white blood cells of
lymphoid origin reproduce without developing into normal B and T cells. It is the most
common leukemia in pediatrics, accounting for up to 80% of cases in this group vs. 20%
of cases in adults.
2. Acute myelogenous leukemia (AML): AML is also characterized by the hyperplasia of
blasts, but in this case, of myeloid origin. It accounts for half of the leukemia cases
diagnosed in teenagers and people in their 20s. It is the most common acute leukemia in
adults.
3. Chronic lymphocytic leukemia (CLL): CLL occurs when mature but abnormal white blood
cells of lymphoid origin undergo hyperplasia, leading to a monoclonal population of
dysfunctional lymphocytes. Most cases occur in people between ages 60 and 70.
4. Chronic myelogenous leukemia (CML): A monoclonal population of self-renewing,
dysfunctional myeloid cells (e.g., neutrophils, basophils, eosinophils, macrophages)
characterizes CML. Most cases occur in people between ages 25 and 60.
Note
1. Acute vs. chronic: Acute leukemias are characterized by abnormal cells that are less
mature, develop quickly, and leave the bone marrow as dysfunctional cells called “blasts.”
These blasts crowd out healthy cells in the bone marrow, causing the rapid onset of
symptoms. Blasts normally make up 1% to 5% of marrow cells, and having more than 20%
blasts in the bone marrow is required for a diagnosis of acute leukemia. In contrast,
chronic leukemias develop slowly and may take years to develop symptoms. They are
composed primarily of more mature and functional cells, and there are generally not
elevated numbers of blasts.
2. Myeloid vs. lymphoid: Hematopoietic stem cells give rise to two types of blood cells:
myeloid and lymphoid. Myeloid cells include monocytes, macrophages, neutrophils,
basophils, eosinophils, erythrocytes, and megakaryocytes. Lymphoid cells include T cells,
B cells, and natural killer cells. So myeloid leukemia affects myeloid cells and lymphoid
leukemia affects lymphoid cells.
Causes of Leukemia
Several risk factors are associated with a higher risk of developing leukemia:
1. Exposure to ionizing radiation is associated with an increased risk of multiple subtypes of
leukemia.

2. Exposure to benzene is a risk factor for leukemia in adults, particularly AML.

3. Previous exposure to chemotherapy, especially alkylating agents and topoisomerase
inhibitors, increases the risk for acute leukemia later in life.
4. A history of any hematologic malignancy is a risk factor for subsequently developing
another subtype of leukemia.
5. Viral infections (e.g., human T-cell leukemia virus, Epstein Barr virus) are linked with
subtypes of ALL.
6. Several genetic syndromes (e.g., Down syndrome, Fanconi anemia, Bloom syndrome, Li-
Fraumeni syndrome) are associated with an increased risk of AML and ALL
1. Fever
2. Lethargy
3. Bone pain or tenderness
4. Myalgia
5. Malaise or generalised body weakness
6. Moderate to severe infections which may be recurrent
7. Unexplained or unintentional weight loss
8. Recurrent nosebleeds
9. Tendency to bleed or bruise easily
10. Petechiae – tiny red spots on the skin
11. Excessive sweating, especially at night (nocturnal hyperhidrosis)
12. Chronic Fatigue
13. On palpation, you may feel lymph node swelling and enlargement of the liver and spleen
i.e. Hepatosplenomegaly
14. When you auscultate the patient’s lungs, you may hear decreased breath sounds, shallow
and rapid respirations, a rapid heart rate, and a systolic ejection murmur.
15. Musculoskeletal symptoms (especially in the spine and long bones) can also be clues to
the diagnosis.
16. Shortness of breath,
17. Symptoms related to thrombocytopenia, such as excessive bruising or heavy menstrual
cycles.
NB: Chronic leukemia subtypes occur almost exclusively in adults. Many patients are
asymptomatic at the time of diagnosis, identified only incidentally after
a) Marked leukocytosis is discovered on a CBC performed for another reason.
b) Hepatosplenomegaly and lymphadenopathy can be appreciated in some cases while bleeding
and bruising are less common, presenting features relative to acute leukemia subtypes
Test and Diagnosis


2. CBC and blood smear – peripheral WBC count varies widely from 1,000 to 100,000/mm3
and may include significant numbers of abnormal immature (blast) cells, anemia may be
profound; platelet count may be abnormal and coagulopathies may exist.
3. Bone marrow aspiration and biopsy – cells also studied for chromosomal abnormalities
(cytogenetics) and immunologic markers to classify type of leukemia further.
4. Lymph node biopsy – to detect the spread.
5. Lumbar puncture and examination of cerebrospinal fluid for leukemic cells (especially
ALL).
Management
Medical Management
1. Chemotherapy – uses drugs to kill cancer cells. The most common chemotherapy
protocols for leukemia may include combinations of anti-tumor antibiotics, vinca
alkaloids, and other systemic anti-cancer therapy (SACT) medications.
2. Targeted Therapy – uses drugs that attack specific abnormalities in the cancer cell
3. Immunotherapy – utilizes the immune system to attack the leukemia cells; examples
include immune system modulators and checkpoint inhibitors
4. Radiotherapy. Radiotherapy uses radiation or high-powered energy beams such as
protons and X-rays to kill the cancer cells. This can last from 3 days to 6 weeks.
5. External beam radiation – aims the energy beams at the affected body area
6. Brachytherapy – places radioactive material inside the body in order to perform radiation
therapy
7. Chimeric antigen receptor (CAR)-T Cell Therapy. This is a specialized treatment which
involves the harvesting of the patient’s T-cells, engineering them to fight the leukemia
cells, and infusing them back to the patient’s body.
8. Bone Marrow Transplant. BMT is a procedure wherein the unhealthy bone marrow of the
leukemia patient is removed and replaced by healthy stem cells which will cause a
regeneration of healthy bone marrow to produce normal blood cells. It is also known as
stem cell transplant.
a. Carrying out history of the presenting signs and symptoms e.g. fever, chronic fatigue,
bleeding disorders among others.
diseases
c. Alerting the doctor who will order for investigations and admission, there the nurse
will assist the patient throughout the process.
2. Managing fever (patient has 37.6 and above temperature, chills)

a. Assess the patient’s vital signs at least every 4 hours.

b. Remove excessive clothing, blankets, and linens. Adjust the room temperature.
c. Administer and monitor the prescribed antibiotics and anti-pyretics.
d. Assess the mental status of the patient because elevated temperatures can alter
the function of the mind.
e. Offer a tepid sponge bath.
f. Elevate the head of the bed
3. To relieve acute pain
a. Assess pain.
b. Place patient at complete rest pain episode.
c. Instruct patient to notify nurse immediately when pain occurs.
d. Assess and document patient response to medication to provides information
about disease progression and also aids in evaluating effectiveness of
interventions, and may indicate need for change in therapeutic regimen.
e. Identify precipitating event, if any: frequency, duration, intensity, and location of
pain which will helps differentiate this chest pain, and aids in evaluating possible
progression to unstable angina.
f. Stay with patient who is experiencing pain or appears anxious to allay anxiety
g. Maintain quiet, comfortable environment and also restrict visitors as necessary to
prevent mental stress.
4. To manage fatigue
a. Ask the patient to rate fatigue level (mild, moderate, or severe fatigue) to assess
the patient’s activities of daily living, as well as actual and perceived limitations to
physical activity inorder to create a baseline of activity levels, degree of
fatigability, and mental status related to fatigue and activity intolerance.
b. For patients with grade 3 fatigue (severe fatigue), consider discussing having a
treatment break with the oncology team because anti-cancer therapies such as
chemotherapy treatments may increase the fatigue levels in a cancer patient,
disabling them to perform even the most basic daily activities such as eating and
bathing. Having a treatment break may be needed to allow the patient to
recuperate before receiving further doses.
c. Encourage progressive activity through self-care and exercise as tolerated. Explain
the need to reduce sedentary activities such as watching television and using
social media in long periods. Alternate periods of physical activity with rest and
sleep to gradually increase the patient’s tolerance to physical activity.
d. Teach deep breathing exercises and relaxation to allow the patient to relax while
at rest. To allow enough

5. To maintain healthy normal weight (patients complains of anorexia, unexplained weight

loss
a. Explore the patient’s daily nutritional intake and food habits (e.g., meal times,
duration of each meal session, snacking, etc.) inorder to create a baseline of the
patient’s nutritional status and preferences.
b. Create a daily weight chart and a food and fluid chart. Discuss with the patient the
short term and long-term nutrition and weight goals.
c. Help the patient to select appropriate dietary choices to increase dietary fiber,
caloric intake and alcohol and coffee intake inorder to promote nutrition and
healthy food habits, as well as to boost the energy levels of the patient. Dietary
fiber can help reduce stool transit time, thus promoting regular bowel movement.
d. Refer the patient to the hematology/oncology dietitian to provide a more
specialized care for the patient in terms of nutrition and diet in relation to newly
diagnosed leukemia.
e. Symptom control: Administer the prescribed medications for abdominal cramping
and pain, such as anti spasmodics. Promote bowel emptying using laxatives as
prescribed for constipation. On the other hand, provide advice on taking anti-
diarrheal medications for diarrhea.
6. Preventing and Managing bleeding:
a. Watch for signs of minor bleeding, such as petechiae, ecchymosis, conjunctival
hemorrhage, epistaxis, bleeding gums, bleeding at puncture sites, vaginal
spotting, and heavy menses.
b. Be alert for signs of serious bleeding, such as headache with change in
responsiveness, blurred vision, hemoptysis, hematemesis, melena, hypotension,
tachycardia, dizziness.
c. Test all urine, stool, emesis for gross and occult blood.
d. Monitor platelet counts daily.
e. Administer blood components as directed.
f. Keep patient on bed rest during bleeding episodes.
7. Patient Education and Health Maintenance:
a. Teach signs and symptoms of infection and advise whom to notify.
b. Encourage adequate nutrition to prevent emaciation from chemotherapy.
c. Teach avoidance of constipation with increased fluid and fiber, and good perineal
care.
d. Teach bleeding precautions.
e. Encourage regular dental visits to detect and treat dental infections and disease.
8. Preventing infection: (due to lowered immunity)

a. Frequently monitor the client for pneumonia, pharyngitis, esophagitis, perianal

cellulitis, urinary tract infection, and cellulitis, which are common in leukemia and
which carry significant morbidity and mortality.
b. Monitor for fever, flushed appearance, chills, tachycardia; appearance of white
patches in the mouth; redness, swelling, heat or pain in the eyes, ears, throat, skin,
joints, abdomen, rectal and perineal areas; cough, changes in sputum; skin rash.
c. Check results of granulocyte counts. Concentrations less than 500/mm3 put the
patient at serious risk for infection.
d. Avoid invasive procedures and trauma to skin or mucous membrane to prevent
entry of microorganisms.
e. Use the following rectal precautions to prevent infections: Avoid diarrhea and
constipation, which can irritate the rectal mucosa, avoid the use of rectal
thermometers, and keep perineal are clean.
f. Care for the patient in private room with strict hand washing practice.
g. Encourage and assist patient with personal hygiene, bathing, and oral care.
h. Obtain cultures and administer antimicrobials promptly as directed.
Complications
Leukemia may cause several complications, which may include:
1. Recurrent infections due to low levels of immunity
2. Unintentional weight loss
3. Anemia
4. Bleeding problems
5. Metabolic abnormalities – may lead to organ failure, particularly in the kidneys
6. Central nervous system impairment
7. Cataracts
8. Infertility
9. Increased risk of other types of cancer
10. Mental health problems
11. Poor quality of life
12. Renal dysfunction
13. Tumor lysis syndrome
14. Nutritional depletion
15. Mucositis
RESPIRATORY TRACT DISORDERS

These are diseases that affect the respiratory system.
They will be categorized into 2 parts

1. Upper respiratory tract disorders

2. Lower respiratory tract disorders
UPPER RESPIRATORY TRACT DISORDERS

These are diseases that affect the nose, pharynx, and larynx.
1. Common Cold
2. Tonsillitis
3. Sinusitis
4. Pharyngitis
5. Laryngitis
6. Influenza
COMMON COLD/CORYZA
Introduction
It is the acute inflammation of the upper respiratory tract; rhinitis (nasal mucosa) and
rhinopharyngitis (nasal and pharyngitis).
Causes of common cold
1. The most common virus is rhinovirus. Other viruses include the influenza virus,
adenovirus, enterovirus, and respiratory syncytial virus.
2. Bacteria may cause roughly 15% of sudden onset pharyngitis presentations. The most
common is S. pyogenes, a Group A streptococcus.
Manifestations of common cold infection typically appear after an incubation period of 12-72
hours and last 7-11 days, but may persist for longer.
Signs and symptoms include the following:
1. Nasal dryness or irritation - May be first symptom
2. Sore throat or throat irritation – Common and bothersome initial symptom
3. Nasal discharge, nasal congestion, and sneezing – Intensify over 2-3 days
4. Headache
5. Facial and ear pressure
6. Loss of sense of smell and taste
7. Cough (30% of infected individuals)
8. Hoarseness (20%)
9. Irritability or restlessness
10. Fever (unusual; when present, typically low grade)
Test and Diagnosis
History taking and physical examination – include the following:

1. Inspection of the nose and ears to check for any other possible sites of infection.
2. Inspection of the skin for any rash related to scarlet fever to rule out the condition
3. Palpation of the lymph nodes around the neck
4. Auscultation to listen to the patient’s breathing and heart sounds.
5. In some cases, mononucleosis may be ruled out as it can also cause inflammation of the
tonsils.
6. Other diagnostic tests may be performed as follow:
7. Throat swab – a sterile swab rubbed over the throat will be sent to the lab to check for
streptococcal bacteria and the need for antibiotics
8. Complete blood count – to show the presence of either a viral or bacterial infection
depending on what blood cell is elevated
9. Because of the prolonged time to obtain positive culture findings, rhinovirus culture has
rarely been found useful in clinical settings.
10. PCR testing of respiratory specimens may be useful in evaluating severely
immunocompromised patients.
Management
Medical Management
Drug therapy
1. NSAIDS
2. Antihistamines
3. Corticosteroids
4. Nasal decongestants
a. Carrying out history of the presenting signs and symptoms e.g. fever, flue among
others.
diseases
2. Managing fever
c. Administer the prescribed antibiotic and anti-pyretic.
d. Offer a tepid sponge bath.
e. Elevate the head of the bed.
3. To relieve headache, joint pains, flue and cough

a. Assess the patient’s vital signs and characteristics of pain at least 30 minutes after
b. Elevate the head of the bed and position the patient in semi Fowler’s.
c. Encouraging patient to sneeze into the elbow not in the hand
d. Must were a mask most time
e. Should be isolated until he improves
f. Encouraging patients to take soothing fluids like warm water and honey or lemon
g. Administer cough suppressants, antibiotics and analgesics as prescribed
h. Encourage patients to verbalise feeling of pain
i. Measure the pain compliants of patients using a pain scale
j. Encourage patients to take more fluids at least 3 liters
4. Prevention of complication
a. Assess the patient’s vital signs and characteristics of respirations at least every 4
hours. Assess for signs of hypoxia.
b. Place the patient on a side-lying or prone position.
c. Suction secretions.
d. Positioning the mattress at a 45° angle
e. Discontinuing smoking or using alcohol
f. Administer the prescribed medications (e.g. corticosteroids) and antibiotic
medications.
a. Teach the patient
i. Self isolation
ii. Wearing masks while in public
iii. Maintain social distance
b. Assess vital signs and observe for any signs of infection as well as for any signs of
respiratory distress.
c. Perform a focused assessment on the oropharyngeal region, particularly checking
for any collection of abscess.
d. Teach the patient how to perform proper hand hygiene.
e. Administer antibiotics as prescribed.
f. Disinfecting the environment using phenol-alcohol–based compounds
g. Washing hands
6. Health education of the patients
a. Educating the patient about wearing mask, maintaining hand hygiene
b. Educating the patients about the disease
7. Discharge advice
a. Encourage proper hand hygiene, wearing masks

b. Encourage proper adherence to drugs

c. Inform the patient about the follow up date and encourage the patient to attend
Complications
1. Otitis media
2. Sinusitis
3. Chronic bronchitis
4. Exacerbations of reactive airway disease (e.g. asthma)
TONSILITIS
Introduction
Tonsillitis refers to the inflammation of the palatine tonsils
The inflammation usually extends to the adenoid and the lingual tonsils.
Tonsillitis, or inflammation of the tonsils, is a common disease and makes up approximately 1.3%
of outpatient visits. It is predominantly the result of a viral or bacterial infection and, when
uncomplicated, presents as a sore throat.
Types of Tonsillitis
Tonsilitis can be classified according to the duration i.e. as acute or chronic.
1. Acute tonsilitis has a sudden onset, and it resolves within less than 3 months. It may settle
completely and recur in the future.
2. Chronic tonsilitis can last up to more than 3 months or having more than 5 episodes of
tonsillitis in a year. It is associated with a lot of complications e.g. rheumatic fever, Peri-
tonsillar abscess.
Classification of tonsilitis according to cause
1. Infectious tonsilitis: the cause is a pathogen e.g. commonly viruses, bacteria.
2. Non-infectious tonsilitis: Caused by non-pathogens e.g. GERD.
Pathophysiology
Tonsillitis develops when the pathogen, viral or bacterial, infects the tonsils and elicits an
inflammatory response. It develops when the viruses infiltrate the tonsils and cause an
inflammatory response of up-regulated cytokines. Bacterial tonsillitis considered acute is
primarily caused by group A β-hemolytic
streptococcus (GABHS) streptococcus pyogenes infection. s. pyogenes and taxonomically-similar
bacteria infiltrate the tonsillar epithelium, successfully penetrating the protective mucosal films
in the oral and nasal cavity. Recurrent bacterial tonsillitis is caused primarily by staphylococcus
aureus. Following invasion, S. aureus is internalized by non-phagocytic cells through fibronectin-
binding protein and beta-integrins. Invasion of non-eukaryotic cells results in the up-regulation
of cytokines, resulting in tonsillitis. Tonsillitis is associated with conditions and diseases
associated with its viral and bacterial pathogens.
Causes of tonsillitis
1. Viral: rhinovirus, respiratory syncytial virus, adenovirus, and coronavirus, Epstein-Barr

(causing mononucleosis), cytomegalovirus, hepatitis A, rubella, and HIV may also cause
tonsilitis.
2. Bacterial infections are typically due to group A beta-hemolytic Streptococcus (GABHS),
but Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenza have
also been cultured. Bacterial tonsillitis can result from both aerobic and anaerobic
pathogens. In unvaccinated patients, Corynebacterium diphtheriae causing diphtheria
should even merit consideration as an etiology. In sexually active patients, HIV, syphilis,
gonorrhea, and chlamydia are possible as additional causes. Tuberculosis has also been
implicated in recurrent tonsilitis, and clinicians should assess patients' risks.
1. Sore throat – commonly the first symptom noted in tonsillitis; the tonsils and the
surrounding organs swell causing pain and sore throat
2. Swelling of the tonsils – due to the inflammatory response from infection
3. Erythema – the tonsils turn red in colour with yellowish coating or patches
4. Dysphagia – difficulty swallowing occurs due to the swollen tonsils; food and drink are not
be able to pass through the throat easily
5. Swollen and painful lymph nodes in the neck- the lymph nodes, as part of the immune
system, react to the infection may feel tender upon palpation
6. Fever –occurs as the body’s response to the infection process
7. Headache
8. Loss of appetite – the general unwell feeling caused by tonsillitis together with dysphagia
can cause loss of appetite
9. Fatigue – the decline in oral fluid and food intake can reduce energy causing easy
fatiguability
10. Bad breath – caused by the presence of bacteria in the mouth
Test and Diagnosis

1. Inspection of the tonsils by shining a torch into the throat with the mouth wide open
tonsils.

Management
Medical Management
Treatment of acute tonsillitis is largely supportive and focuses on maintaining adequate
hydration and caloric intake and controlling pain and fever.
1. Hydration: Inability to maintain adequate oral caloric and fluid intake may require IV
hydration, antibiotics, and pain control; home intravenous therapy under the supervision
of qualified home health providers or the independent oral intake ability of patients
ensures hydration; intravenous corticosteroids may be administered to reduce
pharyngeal edema.
2. Management of airway obstruction: Airway obstruction may require management by
placing a nasal airway device, using intravenous corticosteroids, and administering
humidified oxygen; observe the patient in a monitored setting until the airway
obstruction is clearly resolving.
3. Tonsillectomy: Tonsillectomy is indicated for individuals who have experienced more than
six (6) episodes of streptococcal pharyngitis (confirmed by positive culture) in 1 year, 5
episodes in 2 consecutive years, or 3 or more infections of tonsils and/or adenoids per
year for 3 years in a row despite adequate medical therapy, or chronic or recurrent
tonsillitis associated with the streptococcal carrier state that has not responded to beta-
lactamase–resistant antibiotics.
4. Adenoidectomy: Because adenoid tissue has similar bacteriology to the pharyngeal tonsils
and because minimal additional morbidity occurs with adenoidectomy if tonsillectomy is
already being performed, most surgeons perform an adenoidectomy if adenoids are
present and inflamed at the time of tonsillectomy.
5. Diet: Hydration is important, and the oral route is usually adequate.
6. Activity: Adequate rest for children with tonsillitis accelerates recovery.
7. Pharmacologic Management: Medications that are used to manage tonsillitis include
antibiotics, anti-inflammatory agents (e.g., corticosteroids), antipyretics and analgesics
(e.g., acetaminophen, ibuprofen), and immunologic agents (e.g., gamma globulin).
Nursing management
a. Carrying out history of the presenting signs and symptoms e.g. fever, sore throat
among others.

diseases
c. Alerting the doctor who will order for investigations and admission, there the nurse
will assist the patient throughout the process.
2. Managing fever
3. To relieve patient’s pain (headaches, joint pains, dysphagia)
c. Adminstration of prescribed analgesics
d. Encourage patient to verbalise pain feelings
e. Encourage patients to consume warm water with honey to sooth the throat
f. Perform a focused assessment on the oropharyngeal region, particularly checking
g. Use of cold compresses on the fore head to relive headaches
h. Ensure adequate rest of the patient
i. Encourage the patient to avoid excessive talking to avoid strain on the throat.
4. Diet
a. Encourage patient to take more fluids at least 3 liters a day.
b. Provide the patient with appetizing foods to manage anorexia
5. To relieve the patient’s anxiety and Health educate the patient
a. Re-assure the patients
b. Assess patient’s fears and provide counselling
c. Health educate the patient about the disease
6. Advice on discharge
a. Encourage the patient to take a lot of warm fluids
b. Encourage the patient to adhere to prescribed drugs
c. To return for follow up.
Complications
Tonsillitis can be acute or chronic. When the infection is frequently recurring, the chance of
complications from developing is quite high.

1. Obstructive sleep apnea: Due to the position of the tonsils, their swollen state can block
the airway. This happens particularly when a person assumes prone position, such as
when sleeping.
2. Tonsillar cellulitis. Infection can spread to surrounding tissues causing tonsillar cellulitis.
3. Peri-tonsillar abscess. In some cases, infection can cause pus production which then
collects behind the tonsils.
4. Strep infection. In some cases of tonsillitis caused by bacterial infection, other strep
infection can occur, which can lead to:
5. Rheumatic fever. Rheumatic fever is a serious inflammatory condition caused by
inadequately treated tonsillitis or scarlet fever. It can affect the heart, joints, the nervous
system, and the skin.
6. Post-streptococcal glomerulonephritis. This is a rare condition involving the inflammation
of the kidneys due to a streptococcus infection. The best way to avoid this condition is to
treat any other streptococcus infection.
7. Post-streptococcal reactive arthritis. This is a condition involving arthritis of just one joint
associated with a recent streptococcus infection.
SINUSITIS/RHINOSINUSITIS
Introduction
Sinusitis is the inflammation and swelling of the lining of the sinuses. Which blocks the openings
into the nose, prevents normal drainage and creates a breeding ground for further infection.
Possible causes are a viral, bacterial or fungal infection, or an allergy.
Types of sinusitis
1. Acute sinusitis: is diagnosed when symptoms last up to four weeks (Brook et al, 2000).
2. Sub-acute (or relapsing) sinusitis: is diagnosed when symptoms persist or recur after four
weeks, but last for less than three months.
3. Chronic sinusitis: is diagnosed when symptoms persist for more than three months. It is
also diagnosed when people have more than three or four significant episodes annually,
or repeatedly fail to respond to medical treatment.
Pathophysiology
Most commonly a viral upper respiratory infection causes sinusitis secondary to edema and
inflammation of the nasal lining and production of thick mucus that obstructs the paranasal
sinuses and allows a secondary bacterial overgrowth. There are frontal, maxillary, sphenoid, and
ethmoid sinuses. Allergic rhinitis can lead to sinusitis also due to ostial obstruction. Ciliary
immobility can lead to increased mucus

viscosity, further blocking drainage. Bacteria are introduced into the sinuses by coughing and
nose blowing. Bacterial sinusitis usually occurs after a viral upper respiratory infection and
worsening symptoms after 5 days, or persistent symptoms after 10 days.
Causes of sinusitis
1. Viral: rhinovirus, respiratory syncytial virus, adenovirus, and coronavirus, Epstein-Barr
(causing mononucleosis), cytomegalovirus, hepatitis A, rubella, and HIV may also cause
tonsilitis.
2. Bacterial infections are typically due to group A beta-hemolytic Streptococcus (GABHS),
but Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenza have
also been cultured. Bacterial tonsillitis can result from both aerobic and anaerobic
pathogens. In unvaccinated patients, Corynebacterium diphtheriae causing diphtheria
should even merit consideration as an etiology. In sexually active patients, HIV, syphilis,
gonorrhea, and chlamydia are possible as additional causes. Tuberculosis has also been
implicated in recurrent tonsilitis, and clinicians should assess patients' risks.
1. Facial pain and tenderness.
2. Painful mastication.
3. Reduced sense of smell.
4. Headache that worsens when leaning forwards.
5. Pyrexia (greater than 38.5°C).
6. General malaise.
7. Yellow/green nasal discharge.
8. Swelling around the eyes.
9. Blocked nose.
10. Nausea.
Test and Diagnosis
tonsils.

Management
Medical Management
1. Antimicrobials are recommended for those with severe symptoms, or persistent
symptoms of at least seven days duration. Most people with acute sinusitis recover
spontaneously.
2. Antimicrobials: amoxicillin; erythromycin; oxytetracycline or doxycycline as first-line
treatments. Co-amoxiclav or ciprofloxacin where response to first-line treatments has
been poor.
3. Decongestants: despite a lack of placebo-controlled trials, decongestants are often used.
Use for more than seven days can result in rebound symptoms (rhinitis medicamentosa).
4. Intranasal corticosteroids: recent studies suggest there may be benefits for acute sinusitis
when these are added to antimicrobials (Dolor et al, 2001). However, the results are
inconclusive.
5. Steam inhalation: not recommended for routine use. Benefits are uncertain and there
may be a danger of scalding.
Nursing management
among others.
diseases
2. Managing fever
3. To relieve patient’s pain (headaches, joint pains, dysphagia)

e. Encourage patients to consume warm water with honey.

f. Use of cold compresses on the fore head to relive headaches
g. Ensure adequate rest of the patient
h. Encourage the patient to avoid excessive talking to avoid strain on the throat.
i. Minimize the noises to reduce the irritability of the patient
4. Diet
a. Encourage patient to take more fluids at least 3 liters a day.
b. Provide the patient with appetizing foods to manage anorexia
Complications
Tonsillitis can be acute or chronic. When the infection is frequently recurring, the chance of
complications from developing is quite high.
1. Obstructive sleep apnea: Due to the position of the tonsils, their swollen state can block
the airway. This happens particularly when a person assumes prone position, such as
when sleeping.
2. Tonsillar cellulitis. Infection can spread to surrounding tissues causing tonsillar cellulitis.
3. Peri-tonsillar abscess: In some cases, infection can cause pus production which then
collects behind the tonsils.
4. Strep infection. In some cases of tonsillitis caused by bacterial infection, other strep
infection can occur, which can lead to:
5. Rheumatic fever. Rheumatic fever is a serious inflammatory condition caused by
inadequately treated tonsillitis or scarlet fever. It can affect the heart, joints, the nervous
system, and the skin.
6. Post-streptococcal glomerulonephritis. This is a rare condition involving the inflammation
of the kidneys due to a streptococcus infection. The best way to avoid this condition is to
treat any other streptococcus infection.
7. Post-streptococcal reactive arthritis. This is a condition involving arthritis of just one joint
associated with a recent streptococcus infection.

PHARYNGITIS
Introduction
Pharyngitis is the inflammation of the mucous membranes of the pharynx.
In most cases, the cause is an infection, either bacterial or viral. Other less common causes of
pharyngitis include allergies, trauma, cancer, reflux, and certain toxins.
Types of Pharyngitis
Tonsilitis can be classified according to the duration i.e. as acute or chronic.
1. Acute pharyngitis has a sudden onset, and it resolves within less than 3 months. It may
settle completely and recur in the future.
2. Chronic pharyngitis can last up to more than 3 months or having more than 5 episodes of
tonsillitis in a year.
Classification of pharyngitis according to cause
1. Infectious Pharyngitis: the cause is a pathogen e.g. commonly viruses, bacteria.
2. Non-infectious pharyngitis: Caused by non-pathogens e.g. GERD.
Pathophysiology
Bacteria and viruses can cause direct invasion of the pharyngeal mucosa. Certain viruses like
rhinovirus can cause irritation secondary to nasal secretions. In almost all cases, there is a local
invasion of the pharyngeal mucosa which also results in excess secretion and edema.
Causes of pharyngitis
1. Viral causes: About 50% to 80% of pharyngitis, or sore throat, symptoms are viral in origin
and include a variety of viral pathogens. These pathogens are predominantly rhinovirus,
influenza, adenovirus, coronavirus, and parainfluenza. Less common viral pathogens
include herpes, Epstein-Barr virus, human immunodeficiency virus (HIV), and
coxsackievirus. More severe cases tend to be bacterial and may develop after an initial
viral infection.
2. Bacterial causes: The most common bacterial infection is Group A beta-hemolytic
streptococci, which causes 5% to 36% of cases of acute pharyngitis. Other bacterial
etiologies include Group B & C streptococci, Chlamydia pneumoniae, Mycoplasma
pneumoniae, Haemophilus influenzae, Candida, Neisseria meningitidis, Neisseria
gonorrhoeae, Arcanobacterium haemolyticum, Fusobacterium necrophorum, and
Corynebacterium diphtheriae. Environmental allergies and chemical exposures may also
cause acute pharyngitis.
3. Pharyngitis symptoms may also be part of the symptom complexes of other serious
illnesses, including peritonsillar abscess, retropharyngeal abscess, epiglottitis, and
Kawasaki disease.
1. Fever
2. Tonsillar exudates

3. Fatigue
4. Throat pain
5. Sore throat
6. Nasal congestion
7. Postnasal drip
8. Head ache
9. Painful cervical adenopathy
10. Pharyngeal erythema
11. Ear pain
NB: Uncomplicated infectious pharyngitis, both viral and bacterial, typically is self-limited to 5 to
7 days, is not progressive, is bilateral, does not have trismus, and does not have evidence of
airway obstruction (stridor).
Test and Diagnosis
tonsils.
Management
Medical Management
Treatment of pharyngitis is largely supportive and focuses on maintaining adequate hydration
and caloric intake and controlling pain and fever.
1. Hydration: Inability to maintain adequate oral caloric and fluid intake may require IV
hydration, antibiotics, and pain control; home intravenous therapy under the supervision
of qualified home health providers or the independent oral intake ability of patients
ensures hydration; intravenous corticosteroids may be administered to reduce
pharyngeal edema.
2. Diet: Hydration is important, and the oral route is usually adequate.
3. Activity: Adequate rest for children with pharyngitis accelerates recovery.

4. Pharmacologic Management: Medications that are used to manage pharyngitis include

antibiotics, anti-inflammatory agents (e.g., corticosteroids), antipyretics and analgesics
(e.g., acetaminophen, ibuprofen), and immunologic agents (e.g., gamma globulin).
1. Assessment of the patients
a. Carrying out history of the presenting signs and symptoms e.g. fever, ear pain,
sore throat among others.
diseases
2. Managing fever
e. Elevate the head of the bed
f. Offer a cold drink
3. To relive pain
c. Provide throat soothing drinks like warm water and honey
d. Encourage patient to minimize talking to reduce strain of the throat
e. Encourage patient to verbalize feelings of pain
f. Encourage the patient to avoid loud sound to reduce ear pain
4. Prevention of complication
d. Positioning the mattress at a 45° angle
e. Discontinuing smoking or using alcohol
f. Administer the prescribed medications (e.g. corticosteroids) and antibiotic
medications.
5. To prevent infection and to promote good nutrition
a. Assess vital signs and observe for any signs of infection as well as for any signs of

b. Perform a focused assessment on the oropharyngeal region, particularly checking

c. Teach the patient how to perform proper hand hygiene.
d. Encourage the patient to take a lot of warm fluids at least 3 liters a day.
e. Encourage the patient to consume more of vitamin rich foods and eating warms
foods all the time.
f. Administer antibiotics as prescribed.
Complications
1. Epiglottitis
2. Otitis media
3. Mastoiditis
4. Sinusitis
5. Acute rheumatic fever
6. Post-streptococcal glomerulonephritis
LARYNGITIS
Introduction
Laryngitis refers to inflammation of the larynx.
It can present in both acute and chronic forms..
Types of Laryngitis
Laryngitis can be classified according to the duration i.e. as acute or chronic.
1. Acute Laryngitis: It is often a mild and self-limiting condition that typically lasts for a
period of 3 to 7 days.
2. Chronic Laryngitis: If this laryngitis lasts for over 3 weeks, then it is termed as chronic
laryngitis.
Classification of Laryngitis according to cause
1. Infectious Laryngitis: the cause is a pathogen e.g. commonly viruses, bacteria.
2. Non-infectious Laryngitis: Caused by non-pathogens e.g. GERD.
Pathophysiology
1. Acute laryngitis is characterized by inflammation and congestion of the larynx in the early
stages. This can encompass the supra-glottic, glottic, or subglottic larynx (or any
combination thereof), depending on the inciting organism.
2. As the healing stage begins, white blood cells arrive at the site of infection to remove the
pathogens.
3. This process enhances vocal cord edema and affects vibration adversely, changing the
amplitude, magnitude, and frequency of the normal vocal fold dynamic.
4. As the edema progresses, the phonation threshold pressure can increase. The generation
of adequate phonation pressure becomes more difficult, and the patient develops
phonatory changes both as a result of the changing fluid-wave dynamics of the inflamed
and edematous tissue, but also as a result of both conscious and unconscious adaptation
to attempt to mitigate these altered tissue dynamics.
5. Sometimes edema is so marked that it becomes impossible to generate adequate
phonation pressure.
6. In such a situation, the patient may develop frank aphonia. Such maladaptations may
result in prolonged vocal symptoms after an episode of acute laryngitis that can persist
long after the inciting event has resolved.
7. Acute laryngitis resolves within 2 weeks, and is due to local inflammation of the vocal
folds and surrounding tissues in response to a trigger, whether that trigger is infectious
or non-infectious. If symptoms persist beyond this timeframe it is either due to super-
infection or due to a transition to chronic laryngitis.
Causes of Laryngitis
Acute Laryngitis
Infectious causes
1. Viral agents such as rhinovirus, parainfluenza virus, respiratory syncytial virus,
coronavirus, adenovirus, and influenza are all potential etiologic agents (listed in roughly
descending order of frequency). It is possible for bacterial super-infection to occur in the
setting of viral laryngitis, this classically occurs approximately seven days after symptoms
begin.
2. Bacterial organisms are Streptococcus pneumoniae, Haemophilus influenzae, and
Moraxella catarrhalis, in that order. Exanthematous febrile illnesses such as measles,
chickenpox, and whooping cough are also associated with acute laryngitis symptoms, so
it is prudent to obtain an accurate immunization history.
3. Laryngitis caused by fungal infection like candida albicans is very rare in
immunocompetent individuals, and more often presents as chronic laryngitis in the
immunocompromised or in patients using inhaled steroid medications.
Non-infectious causes

Acute non-infectious laryngitis can be due to vocal trauma/abuse/misuse, allergy, gastro-

esophageal reflux disease, asthma, environmental pollution, smoking, inhalational injuries, or
functional/conversion disorders.
Chronic Laryngitis
A variety of factors can cause chronic laryngitis.
1. Long-term cigarette smoking can irritate your vocal cords and cause your throat to swell.
2. Gastroesophageal reflux (GERD) causes the contents of the stomach to move up into your
esophagus. This can irritate the throat over time.
3. Excessive exposure to toxic chemicals can also lead to chronic laryngitis.
4. Bronchitis
5. Allergies
6. Vocal cord polyps or cysts
7. Pneumonia
Acute Laryngitis
In addition to symptoms of an upper respiratory tract infection (i.e. fever, cough, rhinitis), the
patient also experiences dysphonia or a hoarse voice. The individual may also experience the
following:
1. Weakened voice
2. Loss of voice
3. Hoarseness of the voice
4. Constant tickling or minor throat irritation
5. Dry cough
6. Odynophonia
7. Dysphagia
8. Odynophagia (painful swallowing)
9. Dyspnea
10. Rhinorrhea
11. Postnasal discharge
12. Sore throat
13. Congestion
14. Fatigue
15. Malaise
Chronic Laryngitis
1. Hoarseness
2. Loss of voice
3. A raw or irritated throat

4. A dry cough
5. Fever
6. Swelling of the lymph nodes in your neck
7. Difficulty swallowing
Test and Diagnosis
Acute Laryngitis
1. History of signs and symptoms of acute laryngitis for more than 3 weeks
2. Laryngoscopy
Chronic laryngitis
1. History of signs and symptoms of acute laryngitis for more than 3 weeks
2. Laryngoscopy
3. Full blood count
4. MRI and CT scan of the neck and throat
5. High throat swab for culture and sensitivity
Management
Medical Management
Treatment is often supportive in nature and depends on the severity of laryngitis.
1. Voice rest: This is the single most important factor. Use of voice during laryngitis results
in incomplete or delayed recovery. Complete voice rest is recommended although it is
almost impossible to achieve. If the patient needs to speak, the patient should be
instructed to use a "confidential voice;" that is, a normal phonatory voice at low volume
without whispering or projecting.
2. Steam Inhalation: Inhaling humidified air enhances moisture of the upper airway and
helps in the removal of secretions and exudates.
3. Avoidance of irritants: Smoking and alcohol should be avoided. Smoking delays prompt
resolution of the disease process.
4. Dietary modification: dietary restriction is recommended for patients with
gastroesophageal reflux disease. This includes avoiding caffeinated drinks, spicy food
items, fatty food, chocolate, peppermint. Another important lifestyle modification is the
avoidance of late meals. The patient should have meals at least 3 hours before sleeping.
The patient should drink plenty of water. These dietary measures have been shown to be
effective in classic GERD, though their efficacy in LPR is disputed, they are often still
employed.
5. Medications: Antibiotics prescription for an otherwise healthy patient with acute
laryngitis is currently unsupported; however for high-risk patients and patients with
severe symptoms antibiotics may be given. Some authors recommend narrow-spectrum
antibiotics only in the presence of identifiable gram stain and culture.
6. Fungal laryngitis can be treated with the use of oral antifungal agents such as fluconazole.
Treatment is usually required for three weeks period and may be repeated if needed. This
should be reserved for patients with confirmed fungal infection via laryngeal examination
and/or culture.
7. Mucolytics like guaifenesin may be used for clearing secretions.
8. In addition to lifestyle and dietary modifications, LPR-related laryngitis is treated with
anti-reflux medications. Medications that suppress acid production such as H2 receptor
and proton pump blocking agents are effective against gastroesophageal reflux, though
proton pump inhibitors are found to be most effective for LPR. These may require higher
doses or twice-daily dosing schedule to be effective in this setting.
Nursing management
a. Carrying out history of the presenting signs and symptoms e.g. fever, fatigue,
throat pain and hoarseness of the voice among others.
diseases
3. To alleviate pain
c. Administer prescribed analgesics
4. Ensuring clear airway
d. Administer the prescribed medications (e.g. corticosteroids) and antibiotic
medications.
a. Assess vital signs and observe for any signs of infection as well as for any signs of
b. Perform a focused assessment on the oropharyngeal region, particularly checking
c. Teach the patient how to perform proper hand hygiene.
d. Administer antibiotics as prescribed.
6. Educate the patient about self-management
a. Use a humidifier or inhale steam to alleviate dryness.
b. Get vocal therapy to analyze and correct the way you use your voice and any
abnormal speech patterns that place stress on your vocal cords and voice box.
c. Drink lots of fluids.
d. Gargle with 1/2 tsp. of salt and 1/2 tsp. of baking soda in 8 oz. of warm water.
e. Rest your voice.
f. Avoid screaming or talking loudly for long periods of time.
g. Avoid decongestants, which can dry your throat.
h. Suck on lozenges to keep your throat lubricated.
i. Refrain from whispering, which can strain the voice.
Complications
1. Epiglositis
2. Pneumonia
3. Chronic irritation of throat
4. Throat cancer
5. Chronic hoarseness of the voice
INFLUENZA
Introduction
Influenza (flu) is an acute, highly contagious viral respiratory infection that is caused by one of
three types of myxovirus influenzae.
Influenza occurs all over the world and is more common during winter months.
The incubation period is 24 to 48 hours.
Symptoms appear approximately 72 hours after contact with the virus, and the infected person
remains contagious for 3 days. Influenza is usually a self-limited disease that lasts from 2 to 7
days.
Pathophysiology
Influenza is an acute disease that targets the upper respiratory tract and causes inflammation of
the upper respiratory tree and trachea.
The acute symptoms persist for seven to ten days, and the disease is self-limited in most healthy
individuals. The immune reaction to the viral infection and the interferon response are
responsible for the viral syndrome that includes high fever, coryza, and body aches. High-risk
groups who have chronic lung diseases, cardiac disease, and pregnancy are more prone to severe
complications such as primary viral pneumonia, secondary bacterial pneumonia, hemorrhagic
bronchitis, and death. These severe complications can develop in as little as 48 hours from the
beginning of symptoms. The virus replicates in the upper and lower respiratory passages starting
from the time of inoculation and peaking after 48 hours, on average.
An important aspect of influenza A virus is that it is a genetically labile virus with a high rate of
mutations. This results in major changes in antigenic and functional proteins.
Causes of Influenza
It is caused by influenza virus.
There are four types of influenza viruses, A, B, C, and D.
Influenza types A and B cause human infection annually during the epidemic season.
Risk factors for influenza

The following risk factors can make an individual to experience a serious case of influenza:
1. Age – common on those children ages 6 months to 5 years old
2. Certain residential or work conditions – those who reside and have a job in hospitals or
care facilities, or those who live in military barracks
3. Weakened immune system such as people on treatments that block or weaken the
immune system, such as chemotherapy and steroids; people who that are
immunocompromised, such as HIV or AIDS
4. Chronic illnesses that need a regular follow up such as diabetes and other metabolic
disorders
5. Race/Ethnicity –Native Americans are at high risk for influenza. Influenza interventions
might be difficult to implement in those minority areas, because of some factors like
broad disparities in health and social status, as well las barriers in-culture, education and
language
6. Long-term aspirin therapy -e specially on children and adolescents
7. Pregnancy – particularly in the 2nd and 3rd trimesters
8. Obesity – having a body mass index (BMI) of above 40
People who have the flu often feel some or all of these signs and symptoms:
a. Fever or feeling feverish/chills
b. Cough
c. Sore throat
d. Runny or stuffy nose
e. Muscle or body aches
f. Headaches
g. Fatigue (very tired)

h. General malaise
i. Weakness
j. Sore throat
k. Runny nose
l. Anxiety
m. Depressed
n. No appetite
o. Inadequate fluid intake
p. Muscle and joint pain
q. Restless
r. Poor sleep
NB: Some people may have vomiting and diarrhea, though this is more common in children than
adults.
It’s important to note that not everyone with flu will have a fever.
Test and Diagnosis
5. Physical exam – people with flu usually manifest respiratory symptoms such as fever,
colds, sore throat, nasal congestion, headaches, myalgia or body aches, chills, and fatigue
6. Rapid Influenza Diagnostic Test (RIDTs) -one of the most common flu tests; detects the
antigen part of a virus by stimulating immune response
7. Chest X-ray – on severe cases
a. Throat swab – a sterile swab rubbed over the throat will be sent to the lab to check
for streptococcal bacteria and the need for antibiotics
b. Complete blood count – to show the presence of either a viral or bacterial infection
c. Because of the prolonged time to obtain positive culture findings, rhinovirus culture
has rarely been found useful in clinical settings.
d. PCR testing of respiratory specimens may be useful in evaluating severely
immunocompromised patients.
Management
Medical Management
1. People with the flu are advised to get plenty of rest, drink plenty of liquids, avoid using
alcohol and tobacco and, if necessary, take medications such as acetaminophen
(paracetamol) to relieve the fever and muscle aches associated with the flu.
2. Children and teenagers with flu symptoms (particularly fever) should avoid taking aspirin
during an influenza infection (especially influenza type B), because doing so can lead to
Reye’s syndrome, a rare but potentially fatal disease of the liver.
3. Since influenza is caused by a virus, antibiotics have no effect on the infection; unless
prescribed for secondary infections such as bacterial pneumonia.
4. Antiviral medication may be effective, but some strains of influenza can show resistance
to the standard antiviral drugs and there is concern about the quality of the research.
5. Phenylephrine and antitussive agents such as terpin hydrate with codeine are often
prescribed to relieve nasal congestion and coughing. In patients with influenza that is
complicated by pneumonia, antibiotics may be administered to treat a bacterial super-
infection.
Nursing interventions/ management
1. Emergency Interventions
a. Briefly taking history of the patient i.e. when the symptoms began and what
triggered them.
b. Temporally admit the patient in isolation in a sit up position and take vital
observation i.e. TPR/BP, pulsoximetry
c. Alert the physician immediately who will order for investigations.
d. Isolate the patients and perform barrier nursing
e. Administer anti-pyretics, corticosteroids, epinephrine, sympathomimetic aerosol
agents, and IV aminophylline as ordered.
f. Observe the patient closely for respiratory arrest. Monitor his respiratory rate
continuously and other vital signs every 5 minutes. Never leave the patient alone.
g. Make sure the patient receives prescribed oxygen and bronchodilator and
nebulizer therapies as ordered.
h. Monitor for labored respirations, cyanosis, and cold and clammy skin.
i. Monitor and record color, consistency, and amount of sputum.
j. Have emergency equipment brought to the bedside and prepare to assist with
intubation and mechanical ventilation if respiratory arrest occurs.
2. Managing fever
3. To ensure airway clearance:

a. Position head midline with flexion on appropriate for age/condition to gain or
maintain open airway
b. Elevate Head of the bed to decrease pressure on the diaphragm and enhancing
drainage
c. Maintain a patent airway, suctioning of secretions may be done as ordered to
remove secretions that obstructs the airway
d. Observe signs of infections to identify infectious process
e. Auscultate breath sounds & assess air movement to ascertain status & note
progress
f. Instruct the patient to increase fluid intake to help to liquefy secretions.
g. Demonstrate and encourage effective coughing and deep-breathing techniques to
maximize effort
h. Turn the patient q 2 hours to prevent possible aspirations
i. Demonstrate diaphragmatic and pursed-lip breathing to decrease air trapping and
for efficient breathing.
j. Administer bronchodilators if prescribed.
4. Exercise
a. Encourage deep breathing and coughing exercises to maximize effort for
expectoration.
b. Encourage ambulation: Helps mobilize secretions and reduces atelectasis.
c. Encourage opportunities for rest and limit physical activities to prevent situations
that will aggravate the condition
5. To promote rest and conserve energy:
a. Encourage avoidance of overexertion and possible exacerbation of symptoms.
b. Semi-Fowler’s position. The patient should assume a comfortable position to
promote rest and breathing and should change positions frequently to enhance
secretion clearance and pulmonary ventilation and perfusion.
6. Nutrition/Diet
a. Fluid intake. Increase in fluid intake to at least 3L per day to replace insensible
fluid losses unless contraindicated.
b. Provide a high-calorie, high protein diet with small frequent meals.
c. Fluids with electrolytes. This may help provide fluid, calories, and electrolytes.
d. Nutrition-enriched beverages. Nutritionally enhanced drinks and shakes can also
help restore proper nutrition.
a. Instruct patient and family about the cause of influenza, management of
of the disease.
a. Patient education is crucial regardless of the setting because self-care is essential
in achieving a patient’s well-being.
b. Oral antibiotics. Teach the patient about the proper administration, potential side
effects, and symptoms to report.
c. Breathing exercises. Teach the patient breathing exercises to promote secretion
clearance and volume expansion.
d. Follow-up checkup. Strict compliance to follow-up checkups is important to check
the latest
e. chest x-ray result or physical examination findings.
f. Smoking cessation. Smoking should be stopped because it inhibits
tracheobronchial ciliary action and irritates the mucous cells of the bronchi.
g. Encourage the patient to go for a flu vaccine.
h. Advise small, frequent meals to maintain adequate nutrition.
i. Fluid intake should be maintained at approximately 3000 mL/day so that the
secretions remain thin.
j. Teach the patient to maintain pulmonary hygiene measures of coughing, deep
breathing, and incentive spirometry at home.
Prevention of Influenza
Influenza can be prevented from spreading and infecting others by:
1. Proper hand washing
2. Cleaning of objects and surfaces
3. Covering the mouth when coughing
4. Avoiding crowded places
Complications
1. Dehydration
2. Pneumonia
3. Bronchitis
4. Sinus and ear infection
5. Myocarditis/ heart inflammation
6. Encephalitis
7. Myositis
LOWER RESPIRATORY TRACT DISORDERS

1. Pneumonia
2. Tuberculosis
3. Bronchitis
4. Asthma
5. Status asthmaticus
6. Emphysema
PNEUMONIA
Introduction
Pneumonia is an inflammation of the lung parenchyma caused by various microorganisms,
including bacteria, mycobacteria, fungi, and viruses.
Pneumonitis is a more general term that describes the inflammatory process in the lung tissue
that may predispose and place the patient at risk for microbial invasion.
Types of Pneumonia
Pneumonia can be classified according to the duration i.e. as acute and chronic.
1. 1 Acute Pneumonia has a sudden onset, and it resolves less than 3 weeks.
2. Chronic Pneumonia develops slowly and can last more than 3 weeks
Classification of pneumonia according to cause
1. Infectious/contagious Pneumonia: the cause is a pathogen e.g. commonly viruses,

bacteria and fungi in people with weak immunity hence the names bacterial pneumonia,
viral pneumonia, Fungal pneumonia
2. Non-infectious/non contagious Pneumonia: Caused by non-pathogens e.g. side effects of
certain drugs, inhalation of chemical irritants e.t.c
Classification of pneumonia according to the part affected in the lungs (histopathology)
1. Bronchopneumonia: Characterized by patchy foci of consolidation (pus in many alveoli
and adjacent air passages) scattered in one or more lobes of one or both lungs.
2. Lobar pneumonia: Characterized by an acute inflammation of the entire lobe or lung.
Histologically, tissue changes are classified into four stages: congestion, red hepatization,
gray hepatization and resolution.
Classification of pneumonia according to the source of infection
1. Community-Acquired Pneumonia (CAP): Any pneumonia acquired outside of a hospital in
a community setting.
2. Hospital-Acquired Pneumonia (HAP): Any pneumonia acquired 48 hours after being
admitted in an inpatient setting such as a hospital and not incubating at the time of
admission is considered as HAP. This classification helps clear the confusion surrounding
the terms healthcare-associated and hospital-acquired pneumonia. Now all pneumonia

acquired in the setting of assisted-living facilities, rehabilitation facilities, and other
healthcare facilities have been included under community-acquired pneumonia, and a
hospital setting is necessary for classifying pneumonia as HAP.
3. Ventilator Associated Pneumonia (VAP): Any pneumonia acquired 48 hours after
endotracheal intubation is considered as VAP.
Pathophysiology
Infectious pneumonia
Any infectious organisms that reach the alveoli are likely to be highly virulent, as they have
already evaded the host’s physical defense mechanisms. Consequently, they may overwhelm the
macrophages, resulting in production of a fibrin-rich exudate that fills the infected and
neighboring alveolar spaces, causing them to stick together, rendering them airless. The
inflammatory response also results in a proliferation of neutrophils. This can damage lung tissue,
leading to fibrosis and pulmonary oedema, which also impairs lung expansion.
The inflammatory response can also lead to the development of a pleural effusion which is
thought to complicate up to 40% of cases of pneumonia. These changes result in reduced gaseous
exchange. As a result, vital organs become oxygen deprived and the respiratory effort required
with each breath will be increased as a result of the disturbance in normal physiology. Respiratory
and heart rate will increase in response to falling oxygen and rising carbon dioxide levels.
Non-infectious Pneumonia
When a chemical irritant is aspirated it irritates the lung tissue resulting into damage which later
cause inflammation to take place in the lung tissues.
Causes of Pneumonia
Infectious causes
Community-Acquired Pneumonia
1. Bacterial causes: Common typical organisms include Pneumococcus, Haemophilus

influenzae, Moraxella catarrhalis, Group A Streptococcus, and other aerobic and
anaerobic gram-negative organisms. Atypical organisms commonly seen in clinical
practice include Legionella, Mycoplasma, Chlamydia, among others
2. Viral causes: It is often observed that viral species colonize nasopharynx of patients with
CAP. However, some of the most frequent viral agents implicated in CAP include influenza
virus followed by respiratory syncytial virus, parainfluenza virus, and adenoviruses.
3. Fungal causes: Fungal infections are usually implicated in patients with certain
predisposing immunocompromised states like HIV and organ transplant recipients,
among others The 3 commonest ones include Histoplasma, Blastomyces, and
Coccidioides.
Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia

1. Gram-negative bacilli like Escherichia coli, Pseudomonas Aerugenosa, Acinetobacter, and
Enterobacter among others
2. Gram-positive cocci like Staphylococcus aureus; both Methicillin-sensitive and resistant,
although the latter is more prevalent
3. Other viruses and fungi that are more prevalent in immunocompromised and severely ill
patients
Non-Infectious causes
1. Inhalation of chemicals
2. Uremia
3. Radiation-Induced
4. Smoking
5. Trauma to the Lung tissue
6. Rheumatic fever
7. Immunologic (Systemic lupus, Rheumatic fever),
8. Cancer (including leukemia).
9. Cigarette smoking
10. Recent viral respiratory infection (common cold, laryngitis, influenza)
11. Difficulty swallowing (due to stroke, dementia, Parkinson’s disease, or other neurological
conditions)
12. Chronic lung disease (COPD, bronchiectasis, cystic fibrosis)
13. Cerebral palsy
14. Other serious illnesses, such as heart disease, liver cirrhosis, or diabetes mellitus
15. Living in a nursing facility
16. Impaired consciousness (loss of brain function due to dementia, stroke, or other
neurologic conditions)
17. Recent surgery or trauma
18. Immune system problem
Clinical manifestations of pneumonia
1. Chills
2. Fevers
3. Rhonchi and wheezes
4. Use of accessory muscles for breathing
5. Cyanosis
6. Mental status changes
7. Sputum production
8. Pleuritic chest pain. Deep breathing and coughing aggravate the pain in the chest.
9. Rapid and bounding pulse. A rapid heartbeat occurs because the body compensates for
the low concentration of oxygen in the body.
10. Tachypnea: There is fast breathing because the body tries to compensate for the low
oxygen concentration in the body.
11. Purulent sputum: The sputum becomes purulent because of the infection in the lung
parenchyma which produced sputum-filled with pus.
Test and Diagnosis for Pneumonia

1. History taking: The diagnosis of pneumonia is made through history taking, particularly a
recent respiratory tract infection.
2. Physical examination: Mainly, the number of breaths per minute and breath sounds is
assessed during physical examination.
3. Chest x-ray: Identifies structural distribution (e.g., lobar, bronchial); may also reveal
multiple abscesses/infiltrates, empyema (staphylococcus); scattered or localized
infiltration (bacterial); or diffuse/extensive nodular infiltrates (more often viral). In
mycoplasmal pneumonia, chest x-ray may be clear.
4. Fiberoptic bronchoscopy: May be both diagnostic (qualitative cultures) and therapeutic
(re-expansion of lung segment).
5. ABGs/pulse oximetry: Abnormalities may be present, depending on extent of lung
involvement and underlying lung disease.
6. Gram stain/cultures: Sputum collection; needle aspiration of empyema, pleural, and
transtracheal or transthoracic fluids; lung biopsies and blood cultures may be done to
recover causative organism. More than one type of organism may be present; common
bacteria include Diplococcus pneumoniae, Staphylococcus aureus, a-hemolytic
streptococcus, Haemophilus influenzae; cytomegalovirus (CMV). Note: Sputum cultures
may not identify all offending organisms. Blood cultures may show transient bacteremia.
7. CBC: Leukocytosis usually present, although a low white blood cell (WBC) count may be
present in viral infection, immunosuppressed conditions such as AIDS, and overwhelming
bacterial pneumonia. Erythrocyte sedimentation rate (ESR) is elevated.
8. Serologic studies, e.g., viral or Legionella titers, cold agglutinins. Assist in differential
diagnosis of specific organism.
9. Pulmonary function studies. Volumes may be decreased (congestion and alveolar
collapse); airway pressure may be increased and compliance decreased. Shunting is
present (hypoxemia).
10. Electrolytes: Sodium and chloride levels may be low.
11. Bilirubin: May be increased.
12. Percutaneous aspiration/open biopsy of lung tissues. May reveal typical intranuclear and
cytoplasmic inclusions (CMV), characteristic giant cells (rubeola).
Question for research: Differences between Broncho-pneumonia and lobular pneumonia
Management
Medical Management
The management of pneumonia centers is a step-by-step process that zeroes on the treatment
of the infection through identification of the causative agent.
1. Medical therapy
a. Mucolytics increase or liquefy respiratory secretions.
b. Expectorants increase productive cough to clear the airways. They liquefy lower
respiratory tract secretions by reducing its viscosity.
c. Bronchodilators are medications used to facilitate respiration by dilating the airways.
d. Analgesics are given to improve cough effort by reducing discomfort, but should be
used cautiously because they can decrease cough effort and depress respirations.
2. Blood culture: Blood culture is performed for identification of the causal pathogen and
prompt administration of antibiotics in patients in whom CAP is strongly suspected.
3. Administration of macrolides: Macrolides are recommended for people with drug-
resistant S. pneumoniae.
4. Hydration is an important part of the regimen because fever and tachypnea may result in
insensible fluid losses.
5. Administration of antipyretics: Antipyretics are used to treat fever and headache.
6. Administration of antitussives: Antitussives are used for treatment of the associated
cough.
7. Bed rest: Complete rest is prescribed until signs of infection are diminished.
8. Oxygen administration: Oxygen can be given if hypoxemia develops.
9. Pulse oximetry: Pulse oximetry is used to determine the need for oxygen and to evaluate
the effectiveness of the therapy.
10. Aggressive respiratory measures: Other measures include administration of high
concentrations of oxygen, endotracheal intubation, and mechanical ventilation.
Nursing management
a. Carrying out history of the presenting signs and symptoms e.g. fever, ear pain,
sore throat among others.
diseases
3. To prevent airway obstruction by the mucus in the air ways: (patient presents with
excessive sputum, cyanosis, wheezing.
b. Place patient in semi-fowlers position to have a maximum lung expansion
c. Elevate Head of the Bed to decrease pressure on the diaphragm and enhancing
drainage
d. Auscultate breath sounds & assess air movement to ascertain status & note
progress
e. Instruct the patient to increase fluid intake to help to liquefy secretions.
f. Demonstrate and encourage effective coughing and deep-breathing techniques to
maximize effort
g. Turn the patient q 2 hours to prevent possible aspirations
h. Administer bronchodilators if prescribed.
4. To monitor gaseous excahnge
a. Administer prescribed cough suppressants and analgesics
b. Monitor for labored respirations, cyanosis, and cold and clammy skin.
c. Monitor pulse oximetry.
d. Monitor and record color, consistency, and amount of sputum.
e. Assist and monitor effects of nebulizer treatment and another respiratory
physiotherapy: incentive spirometer, IPPB, percussion, postural drainage. Perform
treatments between meals and limit fluids when appropriate.
f. Teach and assist the patient with proper deep-breathing exercises. Demonstrate
proper splinting of the chest and effective coughing while in an upright position.
Encourage patient to do so often.
g. Encourage ambulation: Helps mobilize secretions and reduces atelectasis.
h. Administer medications, as indicated:
5. To relieve pain (patient’s feeling of chest pain, headache, joint pains)
a. Monitor/document characteristics of pain, noting verbal reports, nonverbal cues

(e.g., moaning, crying, restlessness, diaphoresis, clutching chest, rapid breathing),
and hemodynamic response (BP/heart rate changes).
b. Obtain full description of pain from patient including location, intensity (0–10),
duration, characteristics (dull/crushing), and radiation. Assist patient to quantify
pain by comparing it to other experiences.
c. Provide quiet environment, calm activities, and comfort measures (e.g.,
dry/wrinkle-free linens, backrub). Approach patient calmly and confidently.
d. Assist/instruct in relaxation techniques, e.g., deep/slow breathing, distraction
behaviors, visualization, guided imagery.
e. Administer prescribed analgesic medications as indicated.
6. To promote rest and conserve energy: (patient complains of fatigue)
7. To promote fluid intake:
8. To maintain nutrition:
a. Fluids with electrolytes. This may help provide fluid, calories, and electrolytes.
b. Nutrition-enriched beverages. Nutritionally enhanced drinks and shakes can also
of the disease.
a. Oral antibiotics. Teach the patient about the proper administration, potential side
b. Breathing exercises. Teach the patient breathing exercises to promote secretion
c. Follow-up checkup. Strict compliance to follow-up checkups is important to check
the latest chest x-ray result or physical examination findings.
d. Smoking cessation. Smoking should be stopped because it inhibits
e. Be sure the patient understands all medications, including dosage, route, action,
and adverse effects.
f. The patient and family or significant other need to understand the importance of
avoiding fatigue by limiting activity and taking frequent rests.
g. Advise small, frequent meals to maintain adequate nutrition.
h. Fluid intake should be maintained at approximately 3000 mL/day so that the
i. Teach the patient to maintain pulmonary hygiene measures of coughing, deep
Complications
a. Liver abscess
b. Septic shock
c. Pleural effusion
d. COPD
e. Empyema
TUBERCULOSIS
Introduction
Tuberculosis (TB) is an ancient human disease caused by Mycobacterium tuberculosis which
mainly affects the lungs.
However, TB is a multi-systemic disease with a protean presentation. The organ system most
commonly affected include the respiratory system, the gastrointestinal (GI) system, the
lymphoreticular system, the skin, the central nervous system, the musculoskeletal system, the
reproductive system, and the liver.
Stages of progression of Tuberculosis
According to a study conducted by Knechel, the progression of tuberculosis has several stages.
1. Latent Tuberculosis – It is the stage of infection when the person who had been exposed
to the M. tuberculosis nuclei does not manifest signs and symptoms of the disease and
do not have the capacity to infect other people. The nuclei just persist in the system in its
necrotic form which could stay for a long time, not until that immunosuppression or a
certain factor triggers it to become its virulent form.
2. Primary Pulmonary Tuberculosis – Since the most immediate location of pathogenesis of
the organism is in the lungs, primary activation of disease in the pulmonary cavity is
considered. It is usually asymptomatic and only identified through significant diagnostic
examinations. Only the presence of lymphadenopathy is something that is indicative for
its infection.
3. Primary Progressive Tuberculosis – It is the stage of the disease process when it is already
considered as active. Clinical manifestations are evident and the client may reveal positive
in sputum examination for presence of the organism. Sometimes, he or she may manifest
cough with purulent sputum and some pleuritic chest pains because of inflammation in
the parenchymal walls.
4. Extra-pulmonary Tuberculosis – It is when tuberculosis extends its infection to other parts
of the aside from the pulmonary cavity. The most fatal location is the central nervous
system and its infection to the bloodstream. Other locations may include the lymphatic
system, the bones and joints and at times the genitourinary system.
Pathophysiology
Tuberculosis is a highly infectious, airborne disease.
1. Inhalation: Tuberculosis begins when a susceptible person inhales mycobacteria and
becomes infected.
2. Transmission: The bacteria are transmitted through the airways to the alveoli, and are
also transported via lymph system and bloodstream to other parts of the body.
3. Defense: The body’s immune system responds by initiating an inflammatory reaction and
phagocytes engulf many of the bacteria, and TB-specific lymphocytes lyse the bacilli and
normal tissue.
4. Protection: Granulomas new tissue masses of live and dead bacilli, ate surrounded by
macrophages, which form a protective wall.
5. Ghon’s tubercle: They are then transformed to a fibrous tissue mass, the central portion
of which is called a Ghon tubercle.
6. Scarring: The bacteria and macrophages turns into a cheesy mass that may become
calcified and form a collagenous scar.
7. Dormancy: At this point, the bacteria become dormant, and there is no further
progression of active disease.
8. Activation: After initial exposure and infection, active disease may develop because of a
compromised or inadequate immune system response.
Causes of Tuberculosis
M. tuberculosis causes tuberculosis.
M. tuberculosis is an alcohol and acid-fast bacillus. It is part of a group of organisms classified as
the M. tuberculosis complex. Other members of this group are Mycobacterium africanum,
Mycobacterium bovis, and Mycobacterium microti.
Risk factors for Tuberculosis
1. Socio-economic factors: Poverty, malnutrition, wars
2. Immunosuppression: HIV/AIDS, chronic immunosuppressive therapy (steroids,
monoclonal antibodies against tumor necrotic factor), a poorly developed immune
system (children, primary immunodeficiency disorders)
3. Occupational: Mining, construction workers, pneumoconiosis (silicosis)
4. Close contact. Having close contact with someone who has an active TB.
5. Substance abuse: People who are IV/injection drug users and alcoholics have a greater
chance of acquiring tuberculosis.
6. Inadequate health care: Any person without adequate health care like the homeless,
impoverished, and the minorities often develop active TB.
7. Immigration: Immigration from countries with a high prevalence of TB could affect the
patient.
8. Overcrowding: Living in an overcrowded, substandard housing increases the spreading of
the infection.
Clinical manifestations of Tuberculosis
1. Persistent, progressive cough which may be non-productive at first but may produce
purulent sputum in the long term (2 weeks or more)
2. Easy fatigability
3. Anorexia or loss of appetite
4. Weight loss and body wasting
5. Persistent, long term low- grade fever
6. Chills and night sweats
7. Non-resolving bronchopneumonia
8. Dull or pleuritic chest pains
9. Dyspnea
10. Hemoptysis
11. Anemia in some
Test and Diagnosis for Pneumonia

1. Sputum culture: Positive for Mycobacterium tuberculosis in the active stage of the
disease.
2. Gene-Xpert MTB/Rif: automated DNA test on body samples (sputum, lymphonodes
tissue, pleural fluid, CSF etc) which can diagnose pulmonary TB and determine
susceptibility to Rifampicin. It is superior to microscopy.
3. Ziehl-Neelsen (acid-fast stain applied to a smear of body fluid): Positive for acid-fast bacilli
(AFB).
4. Skin tests (purified protein derivative [PPD] or Old tuberculin [OT] administered by
intradermal injection [Mantoux]): A positive reaction (area of induration 10 mm or
greater, occurring 48–72 hr after interdermal injection of the antigen) indicates past
infection and the presence of antibodies but is not necessarily indicative of active disease.
Factors associated with a decreased response to tuberculin include underlying viral or
bacterial infection, malnutrition, lymphadenopathy, overwhelming TB infection,
insufficient antigen injection, and conscious or unconscious bias. A significant reaction in
a patient who is clinically ill means that active TB cannot be dismissed as a diagnostic
possibility. A significant reaction in healthy persons usually signifies dormant TB or an

infection caused by a different mycobacterium.
5. Enzyme-linked immunosorbent assay (ELISA)/Western blot: May reveal presence of HIV.
6. Chest x-ray: May show small, patchy infiltrations of early lesions in the upper-lung field,
calcium deposits of healed primary lesions, or fluid of an effusion. Changes indicating
more advanced TB may include cavitation, scar tissue/fibrotic areas.
7. CT or MRI scan: Determines degree of lung damage and may confirm a difficult diagnosis.
8. Bronchoscopy: Shows inflammation and altered lung tissue. May also be performed to
obtain sputum if patient is unable to produce an adequate specimen.
9. Histologic or tissue cultures (including gastric washings; urine and cerebrospinal fluid
[CSF]; skin biopsy): Positive for Myco-bacterium tuberculosis and may indicate extra-
pulmonary involvement.
10. Needle biopsy of lung tissue: Positive for granulomas of TB; presence of giant cells
indicating necrosis.
11. Electrolytes: May be abnormal depending on the location and severity of infection; e.g.,
hyponatremia caused by abnormal water retention may be found in extensive chronic
pulmonary TB.
12. ABGs: May be abnormal depending on location, severity, and residual damage to the
lungs.
13. Pulmonary function studies: Decreased vital capacity, increased dead space, increased
ratio of residual air to total lung capacity, and decreased oxygen saturation are secondary
to parenchymal infiltration/fibrosis, loss of lung tissue, and pleural disease (extensive
chronic pulmonary TB).
Management
Medical Management
1. Anti-TB drugs are given in fixed dose combination (FDC) regimens according to the
patient’s TB classification
2. Treatment is divided into 2 phases:
a. an initial (intensive) phase of 2 months
b. a continuation phase of 4 months (longer in MDR-TB and severe forms of TB
particularly TB meningitis and osteoarticular TB )
3. TB treatment regimens are expressed in a standard format, e.g. 2RHZE/4RH where:
i. Letters represent abbreviated drug names
ii. Numbers show the duration in months
iii. Shows the division between treatment phases
ST
1 LINE OF TREATMENT
1st line combination
2ND LINE OF TREATMENT

1. Second-Line Anti-tuberculosis Drugs, Group 2
a. Injectable aminoglycosides
i. Amikacin
ii. Kanamycin
iii. Streptomycin
b. Injectable polypeptides
i. Capreomycin
ii. Viomycin
2. Second-Line Anti-Tuberculosis Drugs, Group 3,
a. Oral and Injectable Fluoroquinolones
i. Levofloxacin
ii. Moxifloxacin
iii. Ofloxacin
iv. Gatifloxacin
3. Second-Line Anti-tuberculosis Drugs, Group 4
i. Para-aminosalicylic acid
ii. Cycloserine
iii. Terizidone
iv. Ethionamide
v. Prothionamide
vi. Thioacetazone Linezolid
3RD LINE OF TREATMENT

1. Third-Line Anti-Tuberculosis Drugs, Group 5: These are medications with variable but
unproven efficacy against TB. They are used for total drug-resistant TB as drugs of last
resort.
a. Clofazimine
b. Linezolid
c. Amoxicillin/clavulanic acid
d. Imipenem/Cilastatin
e. Clarithromycin
Side effects management during anti TB treatment
Drug resistance against Anti TB treatment
1. MDR-TB (multi drug resistance Tuberculosis): This refers to tuberculosis with strains of
Mycobacterium which have developed resistance to the classic anti-tuberculosis
medications.
a. Resistance to multiple anti-tuberculosis medications including at least the two

standard anti-tuberculous medications, Rifampicin or Isoniazid, is required to
make a diagnosis of MDR-TB.
b. Seventy-five percent of MDR-TB is considered primary MDR-TB, caused by
infection with MDR-TB pathogens.
c. The remaining 25% are acquired and occur when a patient develops resistance to
treatment for tuberculosis.
d. Inappropriate treatment for tuberculosis because of several factors such as
antibiotic abuse; inadequate dosage; incomplete treatment is the number one
cause of acquired MDR-TB.
2. XDR-T.B (Extremely Multi drug resistance Tuberculosis): This is a more severe type of
MDR-TB where diagnosis requires resistance to at least four anti-tuberculous medications
including resistance to Rifampicin, Isoniazid, and resistance to any two of the newer anti-
tuberculous medications.
a. The newer medications implicated in XDR-TB are the fluoroquinolones
(Levofloxacin and moxifloxacin) and the injectable second-line aminoglycosides,
Kanamycin, Capreomycin, and amikacin.
b. Mechanism of developing XDR-TB is similar to the mechanism for developing
MDR-TB.
c. XDR -TB is an uncommon occurrence.
Risk factors for drug-resistant TB are:

1. Chronic cases (still sputum smear-positive after completing a supervised retreatment
regimen)
2. Contact with known drug-resistant tuberculosis
3. Retreatments (relapses, treatment after failures, return after loss to follow-up)
4. History of frequent interruption of drug treatment
5. HIV-positive patient presumed to have TB
6. Patients who remain sputum smear-positive at month 2 or 3 of first-line anti-TB treatment
7. Health care workers
8. Patients from prisons or other congregate settings
Nursing management
among others.
diseases
d. The patients will be nursed in Isolation
2. Managing fever
3. To relieve patient’s pain (headaches, joint pains)
e. Encourage patients to consume warm water with honey.
f. Use of cold compresses on the fore head to relive headaches
g. Ensure adequate rest of the patient
h. Encourage the patient to avoid excessive talking to avoid strain on the throat.
i. Minimize the noises to reduce the irritability of the patient
4. To manage cough, hemoptysis, rhonchi, wheezing
a. Assess respiratory function noting breath sounds, rate, rhythm, and depth,
inability to clear airways that may lead to use of accessory muscles and increased
work of breathing
b. Note ability to expectorate mucus and cough effectively; document character,
amount of sputum, presence of hemoptysis because expectoration may be
difficult when secretions are very thick as a result of infection and/or inadequate
hydration. Blood-tinged or frankly bloody sputum results from tissue breakdown
(cavitation) in the lungs or from bronchial ulceration and may require further
evaluation or intervention.
c. Place patient in semi or high-Fowler’s position.
d. Assist patient with coughing and deep-breathing exercises because positioning
helps maximize lung expansion and decreases respiratory effort.
e. Clear secretions from mouth and trachea; suction as necessary to prevents

obstruction and aspiration.
f. Place a pillow when the client is sleeping to provide adequate lung expansion
while sleeping.
g. Maintain fluid intake of at least 2500 mL/day unless contraindicated because high
fluid intake helps thin secretions, making them easier to expectorate.
h. Humidify inspired air and oxygen to prevent drying of mucous membranes and
helps thin secretions.
i. Administer medications as indicated.
j. Be prepared for/assist with emergency intubation because intubation may be
necessary in rare cases of bronchogenic TB accompanied by laryngeal edema or
acute pulmonary bleeding.
k. Maintain a patent airway, suctioning of secretions may be done as ordered to
5. To manage dyspnea
a. Assess for dyspnea (using 0–10 scale), tachypnea, abnormal or diminished breath
sounds, increased respiratory effort, limited chest wall expansion, and fatigue.
b. Evaluate change in level of mentation.
c. Note cyanosis and/or change in skin color, including mucous membranes and nail
beds because accumulation of secretions and/or airway compromise can impair
oxygenation of vital organs and tissues.
d. Demonstrate and encourage pursed-lip breathing during exhalation to creates
resistance against outflowing air to prevent collapse or narrowing of the airways,
thereby helping distribute air throughout the lungs and relieve or reduce
shortness of breath.
e. Promote bed rest or limit activity and assist with self-care activities as necessary
thereby Reducing oxygen consumption and demand during periods of respiratory
compromise may reduce severity of symptoms.
f. Monitor serial ABGs and pulse oximetry because decreased oxygen content
(PaO2) and/or saturation or increased PaCO2 indicate need for intervention or
change in therapeutic regimen.
6. To manage anorexia, weight loss:
a. Ascertain patient’s usual dietary pattern. Include in selection of food which may
be helpful in identifying specific needs and strengths. Consideration of individual
preferences may improve dietary intake.
b. Monitor Input and Out of food and weight periodically may be useful in measuring
effectiveness of nutritional and fluid support.
c. Investigate anorexia and nausea and vomiting, and note possible correlation to
medications. Monitor frequency, volume, consistency of stools because it may
affect dietary choices and identify areas for problem solving to enhance intake and
utilization of nutrients.
d. Encourage and provide for frequent rest periods which helps to conserve energy,
especially when metabolic requirements are increased by fever.
e. Provide oral care before and after respiratory treatments which will reduces bad
taste left from sputum or medications used for respiratory treatments that can
stimulate the vomiting center.
f. Encourage small, frequent meals with foods high in protein and carbohydrates
which maximizes nutrient intake without undue fatigue/energy expenditure from
eating large meals, and reduces gastric irritation.
g. Encourage SO to bring foods from home and to share meals with patient unless
contraindicated which will creates a more normal social environment during
mealtime, and helps meet personal, cultural preferences.
h. Consult with respiratory therapy to schedule treatments 1–2 hr before or after
meals which may help reduce the incidence of nausea and vomiting associated
with medications or the effects of respiratory treatments on a full stomach.
i. Monitor laboratory studies: BUN, serum protein, and pre-albumin, albumin
because Low values reflect malnutrition and indicate need for intervention and
change in therapeutic regimen.
j. Administer antipyretics as appropriate because fever increases metabolic needs
and therefore calorie consumption.
of the disease.
b. Discharge advice
a. Disposal of secretions. Cough and sneeze into tissues and to dispose of all
secretions in a separate trash can.
b. Isolation. Wear a mask when going outside of the room.
c. Activity and nutrition. Remind the patient to take a lot of rest and to eat balanced
meals to aid recovery.
d. Adverse effects. Advise the patient to watch out for adverse effects of medications
and to report them to the physician immediately.
e. Oral antibiotics. Teach the patient about the proper administration, potential side
f. Breathing exercises. Teach the patient breathing exercises to promote secretion

g. Follow-up checkup. Strict compliance to follow-up checkups is important to check
h. Smoking cessation. Smoking should be stopped because it inhibits
i. Be sure the patient understands all medications, including dosage, route, action,
j. The patient and family or significant other need to understand the importance of
k. Advise small, frequent meals to maintain adequate nutrition.
l. Fluid intake should be maintained at approximately 3000 mL/day so that the
m. Teach the patient to maintain pulmonary hygiene measures of coughing, deep
Complications
1. Multi drug resistant TB
2. Spontaneous pneumothorax and pleural effusion
3. TB pericarditis, TB meningitis, TB peritonitis
4. Bone TB: can be TB spine with gibbus, TB joints with deformity)
5. Respiratory failure
BRONCHITIS
Introduction
Bronchitis is an inflammation of the mucous membranes of the bronchi (the larger and medium-
sized airways that carry airflow from the trachea into the more distal parts of the lung
parenchyma).
Types of Bronchitis
Bronchitis can be classified according to the duration i.e. as acute and chronic.
1. Acute Bronchitis: It is an inflammation of the large airways of the lung that has a sudden
onset, and it resolves within 10 days
2. Chronic Bronchitis: It is an inflammation of the large airways of the lung that can last for
several weeks and occurs gradually.
Classification of bronchitis according to cause
1. Infectious/contagious bronchitis: the cause is a pathogen e.g. commonly viruses,
bacteria and fungi in people with weak immunity hence the names bacterial bronchitis,
viral bronchitis, Fungal bronchitis
2. Non-infectious/non contagious bronchitis: Caused by non-pathogens e.g. side effects of

certain drugs, inhalation of chemical irritants e.t.c
Pathophysiology
Acute bronchitis
Acute bronchitis is the result of acute inflammation of the bronchi secondary to various triggers,
most commonly viral infection, allergens, pollutants, etc. Inflammation of the bronchial wall leads
to mucosal thickening, epithelial-cell desquamation, and denudation of the basement
membrane. At times, a viral upper respiratory infection can progress to infection of the lower
respiratory tract resulting in acute bronchitis.
Chronic Bronchitis
Chronic bronchitis is thought to be caused by overproduction and hypersecretion of mucus by
goblet cells. Epithelial cells lining the airway response to toxic, infectious stimuli by releasing
inflammatory mediators such as interleukin 8, colony stimulating factor and other pro-
inflammatory cytokines. There is also an associated decrease in the release of regulatory
substances such as angiotensin-converting enzyme and neutral endopeptidase. The alveolar
epithelium is both the target as well as the initiator of the inflammatory process in chronic
bronchitis. During an acute exacerbation of chronic bronchitis, the bronchial mucous membrane
becomes hyperemic and edematous with diminished bronchial mucociliary function. This, in turn,
leads to airflow impediment because of luminal obstruction to small airways. The airways
become clogged by debris and this further increases the irritation. The characteristic cough of
bronchitis is caused by the copious secretion of mucus in chronic bronchitis.
Causes of Bronchitis
Acute Bronchitis
1. Acute bronchitis is caused by infection of the large airways commonly due to viruses and
is usually self-limiting i.e. approximately 95% of acute bronchitis in healthy adults are
secondary to viruses. The predominant viruses that are causative are Influenza type A
and B, and the dominant bacterial agents are Staphylococcus, Streptococcus, and
Mycoplasma pneumonia.
2. It can sometimes be caused by allergens and irritants (smoke inhalation, polluted air
inhalation, dust, among others)
Chronic Bronchitis
1. There are many known causes of chronic bronchitis, but the most important causative
factor is exposure to cigarette smoke either due to active smoking or passive inhalation.
2. Many inhaled irritants to the respiratory tract such as smog, industrial pollutants, and
toxic chemicals can cause chronic bronchitis.
3. Although bacterial and viral infections usually cause acute bronchitis repeated exposure
to infections can cause chronic bronchitis.
4. People who have an associated background in respiratory diseases such as asthma, cystic
fibrosis, or bronchiectasis have a higher predisposition to develop chronic bronchitis.
5. People who have repeated exposure to environmental pollutants such as dust or airborne
chemicals such as ammonia and sulfur dioxide have a higher risk of developing chronic
bronchitis.
6. Chronic gastroesophageal reflux is a well-documented but less frequent cause of chronic
bronchitis.
Clinical manifestations of Bronchitis

Acute Bronchitis
Patients with acute bronchitis present with:
1. Productive cough
a. Usually, their cough is the predominant complaint and the sputum is clear or
yellowish, although sometimes it can be purulent although purulent sputum does
not correlate with bacterial infection or antibiotic use.
b. Cough after acute bronchitis typically persists for 10 to 20 days but occasionally
may last for 4 or more weeks. The median duration of cough after acute bronchitis
is 18 days. Paroxysms of cough accompanied by inspiratory whoop or post-tussive
emesis should raise concerns for pertussis.
2. Malaise
3. difficulty breathing
4. Wheezing
5. A prodrome of upper respiratory infection (URI) symptoms like
6. Runny nose
7. Sore throat
8. Fever: A low-grade fever may be present as well however high-grade fevers in the setting
of acute bronchitis are unusual and further diagnostic workup is required.
Chronic bronchitis
1. Cough
a. The most common symptom of patients with chronic bronchitis is a cough.
b. The history of a cough typical of chronic bronchitis is characterized to be present
for most days in a month lasting for 3 months with at least 2 such episodes
occurring for 2 years in a row.
c. A productive cough with sputum is present in about 50% of patients. The sputum
color may vary from clear, yellow, green or at times blood tinged. The color of
sputum may be dependent on the presence of secondary bacterial infection.
d. Very often changes in sputum color can be due to peroxidase released by

leucocytes in the sputum. Therefore, color alone is not a definite indication of
bacterial infection.
2. History of possible exposure to inhaled irritants or chemicals as well as full details
regarding smoking habits.
3. Fever is uncommon in chronic bronchitis and when present can be suggestive of
associated influenza or pneumonia.
4. Generalised malaise is a commonly associated symptom.
5. Chest pain or abdominal muscle pain caused by continuous forceful coughing.
NB: Uncomplicated chronic bronchitis presents with a cough, and there is no evidence of airway
obstruction physiologically.
Investigations
1. History taking: The diagnosis of bronchitis is made through history taking, particularly a
recent respiratory tract infection, recent use of inhaled irritant, patient complaint.
2. Physical examination: Mainly, the number of breaths per minute and breath sounds is
assessed during physical examination.
3. Chest x-ray
4. Fiberoptic bronchoscopy: May be both diagnostic (qualitative cultures) and therapeutic
(re-expansion of lung segment).
5. ABGs/pulse oximetry: Abnormalities may be present, depending on extent of lung
involvement and underlying lung disease.
6. Gram stain/cultures: Sputum collection; needle aspiration of empyema, pleural, and
transtracheal or transthoracic fluids; lung biopsies and blood cultures may be done to
recover causative organism. More than one type of organism may be present; common
bacteria include Diplococcus pneumoniae, Staphylococcus aureus, a-hemolytic
streptococcus, Haemophilus influenzae; cytomegalovirus (CMV). Note: Sputum cultures
may not identify all offending organisms. Blood cultures may show transient bacteremia.
7. CBC: Leukocytosis usually present, although a low white blood cell (WBC) count may be
present in viral infection, immunosuppressed conditions such as AIDS, and overwhelming
bacterial pneumonia. Erythrocyte sedimentation rate (ESR) is elevated.
8. Serologic studies, e.g., viral or Legionella titers, cold agglutinins. Assist in differential
diagnosis of specific organism.
9. Pulmonary function studies. Volumes may be decreased (congestion and alveolar
collapse); airway pressure may be increased and compliance decreased. Shunting is
present (hypoxemia).
10. Electrolytes: Sodium and chloride levels may be low.
Management
Medical Management
Acute Bronchitis
Acute bronchitis is self-limiting and treatment is typically symptomatic and supportive therapy.
1. For cough relief, non-pharmacological and pharmacological therapy should be offered.
a. Non-pharmacological therapy includes hot tea, honey, ginger, throat lozenges,
etc.
b. Antitussive agents like dextromethorphan, codeine, and guaifenesin are
frequently used in clinical practice to suppress cough based on their effectiveness
in chronic bronchitis however codeine should be avoided due to its addictive
potential.
2. For treatment of wheezing i.e. Inhaled bronchodilators to reduce bronchospasm and
promote sputum expectoration.
3. Analgesic and antipyretic agents may be used to treat associated malaise, myalgia, and
fever.
4. Prednisone or other steroids can be given to help with the inflammation as well.
5. Lifestyle modification like smoking cessation and the avoidance of allergens and
pollutants play an important role in the avoidance of recurrence and complications.
6. Flu vaccine and pneumonia vaccine are especially recommended in special groups
including adults older than 65, children younger than two years (older than six months),
pregnant women, and residents of nursing homes and long-term care facilities. People
with asthma, COPD, and other immunocompromised adults are also at higher risk of
developing complications.
7. A course of oral antibiotics such as a macrolide may be instituted, but is controversial.
Chronic bronchitis
The primary aim of treatment for chronic bronchitis is to relieve symptoms, prevent complication
and slow the progression of the disease.
The primary goals of therapy are aimed at reducing the overproduction of mucus, controlling
inflammation and lowering cough.
Pharmacological interventions are the following:
1. Bronchodilators: Short and long-acting β-Adrenergic receptor Agonists as well as
Anticholinergic help by increasing the airway lumen, increasing ciliary function and by
increasing mucous hydration.
2. Glucocorticoids: Reduce inflammation and mucus production. Inhaled corticosteroids
reduce exacerbation and improve quality of life. However, it is administered under
medical supervision and for short periods of time as long-term usage can induce
osteoporosis, diabetes, and hypertension.
3. Antibiotic therapy: is not indicated in the treatment of chronic bronchitis however

macrolide therapy has been shown to have anti-inflammatory property and hence may
have a role in the treatment of chronic bronchitis.
4. Phosphodiesterase-4 inhibitors: decrease inflammation and promote airway smooth
muscle relaxation by preventing the hydrolysis of cyclic adenosine monophosphate a
substance when degraded leads to the release of inflammatory mediators.
Non Pharmacological Measures
1. The most critical non-pharmacological intervention is smoking cessation. Smoking
cessation improves mucociliary function and decreases goblet cell hyperplasia and
Smoking cessation has also been shown to reduce airway injury resulting in lower levels
of exfoliated mucus in tracheobronchial cells.
2. Pulmonary rehabilitation is an important part of treatment for chronic bronchitis which
consists of education, lifestyle modification, regular physical activity and avoidance of
exposure to known pollutants either at work or living environment.
Nursing management
1. Assessment
a. Refer to the notes of assessment nursing interventions above
2. Management of fevers
a. Refer to the notes of fever nursing interventions above
3. Prevention of infection
a. Refer to the nursing interventions of influenza under infection prevention
4. To improve airway clearance (managing wheezing)
b. Elevate HOB to decrease pressure on the diaphragm and enhancing drainage
c. Observe signs of infections to identify infectious process
progress
maximize effort
g. Keep back dry to prevent further complications
i. Administer bronchodilators if prescribed.
5. To ensure effective breathing pattern (managing difficulty in breathing)
a. Place patient in semi-fowlers position to have a maximum lung expansion
b. Increase fluid intake as applicable to liquefy secretions.
c. Keep patient back dry to avoid stasis of secretions and avoid further complication
d. Place a pillow when the client is sleeping to provide adequate lung expansion
while sleeping.
e. Instruct how to splint the chest wall with a pillow for comfort during coughing and
elevation of head over body as appropriate to promote physiological ease of
maximal inspiration
f. Maintain a patent airway, suctioning of secretions may be done as ordered to
g. Provide respiratory support. Oxygen inhalation is provided per doctor’s order to
aid in relieving patient from dyspnea
h. Administer prescribed cough suppressants and analgesics and be cautious,
however, because opioids may depress respirations more than desired to
promote deeper respirations and cough
6. To ensure effective gaseous exchange (managing or prevention of cyanosis)
a. Administer oxygen as prescribed.
c. Provide CPT
d. Perform naso-tracheal suctioning if the client is unable to clear secretions.
e. Monitor pulse oximetry.
f. Monitor and record color, consistency, and amount of sputum.
g. Assist and monitor effects of nebulizer treatment and another respiratory
h. Coordination of treatments and oral intake reduces likelihood of vomiting with
coughing, expectorations.
i. Teach and assist the patient with proper deep-breathing exercises. Demonstrate
i. Deep breathing exercises facilitates maximum expansion of the lungs and
smaller airways, and improves the productivity of cough.
ii. Coughing is a reflex and a natural self-cleaning mechanism that assists the
cilia to maintain patent airways. It is the most helpful way to remove most
secretions.
iii. Splinting reduces chest discomfort and an upright position favors deeper
and more forceful cough effort making it more effective.
j. Encourage ambulation: Helps mobilize secretions and reduces atelectasis.
k. Administer medications, as indicated:
7. To promote rest and conserve energy (managing general body weakness/malaise)

8. To promote fluid intake
9. To maintain nutrition
of the disease.
11. Relive of anxiety
a. Refer to nursing interventions above
12. Discharge and Home Care Guidelines: Patient education is crucial regardless of the setting
because self-care is essential in achieving a patient’s well-being.
Complications
1. Secondary pneumonia
2. Respiratory distress
3. Days missed of school/work
ASTHMA
Introduction
Definition: Asthma is a chronic inflammatory disease of the airways that causes airway hyper-
responsiveness, mucosal edema, and mucus production.
OR: Asthma is a chronic disease with acute exacerbations characterized by intermittent airway
obstruction in response to a variety of stimuli.
Inflammation ultimately leads to recurrent episodes of asthma symptoms.
Patients with asthma may experience symptom-free periods alternating with acute
exacerbations that last from minutes to hours or days.
Asthma, the most common chronic disease of childhood, can begin at any age.
Classification of Asthma
Classification of asthma according to cause
1. Allergy-Induced Asthma: It is the Most Common type of asthma and it is triggered by
allergens. They enter the body through inhalation, swallowing, touching, or injection. An
“allergen” or an “antigen” is a foreign particle which enters the body. Our immune system
over-reacts to these often harmless items, forming “antibodies” which are normally used
to attack viruses or bacteria. Mast cells release these antibodies called immunoglobulin E
and other chemicals . Immunoglobulin E causes immune system cells to release chemicals
that produce inflammation in the lungs.
2. Non – allergic Asthma: Any form of asthma that is not triggered by allergies is termed
“non-allergic asthma.” It is not allergy-related, in fact it is caused by anything except an
allergy. While the symptoms of non-allergic asthma are more or less identical to those of
allergic asthma, the triggers are different.
a. Exercise-Induced Bronchoconstriction (EIB): Is Asthma Triggered by Physical
Activity. When airflow is obstructed as a result of exercise, it’s known as exercise-
induced bronchoconstriction (EIB), which is a subcategory of asthma. EIB was
previously known as exercise-induced asthma; However, exercise-induced asthma
incorrectly implies that exercise is the underlying cause of asthma, when it is
actually its trigger, not the cause.
b. Occupational Asthma: Is Triggered by an Irritant being exposed to at Work. i.e. if
the asthma started when the patient changed jobs, improves when he is away
from the work environment, or is triggered by chemicals that make it difficult to
breathe.
c. Nocturnal asthma: this type involves the same symptoms as other types of
asthma, but they are exacerbated during the evening hours:
Pathophysiology
Asthma is a condition of acute, fully reversible airway inflammation, often following exposure to
an environmental trigger. The pathological process begins with the inhalation of an irritant (e.g.,
cold air) or an allergen (e.g., pollen), which then, due to bronchial hypersensitivity, leads to
airway inflammation and an increase in mucus production. This leads to a significant increase in
airway resistance, which is most pronounced on expiration.
Airway obstruction occurs due to the combination of:
1. Inflammatory cell infiltration.
2. Mucus hypersecretion with mucus plug formation.
3. Smooth muscle contraction.
These irreversible changes may become irreversible over time due to
1. Basement membrane thickening, collagen deposition, and epithelial desquamation.
2. Airway remodeling occurs in chronic disease with smooth muscle hypertrophy and
hyperplasia.
If not corrected rapidly, asthma may become more difficult to treat, as the mucus production
prevents the inhaled medication from reaching the mucosa. The inflammation also becomes
more edematous.
Risks of Asthma
Allergic asthma/Extrinsic Asthma/Atopic asthma
Environmental allergens like
1) Cockroach particles
2) Cat hair and saliva
3) Dog hair and saliva
4) House dust mites
5) Mold or yeast spores
6) Metabisulfite, used as a preservative in many beverages and some foods
7) Pollen
Non allergic asthmas/ Intrinsic asthma

1. It may be caused by inhalation of chemicals such as cigarette smoke or cleaning agents,
2. Taking aspirin or beta blockers
3. A chest infection
4. Stress
5. Laughter
6. Exercise
7. Cold air
8. Food preservatives
9. Gas, wood, coal, and kerosene heating units
10. Natural gas, propane, or kerosene used as cooking fuel

11. Fumes
12. Smog
13. Viral respiratory infections
14. Wood smoke
15. Weather changes
Clinical manifestations of Asthma
1. No fever (if fever present, refer to pneumonia)
2. Difficulty in breathing (usually recurrent attacks) with chest tightness, with or without use
of accessory muscles.
3. Patients may not appear very distressed despite a severe attack
4. Wheezing, rhonchi
5. Cough - usually dry, may be intermittent, persistent, or acute, especially at night
6. Severe forms: failure to complete sentences, darkening of lips, oral mucosa and
extremities (cyanosis)
7. Asthma attacks frequently occur at night or in the early morning.
8. An asthma exacerbation is frequently preceded by increasing symptoms over days, but it
may begin abruptly.
9. Expiration requires effort and becomes prolonged.
10. As exacerbation progresses, central cyanosis secondary to severe hypoxia may occur.
11. Additional symptoms, such as diaphoresis, tachycardia, and a widened pulse pressure,
may occur.
12. Exercise-induced asthma: maximal symptoms during exercise, absence of nocturnal
symptoms, and sometimes only a description of a “choking” sensation during exercise.
13. A severe, continuous reaction, status asthmaticus, may occur. It is life-threatening.
14. Eczema, rashes, and temporary edema are allergic reactions that may be noted with
asthma.
Life-threatening asthma
It is a type of asthma that does not respond to systemic steroids and beta 2 agonist nebulization.
It is necessary to identify it early as it may lead to high mortality. It has the following characteristic
findings on examination
1. Peak expiratory flow less than 33% of personal best
2. Oxygen saturation less than 92%
3. The normal partial pressure of carbon dioxide
4. Cyanosis
5. Feeble respiratory effort
6. Bradycardia
7. Arrhythmias
8. Hypotension
9. Confusion, coma
10. Exhaustion
Investigations
1. Spirometry- measuring the movement of air in and out of the lung after the patient takes
the deepest breath
2. Chest X rays –show areas with hyperinflation with local atelectasis and flattened
diaphragm.
3. Complete blood count- reveals the increase, eosinophil count.
4. Pulse oximetry- show decreased of oxygen saturation.
5. Serum IgE level- may increase from an allergic reaction.
6. Skin testing-may identify specific allergens.
7. Arterial blood gas (ABG)– analysis may detect hypoxemia.
8. Pulmonary function test– reveal airway obstruction and decrease peak expiration flow
rate.
Management
Medical Management
Mild to moderate
1. The patient is treated as an out-patient
2. Reassure patient; place him in a ½ sitting position
3. Administer prescribed
4. salbutamol –– Inhaler 2-10 puffs via a large volume spacer and repeat every 20-30 min if
necessary
5. Prednisolone 50 mg (1 mg/kg for children)
6. Monitor response for 30-60 min. If not improving or relapse in 3-4 hours
7. If improving, send home with
8. Prednisolone 50 mg (1 mg/kg for children) once a day for 5 days (3 days for children)
9. Institute or step up chronic treatment (see next section)
10. Instruct the patients on self-treatment and when to come back
11. Review in 48 hours
Severe Asthma
1. Admit patient; place him in a ½ sitting position
2. Give high flow oxygen continuously, at least 5 litres/minute, to maintain the SpO2 ≥ 94%
if available
3. Give salbutamol –– Inhaler 2-10 puffs via a large volume spacer and repeat every 20-30
min if necessary during the 1st hour
4. Prednisolone 50 mg (1 mg/kg for children) or hydrocortisone 100 mg (children 4 mg/kg

max 100 mg) IV every 6 hours until patient can take oral prednisolone
5. Monitor response after nebulisation
6. If response poor
7. Ipratropium bromide nebuliser 500 micrograms (250 microgram in children below 12)
every 20- 30 min for the first 2 hours then every 4-6 hours or aminophylline 250 mg slow
IV bolus (child 5 mg/kg) if patient is not taking an oral theophylline
8. Alternatively, if symptoms have improved, respiration and pulse settling, and peak flow
>50%
9. Step up the usual treatment
10. And continue with prednisolone to complete 5 days of treatment
11. Review within 24 hours
a. Monitor symptoms and peak flow
b. Arrange self-management plan
Nursing management
1. Emergency Interventions
a. Briefly taking history of the patient i.e. when the symptoms began and what
triggered them.
b. Temporally admit the patient in a sit up position and take vital observation i.e.
TPR/BP, pulsoximetry
c. Alert the physician immediately who will order for investigations.
d. Administer corticosteroids, epinephrine, sympathomimetic aerosol agents, and IV
aminophylline as ordered.
e. Observe the patient closely for respiratory arrest. Monitor his respiratory rate
continuously and other vital signs every 5 minutes. Never leave the patient alone.
f. Make sure the patient receives oxygen and bronchodilator and nebulizer
therapies as ordered.
g. Monitor for labored respirations, cyanosis, and cold and clammy skin.
h. Monitor and record color, consistency, and amount of sputum.
i. Have emergency equipment brought to the bedside and prepare to assist with
intubation and mechanical ventilation if respiratory arrest occurs.
2. To improve airway clearance:
b. Elevate Head of the bed to decrease pressure on the diaphragm and enhancing
drainage
c. Maintain a patent airway, suctioning of secretions may be done as ordered to
d. Observe signs of infections to identify infectious process

e. Auscultate breath sounds & assess air movement to ascertain status & note
progress
f. Instruct the patient to increase fluid intake to help to liquefy secretions.
g. Demonstrate and encourage effective coughing and deep-breathing techniques to
maximize effort
i. Demonstrate diaphragmatic and pursed-lip breathing to decrease air trapping and
for efficient breathing.
j. Administer bronchodilators if prescribed.
3. Exercise
a. Encourage deep breathing and coughing exercises to maximize effort for
expectoration.
b. Encourage ambulation: Helps mobilize secretions and reduces atelectasis.
c. Encourage opportunities for rest and limit physical activities to prevent situations
that will aggravate the condition
4. To promote rest and conserve energy:
5. Nutrition
c. Fluids with electrolytes. This may help provide fluid, calories, and electrolytes.
d. Nutrition-enriched beverages. Nutritionally enhanced drinks and shakes can also
of the disease.
7. Advice on discharge: Patient education is crucial regardless of the setting because self-
care is essential in achieving a patient’s well-being.

e. Advise small, frequent meals to maintain adequate nutrition.
f. Fluid intake should be maintained at approximately 3000 mL/day so that the
g. Teach the patient to maintain pulmonary hygiene measures of coughing, deep
Complications
1. Pneumonia
2. Respiratory distress
3. COPD
STATUS ASTHMATICUS
Introduction
Definition: Status asthmaticus is severe and persistent asthma that does not respond to
conventional therapy; attacks can occur with little or no warning and can progress rapidly to
asphyxiation.
OR: Status asthmaticus is a medical emergency, an extreme form of asthma exacerbation
characterized by hypoxemia, hypercarbia, and secondary respiratory failure.
All patients with bronchial asthma are at risk of developing an acute episode with a progressive
severity that is poorly responsive to standard therapeutic measures, regardless of disease
severity or phenotypic variant. This is also known as status asthmaticus.
If not recognized and managed appropriately, asthmatics portends the risk of acute ventilatory
failure and even death.
Cause of status asthmaticus
1. Infection
2. Anxiety
3. Nebulizer abuse
4. Dehydration
5. Increased adrenergic blockage
6. Nonspecific irritants
7. Hypersensitivity to aspirin.
Risk factors for developing severe or persistent status asthmaticus
1. History of increased use of home bronchodilator treatment without improvement or
effect
2. History of previous intensive care unit (ICU) admissions, with or without intubation and
mechanical ventilatory support
3. Asthma exacerbation despite recent or current use of corticosteroids
4. Frequent emergency department visits and/or hospitalization (implies poor control)
5. Less than 10% improvement in peak expiratory flow rate (PEFR) from baseline despite
treatment
6. History of syncope or seizures during acute exacerbation
7. Oxygen saturation below 92% despite supplemental oxygen
8. Subgroup of asthma patients who are poor perceivers of dyspnea are a greater risk of
intubation and death
1. Tachypnea
2. Wheezing: Initially, wheezing is heard only during expiration, but wheezing later occurs
during expiration and inspiration and later, as bronchoconstriction worsens, the wheezing
may disappear, which may indicate severe airflow obstruction
3. The chest is hyper-expanded
4. Accessory muscles, particularly the sternocleidomastoid, scalene, and intercostal
muscles, are used.
5. An inability to speak more than one or two words at a time
6. The patient’s level of consciousness may progress from lethargy to agitation, air hunger,
and even syncope and seizures.
7. If untreated, prolonged airway obstruction and marked increase in the work of breathing
may eventually lead to bradycardia, hypoventilation, and even cardiorespiratory arrest.
Management of status asthmaticus
Medical management
Emergency care
1. Admit patient; place him in a ½ sitting position
2. Give high flow oxygen continuously, at least 5 litres/minute, to maintain the SpO2 ≥ 94%
if available
3. Give salbutamol
a. Inhaler 2-10 puffs via a large volume spacer
b. Repeat every 20 min for 1 hour
4. Hydrocortisone 100 mg IV stat or prednisolone 50 mg.
5. Ipratropium bromide nebuliser 500 micrograms every 20- 30 minutes for the first 2 hours
then every 4-6 hours
6. Monitor response for 15-30 minutes
7. If response is poor
8. Aminophylline 250 mg slow IV bolus. if patient is not taking an oral theophylline
Nursing management
The main focus of nursing management is to actively assess the airway and the patient’s response
to treatment. The nurse should be prepared for the next intervention if the patient does not
respond to treatment.
1. Constantly monitor the patient for the first 12 to 24 hours, or until status asthmaticus is
under control. Blood pressure and cardiac rhythm should be monitored continuously
during the acute phase and until the patient stabilizes and responds to therapy.
2. Assess the patient’s skin turgor for signs of dehydration; fluid intake is essential to combat
dehydration, to loosen secretions, and to facilitate expectoration.
3. Administer IV fluids as prescribed, up to 3 to 4 L/day, unless contraindicated.
4. Encourage the patient to conserve energy.
5. Ensure patient’s room is quiet and free of respiratory irritants (eg. flowers, tobacco
smoke, perfumes, or odors of cleaning agents); non allergenic pillows should be used.
The rest of the nursing interventions refer to those of asthma.
EMPHYSEMA /PULMONARY EMPHYSEMA

Introduction
Emphysema is the enlargement and destruction of the alveolar, bronchial, and bronchiolar tissue
with resultant loss of recoil, air trapping, thoracic over-distention, sputum accumulation, and loss
of diaphragmatic muscle tone.
Emphysema is primarily a pathological diagnosis that affects the air spaces distal to the terminal
bronchiole. It is characterized by abnormal permanent enlargement of lung air spaces with the
destruction of their walls without any fibrosis and destruction of lung parenchyma with loss of
elasticity.
Pulmonary emphysema, a progressive lung disease, is a form of chronic obstructive pulmonary
disease (COPD). The Global Initiative for chronic obstructive lung disease (GOLD) has defined
COPD as "a common, preventable, and treatable disease that is characterized by persistent
respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities
usually caused by significant exposure to noxious particles or gases.
NB: Emphysema, Asthma and Chronic Bronchitis are disease under COPD.
Pathophysiology
The alveoli and the small distal airways are primarily affected by the disease, followed by effects
in the larger airways. Elastic recoil is usually responsible for splinting the bronchioles open.
However, with emphysema, the bronchioles lose their stabilizing function and therefore causing
a collapse in the airways resulting in gas to be trapped distally.
There is an erosion in the alveolar septa causing there to be an enlargement of the available air
space in the alveoli. There is sometimes a formation of bullae with their thin walls of diminished
lung tissue.
Smoking contributes to the development of the condition initially by activating the inflammatory
process. The inhaled irritants cause inflammatory cells to be released from polymorphonuclear
leukocytes and alveolar macrophages to move into the lungs. Inflammatory cells are known as
proteolytic enzymes, which the lungs are usually protected against due to the action of anti-
proteases such as the alpha1-antitrypsin. However, the irritants from smoking will have an effect
on the alpha1-antitrypsin, reducing its activity. Therefore emphysema develops in this situation
when the production and activity of anti-protease are not sufficient to counter the harmful
effects of excess protease production. A result of this is the destruction of the alveolar walls and
the breakdown of elastic tissue and collagen. The loss of alveolar tissue leads to a reduction in
the surface area for gas exchange, which increases the rate of blood flow through the pulmonary
capillary system
Causes of Emphysema
The common causes of emphysema are as follows:
1. Tobacco smoking
2. Marijuana use
3. Air pollution
4. Chemical fumes and dust
5. Rarely, inherited deficiency in alpha-1-antitrypsin
The risk factors that increase the development of emphysema include:
1. Smoking – Smokers are more susceptible in developing emphysema due to the damaged
brought to the lungs
2. Age – Although lung damage from emphysema develops slowly, most patients with
tobacco-induced conditions are observed between the ages 40 to 60 years old.
3. Exposure to secondhand smoke or passive smoking
4. Occupational exposure to fumes or dust – Inhalation of industrial-related pollution (e.g.,
working in the coal mines) predisposes its workers to emphysema.
5. Exposure to indoor and outdoor pollution – Fumes from factories, car exhausts, etc. can
also contribute to emphysema.
Clinical manifestations of Emphysema
1. Chronic shortness of breath: Exertional dyspnea: Initially, there is exertional dyspnea with
significant physical activity, especially arm work at or above shoulder level with
progression to dyspnea with simple daily activities and even at rest.
2. Chronic cough
a. It can be with or without sputum production.
b. As the disease process advances, the shortness of breath and cough progressively
gets worse.
3. Wheezing: Some patients may present with wheezing because of the airflow obstruction.
4. Weight loss, Anorexia, fatigue: As the disease advances, patients can lose significant body
weight due to systemic inflammation and increased energy spent in the work of
breathing.
5. History of smoking
6. Distant breath sounds, wheezes, crackles at the lung bases, and/or distant heart sounds
are heard on auscultation.
7. Decreased respiratory excursion, resonance to hyper-resonance, decreased breath
sounds with prolonged expiration, normal or decreased fremitus
NB: In the early stages of the disease, the physical examination may be normal. Patients with
emphysema are typically referred to as “pink puffers,” meaning cachectic and non-cyanotic.
Investigations
1. Physical Exam and History Taking– A physical exam focusing on the respiratory function
and assessing for adventitious breath sounds is done to establish baseline data and
identify signs and symptoms.
2. Imaging tests – Chest X-ray will be done as a primary imaging tool and as a method of
ruling out other causes of shortness of breath. A CT-scan is oftentimes utilized as well to
further assess and visualize the inherent lung structures which are often deviated for
patients with lung issues, especially for sufferers of emphysema.
3. Laboratory tests – Arterial blood gases (ABGs) are done to monitor blood oxygenation
levels and to assess for lung capability to transfer oxygen to the bloodstream.
4. Lung function tests – Oftentimes, incentive spirometry is the tool of choice for assessing
for lung vital capacity. In this test, the patient is advised to inhale deeply then exhale
through the device in order to measure the amount of air that is held and exchanged
during respirations.
Management
Medical Management
1. The doctor may prescribe the following medications to treat, lessen or control the
symptoms of emphysema and they are:
a. Bronchodilators – These are given for the relaxation of constricted airways as
manifested by episodes of shortness of breath, coughing, and other breathing
problems.
b. Inhaled steroids –
c. Corticosteroids applied directly on the bronchial tree through inhalation will help
in addressing inflammation that is also associated in emphysema.
d. Antibiotics – Infection may occur as a secondary condition due to the lungs

inability to function properly.
e. Supportive medications – saline nebulization may be done to help alleviate
symptoms of emphysema.
2. Pulmonary rehabilitation: Breathing exercises and techniques will be taught to aid in
adjusting with the demands of having emphysema.
3. Nutrition therapy: People who are overweight would need to reduce their weight to
lessen the effort in breathing. Likewise, patients who are underweight are advised for
proper nutrition to support the body in adjusting with the condition.
4. Supplemental oxygen: Oxygen support will be given for patients with emphysema to
address the inadequate supply given by the patient’s lungs. It is normal for most
emphysema patients to have an oxygen level between 88 to 92% via pulse oximetry.
Oxygen therapy may be required if the patient’s SpO2 drops to less than 88%.
1. Assessment
a. Refer to the notes of assessment nursing interventions above
2. Management of fevers
a. Refer to the notes of fever nursing interventions above
3. Prevention of infection
a. Refer to the nursing interventions of influenza under infection prevention
4. To improve airway clearance (managing wheezing)
b. Elevate HOB to decrease pressure on the diaphragm and enhancing drainage
c. Observe signs of infections to identify infectious process
progress
maximize effort
g. Keep back dry to prevent further complications
i. Administer bronchodilators if prescribed.
5. To ensure effective breathing pattern (managing difficulty in breathing)
a. Place patient in semi-fowlers position to have a maximum lung expansion
b. Increase fluid intake as applicable to liquefy secretions.
c. Keep patient back dry to avoid stasis of secretions and avoid further
complication
d. Place a pillow when the client is sleeping to provide adequate lung expansion
while sleeping.
e. Instruct how to splint the chest wall with a pillow for comfort during coughing
and elevation of head over body as appropriate to promote physiological ease
of maximal inspiration
f. Maintain a patent airway, suctioning of secretions may be done as ordered to
g. Provide respiratory support. Oxygen inhalation is provided per doctor’s order
to aid in relieving patient from dyspnea
h. Administer prescribed cough suppressants and analgesics and be cautious,
however, because opioids may depress respirations more than desired to
promote deeper respirations and cough
6. To ensure effective gaseous exchange (managing or prevention of cyanosis)
a. Administer oxygen as prescribed.
c. Provide CPT
d. Perform naso-tracheal suctioning if the client is unable to clear secretions.
e. Monitor pulse oximetry.
f. Monitor and record color, consistency, and amount of sputum.
g. Assist and monitor effects of nebulizer treatment and another respiratory
h. Coordination of treatments and oral intake reduces likelihood of vomiting with
coughing, expectorations.
i. Teach and assist the patient with proper deep-breathing exercises. Demonstrate
i. Deep breathing exercises facilitates maximum expansion of the lungs and
smaller airways, and improves the productivity of cough.
ii. Coughing is a reflex and a natural self-cleaning mechanism that assists the
cilia to maintain patent airways. It is the most helpful way to remove most
secretions.
iii. Splinting reduces chest discomfort and an upright position favors deeper
and more forceful cough effort making it more effective.
j. Encourage ambulation: Helps mobilize secretions and reduces atelectasis.
k. Administer medications, as indicated:
7. To promote rest and conserve energy (managing general body weakness/malaise)
b. Semi-Fowler’s position. The patient should assume a comfortable position to promote

rest and breathing and should change positions frequently to enhance secretion
clearance and pulmonary ventilation and perfusion.
8. To promote fluid intake
9. To maintain nutrition
of the disease.
11. Relive of anxiety
a. Refer to nursing interventions above
12. Discharge and Home Care Guidelines: Patient education is crucial regardless of the setting
because self-care is essential in achieving a patient’s well-being.
Complications
If left untreated, emphysema may progress to the following conditions:
1. Pneumothorax: A collapsed lung is life-threatening for people with severe cases of
emphysema due to the lungs being already compromised.
2. Heart problems: Co-pulmonale may develop for patients suffering from emphysema. This
happens because of the increased pressure in the arteries connecting the heart and lungs,
resulting in enlarged and weakened sections of the heart.
3. Bullae: Bullae are large spaces in the lungs that develop in people with emphysema.
Having this condition pre-disposes a patient to have pneumothorax.

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CYBER SCHOOL

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AUTHOR FOR MORE DETAILS CONTACT

“Author of this generation” “Education is the key to success”

Copy right @ 2023 by Kawalya Germaine Nelson

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First Edition 2023

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1 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

CIRCULATORY DISORDERS _____________________________________________________ 21

CONGESTIVE CARDIAC FAILURE ______________________________________________________ 34

THROMBUS AND EMBOLUS _________________________________________________________ 48

HEMATOLOGIC DISORDERS ____________________________________________________ 62

RESPIRATORY TRACT DISORDERS _______________________________________________ 82

2 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

INFLUENZA _____________________________________________________________________ 102

LOWER RESPIRATORY TRACT DISORDERS ________________________________________ 108

3 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

No. Textbook Price

4 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

5 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

6 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

7 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

 Lack of immunization programmes

Control of communicable diseases

Eliminating the reservoir (attacking the source)

9 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

1. Immunization; This increases host resistance by strengthening internal defenses. It is one

10 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

4. Inflammatory disease: is a disease caused by an infection with pathogenic organisms.

11 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

12 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

13 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

14 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

15 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

16 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

17 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

9. Smell for: breathe incase of alcohol/poisonous intake/acetone smell especially in patients

18 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

19 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

20 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

21 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

We shall look at the following

Cardinal signs and symptoms of pericarditis

23 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

24 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

13. Ankylosing spondylitis,

25 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

1. Establish a good rapport with the patient

26 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

27 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

29 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

30 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

11. Closely monitor signs for cardiac tamponade.

31 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

32 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

33 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience

There are different complications of endocarditis, those are in the below:

CONGESTIVE CARDIAC FAILURE

34 By Kawalya Germaine Nelson “The Professor” CEO Cyber School Experience