MEDICAL SURGICAL NURSING REVIEW

Course Outline

I. Client in Pain II. Perioperative Nursing Care III. Alterations in Human Functioning a. Disturbances in Oxygenation: Respiratory & Cardiovascular Functions b. Disturbances in Metabolic and Endocrine Functions c. Disturbances in Elimination: Gastrointestinal Problems d. Disturbances in Fluids and Electrolytes: Renal & Genitourinary Functions e. Disturbances in Cellular Functioning: Cancer and Hematologic Problems f. Disturbances in Auditory & Visual Functions g. Disturbances in Musculos eletal Functions IV. Client in Biologic Crisis: Life threatening Conditions of the Human Body

V. Emergency & Disaster - First-aid and Cardiopulmonary Support

-----------------------------------------------------------------------------------------------------------------------------------I. CLIENT IN PAIN

Pain

the fifth vital sign

- an unpleasant sensory and emotional experience associated with actual or poten tial tissue damage.

- Shoc

Basic Categories of Pain: 1. Acute Pain sudden pain which is usually relieved in seconds or after a few we e s. 2. Chronic Pain (Non-Malignant) constant, intermittent pain which usually persis ts even after healing of the injured tissue 3. Cancer-Related Pain- May be acute or chronic; may or may not be relieved by m edications

Pain Transmission: 1. Nociceptors are called pain receptors. These are the free nerve endings in th e s in that respond to intense, potentially damaging stimuli. 2. Peripheral Nervous System 3. Central Nervous System 4. Descending Control System

Factors Influencing Pain Response 1. 2. 3. 4. 5. 6. Past Experience e.g. trauma Anxiety and Depression Culture - beliefs Age infants are more sensitive Gender Placebo Effect

Characteristics of Pain 1. Intensity mild, moderate, excruciating 2. Timing morning or evening, duration may be longer or shorter 3. Location 4. Quality burning, aching, stabbing 5. Personal Meaning to pain tolerance to pain may be different from one person t o the other due to some personal reasons such as economic reasons, wor condition, etc. 6. Aggravating and Alleviating factors patient s environment 7. Pain Behaviors - facial expressions with pain

Pain Assessment 1. Evaluate: Cause, Location, Character and Intensity 2. Numeric Pain Scale 5-severe pain -. 0 no pain

3. Descriptive Pain Scales

mild, moderate, severe

4. Visual Analogue Scales 5. Faces Pain Scale

Nurse s Role in Pain Management 1. Identify goals for Pain management a. Decrease intensity, duration or frequency b. Factors in identifying goals: i. Severity of pain ii. Harmful effects of pain to the client iii. Duration of the pain

3. a. b. c.

Provide Physical care Teach and assist in self-care Environmental conditions Application of ice/heat on painful area

4. Manage anxiety related to Pain a. Teach about the nature of pain that may be felt by the client and reassure hi m/her b. Teach alternative measures to relieve pain c. Stay with the client/ frequent communication with the client

5. Pain Medications may be administered as: a. Balanced Anesthesia given to avoid experiencing pain b. PRN Pro Re Nata as needed c. Preventive ta en before pain is felt d. Individualized Dosage e. Patient-Controlled Analgesia (PCA) patient ta es medication if pain felt is b ecoming intolerable

2. a. b. c.

Establish Nurse-Patient Relationship and Teaching Ac nowledge the verbalization of pain by the client Relieve patient s anxiety Teach measures how to relieve pain

6. a. b. c. d. e. f. g.

Non-pharmacologic Interventions Cutaneous Simulation and Massage Ice and heat therapies Transcutaneous Electrical Nerve Stimulation Distraction Relaxation Techniques Guided Imagery Hypnosis

II. PERIOPERATIVE CARE

o Phases of Perioperative Nursing

a. Pre-operative Nursing b. Inraoperative Nursing c. Post-operative Nursing

A. Pre-operative Care Pre-admission and Admission Test 1. 2. a. b. c. d. e. f. g. Psychological support Client Education: Importance and practice of breathing exercises Location & support of wound Importance of early ambulation Inform and practice leg exercises, positioning, turning Anesthesia and analgesics Educate regarding drains and dressings to be received post-op Recovery room policies and procedures

3. a. b. c. d.

Informed consent At least 18 years of age In sound mind- without psychologic disorder Not under the influence of drugs or alcohol Immediate relative over 18 years old

4. Physical Assessment and preparation a. Physical Preparation NPO, remove dentures, jewelries, clothesetc. b. Nutritional & Fluid Status should be well hydrated c. Drug or alcohol Use may experience delirium or intoxication to anesthetic dru gs because ormal doses do not usually ta e effect to these patients and require hea vier dose to achieve anesthetic effect. d. Respiratory Status - teach breathing exercises e. Cardiovascular Status should have controlled and stable cardiovascular functi oning before operation to prevent intraoperative problems f. Hepatic & Renal Functions normal functioning is important in absorbing anesth etic drugs g. Endocrine Functions- important in monitoring to prevent hypo/hyperglycemia, thyrotoxicosis, acidosis h. Immune Functions allergies esp. to anesthetic drugs i. Psychosocial Factors emotional and psychological preparation to ensure cooperation fom the patient with the procedures j. Spiritual & Cultural Beliefs - blood transfusions, transplants, ligation, etc are against other culture & religion.

5. Pre-operative drugs given 20-60 mins.pre-operative o Ma es patient drowsy, eep siderails up

6. Proper positioning

Semi-Fowlers

HOB elevated at 30 degrees

Head injury, pot-op cranial surgery, post-op cataract removal, increased ICP, dyspneic patients

Fowlers

HOB elevated at 45 degrees

Head injury, pot-op cranial surgery; post-op abdominal surgery; post-op thyroidectomy, post-op cataract surgery, increased ICP; dyspnea

High-Fowler s

HOB elevated at 90 degrees

Pneumothorax, hiatus hernia

Supine/ Dorsal Recumbent

Lying on bac w/ small pillow under head

Spinal cord injury, urinary catheterization

Prone

Lying on abdomen with head turned to the side

Amputation of legs/feet, post lumbar puncture, post myelogram, post tonsillectomy & adenoidectomy (T&A)

Lateral / Side lying

Lying on side, weight on the lateral side, the lower scapula and lower iliac.

Post-abominal surgery, post tonsillectomy & adenoidectomy (T&A), post-liver biopsy ( right side down), post pyloric stenosis (right)

Sim s/ Semi-prone

Lying on side, weight on the clavicle, humerus and anterior aspect of the iliac.

Unconscious client

Lithotomy

Lying on bac with nees and legs bent and raised on a stir up

Perineal, rectal & vaginal procedures

Trendelenburg

Head & body lowered, feet elevated

Reverse Tredelenburg

Head elevated , feet lowered

Cervical traction

Elevate extremity

Support with pillows

Post-op surgical procedure on extremity, cast, edema, thrombophlebitis

Shoc

Prone

Supine Lateral Recumbent

High-Fowler s Reverse Trendelenburg Sim s Position

Jac -Knife Lithotomy

B. Intra-operative Care

1. Ensure sterility of all instruments and supplies at the operating field

Principle: STERILE TO STERILE, CLEAN TO CLEAN Sterile objects touches only sterile surfaces/objects Clean objects touches only clean surfaces/objects

Sterilization techniques: o Autoclave Steam, Ethyl Oxide (Gas) o Glutaraldehyde Solution- Cidex

2. Ensure safety of client in the operating table- prevent falls, drape the pati ent properly, provide warmth

3. Stay with the client to relieve anxiety and support during anesthesia

Anesthesia Administration: a. General Anesthesia via Inhalation b. General Anestheisia via Intravenous c. Regional Anesthesia - local anesthesia d. Conduction Bloc s/ Spinal Anesthesia Epidural & Spinal Bloc - for operation below the waist line - patient is awa e during operation

4. Perform sponge count, instrument count and needle count 5. Aseptic technique in handling and preparing all instruments and supplies 6. Applies grounding device to prevent electrical burn during use of electrosurg ical equipment 7. Proper documentation

C. 1. 2. 3. 4. 5. 6.

Post-operative Care Immediate assessment of VS, and Neuro VS, drainages, surgical dressing Monitoring of vital signs q 15mins until stable Post-operative positioning depending on the procedure performed Deep breathing exercises Early ambulation Health teaching for Independent (self) care upon discharge

III. ALTERATIONS IN HUMAN FUNCTIONING

1. DISTURBANCES IN OXYGENATION

Arterial Blood Gas

Normal Value

pH

Measure of acidity or al alinity

7.35

7.45

pCO2

Partial pressure of carbon dioxide respiratory parameter influenced by lungs only

35 -45

pO2

Partial pressure of oxygen; measure of amount oxygen delivered to lungs

80-100

HCO3

Bicarbonate, metabolic parameter influenced only by metabolic factors

22-26

Respiratory Acidosis Normal Value Respiratory

Al alosis

pH

7.35

pCO2

35 -45

Normal Compensation

HCO3

22-26

Normal Compensation

a. Administer NaHco3 b. Get rid of CO2

7.45

c. Bronchodilators d. Monitor ABG

Nursing Intervention

a. Breathe into paper bag or cupped hands b. Oxygen

Metabolic Acidosis Normal Value Metabolic Al alosis

pH

7.35

7.45

Normal Compensation

pCO2

35 -45 Normal Compensation

HCO3

22-26

a. Treat underlying cause (Starvation, systemic infections, renal failure, Diabetic acidosis, Keratogenic diet, diarrhea, excessive exercise) b. Promote good air exchange c. Give NAHCO3 via IV

Nursing Intervention

Restore fluid loss which may be cause by vomiting, gastric suction, al ali ingestion, excessive diuretic

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

- A group of conditions assoc. w/ chronic obstruction of airflow entering or lea ving the lungs

Major diseases

1. Pulmonary Emphysema airway is obstructed due to destroyed alveolar walls 2. Chronic Bronchitis- increased mucus production that obstructs airway 3. Asthma

Cause: Medical Management: 1. 2. 3. 4. 5. 6. Bronchodilators Antihistamines Steroids Antibiotics Expectorants Oxygen therapy at 2LPM

use cautiously

Nursing Management: 1. Administer meds and O2 as ordered 2. Promote adequate activities to enhance cardiovascular fitness 3. Adequate rests 4. Avoid allergens or other irritants 5. Psychological Support

Clinical Manifestations: . . . . . . . . . . . . Few words between breaths Pursed-lip breathing Cyanosis Distended nec veins Barrel chest increased diameter of thorax Pulsus paradoxus Clubbing of fingers Nicotine Stains Pitting edema exertional dyspnea or dyspnea at rest Enlarged pulsating liver Cough- with or without sputum production

1. 2. 3. 4.

Cigarette smo ing Chronic respiratory infections Family history of COPD Air pollution

CHRONIC BRONCHITIS Blue Bloater

- An inflammation of the bronchi which causes increased mucus production and chr onic cough. - Chronic condition is diagnosed if symptoms occur for 3 months and for 2 consec utive years.

Cause: Cigarette Smo ing, infection, pollution

Clinical Manifestations:

. Slight gynecomastia . Petechiae in midsternal area . Dyspnea

Medical Management: see COPD

Nursing Management: 1. Reduce or avoid irritants 2. Increase humidity 3. Administer medications as ordered

. . . .

Productive cough Thic er, more tenacious mucus Decreased exercise tolerance Wheezes

4. Chest physiotherapy 5. Postural drainage 6. Promote Breathing techniques

EMPHYSEMA Pin Puffer

- A disorder where the alveolar walls are destroyed causing permanent distention of air spaces. - (+) dead areas in the lungs that do not participate in gas or blood exchange

Cause: Cigarette smo ing, Alpha-anti-trypsin deficiency (an enzyme in the alveol ar walls)

Nursing Management: 1. Position: Sit up and lean forward 2. Pulmonary toilet: Cough->Breathe deeply->Chest physiotherapy-> turn & position 3. 4. 5. 6. Frequent rest periods Nebulization IPPB Intermittent Positive Pressure Breathing (aerosolized inhalation) O2 @ 2LPM

Clinical Manifestations: 1. 2. 3. 4. 5. 6. 7. Dyspnea on exertion Tachypnea Barrel-chest Wheezes Pin ish s in color Shallow rapid respirations Pursed lip breathing

Asthma

-A condition where there is an increase responsiveness and/or spasm of the trach ea and bronchi due to various stimuli which causes narrowing of airways

Cause and Ris Factors: 1. Family history of asthma 2. Allergens: dust, pollens, 3. Secondary smo e inhalation

4. Air pollution 5. Stress

Types: 1. Immunologic asthma - occurs in childhood 2. Non-immunologic asthma - occurs in adulthood and assoc w/ recurrent resp infe ctions. - usually >35 y/o 3. Mixed, combined immunologic and non-immunologic

Nursing Management:

1. Promote pulmonary ventilation 2. Facilitate expectoration 3. Health teaching . Breathing techniques . Stress management . Avoid allergens

Clinical Manifestations: . . . . . . . . . Increased tightness of chest, dyspnea Tachycardia, tachypnea Dry, hac ing, persistent cough (+) wheezes, crac les Pallor, cyanosis, diaphoresis Chronic barrel chest, elevated shoulders distended nec veins orthopnea Tenacious, mucoid sputum

Treatment: 1. 2. 3. 4. Steroids, Antibiotics Bronchodilators, expectorants O2, nebulization, aerosol

continues and do not respond to treatment

II. PARENCHYMAL DISORDERS: PNEUMONIA

- An inflammatory process of lung parenchyma assoc. w/ mar ed increase in alveol ar and interstitial fluids

Etiology: 1. Bacterial / Viral streptococcus pneumoniae, pseudomonas aeruginosa, influenza

2. Aspiration 3. Inhalation of irritating fumes

Complication: STATUS ASTHMATICUS - a life-threatening asthmatic attac mptoms of asthma

in w/c sy

Ris factors:

Clinical Manifestations:

1. Chest pain, irritability, apprehensiveness, irritability, restlessness, nause a, anorexia, hx of exposure 2. Cough- productive , rusty/ yellowish/greenish sputum, splinting of affected s ide, chest retration 3. CXR, sputum culture, Blood culture, increased WBC, elevated sedimentation rat e

Nursing Management:

. Rest and adequate activity . Proper Nutrition

PULMONARY EDEMA

- often occurs when the left side of the heart is distended and fails to pump ad

. . . . . o o o

Promote adequate ventilation- positioning, Chest physiotherapy, IPPB Provide rest and comfort Prevent potential complications Health teaching: s in care, hygiene Drug therapy: Antibiotics: penicillin, cephalosphorin, tetracycline, erythromycin Cough suppressants Expectorants

1. 2. 3. 4. 5. 6.

Age: too young and elderly are most prone to develop Smo ing, air pollution URTI Altered conciousness Tracheal intubation Prolonged immobility: post-operative, bed-ridden patients

equately

Clinical Manifestation: o Constant irritating cough, dyspnea, crac les, cyanosis

Pathophysiology:

. Fluid accumulation in the alveolar sacs due to hypovolemia, fluid congestions in the lungs, alveoli are congested

Nursing Management: 1. 2. 3. 4. 5. Diuretics, low sodium diet, I&O promote effective airway clearance, breathing patterns and ventilation Monitor VS Psychological support Administer medications

TUBERCULOSIS

- A chronic lung infection that leads to consumption of alveolar tissues

Etiology:

Mycobacterium tuberculosis.

Ris Factors: 1. Poor living conditions, overcrowded 2. Poor nutritional inta e 3. Previous infection

4. Close contact with infected person 5. Inadequate treatment of primary infection Clinical Manifestations: Diagnostic Tests:

1. CXR 2. Sputum acid-fast 3. Mantoux Test - .1 ml of PPD (Purified Protein Derivative) ; Read after 48-72 hrs. Induration: 10mm bacillus > positive exposure to TB

5 9 mm -> doubtful, may repeat the procedure > 4 mm -> Negative

1. 2. 3. 4. 5. 6. 7. 8. 9.

Productive cough Hemoptysis Dypnea Rales Malaise Night Sweats Weight loss Anorexia, vomiting Indigestion, pallor

Treatment: 1. 2. 3. 4. 5. Ethambutol Rifampicin Isoniazid Pyrazinamide Streptomycin

Client Education: 1. TB is infectious but can be cured 2. Transmitted by droplet infection and not carried on articles li e clothing or

eating utensils 3. Individual is generally considered not infectious after 1- 2 wee s of medicat ion. 4. Medication regimen should be continuous and uninterrupted 5. Regimen is usually 6 months. 6. Regular chec -up to monitor progress should be done. 7. Sputum samples are obtained first before drug therapy is started. 8. Advise proper handwashing and use of mas for people in contact with infected persons who are not yet under treatment.

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CARDIOVASCULAR SYSTEM THE HEART AND MAJOR VESSELS

I. Diagnostic Procedure 1. 2. 3. 4. 5. 6. Laboratory Test Electrocardiogram Echocardiography Central Venous Pressure Pulmonary Artery Pressure/ Swan-Ganz Cardiac Catheterization

Venous Disorders:

1. Thrombophlebitis 2. Varicose Veins

II. Diseases of the Vascular System:

Arterial Disorders: 1. 2. 3. 4. Hypertension Arteriosclerosis Atherosclerosis Aortic Aneurysm

5. Buerger s Disease (Thromboangitis Obliterans) 6. Raynaud s Disease

Cardiac Disorders

a. b. c. d. e. f.

Angina Pectoris Myocardial Infarction Congestive heart Failure Valvular Stenosis AV Heart Bloc Pacema ers

A. DIAGNOSTIC PROCEDURES:

Procedure

Values / Description

Purpose

1. Laboratory Tests

a. Electrolytes Chloride , Mg

Na, K, Ca,

(see fluids & electrolytes)

b. PTT

16-40 sec.

c. PT

9-12 sec.

d. Clotting time

10 mins.

e. Cholesterol

150-250 mg/dl

f. Triglyceride

50-250 mg/dl

> LDL (bad cholesterol) 60-180 mg/dl > HDL (good cholesterol) 30-80 mg/dl

g. BUN

6-20 mg/dl

h. Enzymes: > CPK men- 55-170

- women- 30-135 ( rises 3-6 hrs after M.I.)

> LDH

150-450 u/ml

(rises 12 hrs after M.I.)

> SGOT

5-40 u/ml

i. ESR- 0-30. also rises after MI

Determines hyper alemia, Hypernatremia, etc. - determine the ability of the heart to affect circulation and regulatory functions of fluids and electrolytes.

- determines ability of the blood to form clot or thrombus

- determines the development of atherosclerosis which causes coronary artery disease

- test of renal function; determines adequacy of circulation from the heart to the idneys and its ability to excrete protein and urea

- cardiac enzymes are present in high concentration in the myocardial tissues ; determines tissue damage in the myocardium

2. Electrocardiogram

P- contraction of the atrium QRS complex- contraction of the ventricles T- Resting state of the ventricles PR interval- contraction of atrium until the beginning of the contraction of ventricles ST- ventricles moves to a

resting state

. Determines the electrical impulse of the heart

. Normal impulses ensures adequate circulation to all body organs and tissues

Procedure

Values / Description

Purpose

3. 2-Dimensional Echocardiography (2D Echo)

Ultrasound of the heart

. Determines valvular deformities, thic ening of myocardium, pericardial effusion,etc

4. Central Venous Pressure (CVP)

Normal = 5 Water

10 cm

Measures the right atrial pressure or the pressure of the greater veins within the thorax by threading a catheter into a large central vein. - Subclavian - Jugular - Median - Basilic - Femoral

. Serves as guide for fluid replacement

. Monitor pressures in the right atrium and central veins

. Administer blood

End of catheter or Tip positioned at the right atrium or upper portion superior vena cava

(for femoral insertion, tip is at the inferior vena cava) products, TPN, drug therapy.

. Obtain venous access when peripheral veins are inadequate

. To insert a temporary pacema er . Obtain central venous samples

5. Swan-Ganz Catheter / Pulmonary Artery Pressure (PAP)

Measures the level of pressure in the left atrium

4 Ports: a. Thermodilution port b. Balloon Port for inflating

balloon used for placement of catheter c. Right atrium Port d. Pulmonary atrium port

. Monitor pressure in the ff: c. Right ventricle d. Pulmonary artery e. Distal branches of the pulmonary artery . Thermodilution . Obtain blood for O2 saturation

6. Cardiac Catheterization

Catheter inserted into the right or left side of the heart and vessels and a dye is introduced

Used to determine details on the structure and performance of the valves, heart and circulation

a. Measure O2 concentration, saturation, tension and pressure in the chambers of the heart

b. Detect shunts

c. To get blood samples

d. Determine cardiac output & pulmonary flow

e. Determine need for bypass surgery

Three types of Blood Vessels:

1. Arteries - carries oxygenated blood 2. Veins - carries unoxygenated blood 3. Capillaries allows the delivery of nutrients, oxygen and fluids to the tissue s

B. DISEASES OF THE VASCULAR SYSTEM:

B. 1.ARTERIAL DISORDERS

HYPERTENSION Persistent BP above 140 /90

Types of Hypertension Essential hypertension Secondary hypertension

Etiology:

un nown etiology - most common - may be caused by an increase in cardiac output or increase in peripheral resistance

caused by other physiologic problems Types of Hypertension Essential hypertension Secondary hypertension

Ris Factors Genetic Obesity Stress Loss of elastic tissues Arteriosclerosis of aorta

Renal problems

Endocrine problems Neurologic Disorders

Pregnancy-Induced HPN Many others

Signs & Symptoms

BP=140/90 ; headache, fatigue, wea ness, dizziness, palpitations, flushing, blur red vision and epistaxis

Treatment

1. Non-pharmacologic:

. Weight reduction v Sodium restriction . Diet modification v Exercise . Alcohol & Smo ing cessation v Caffeine Restriction . Relaxation Techniques . Potassium, Calcium, Magnesium supplements (to balance sodium and other electrolytes)

2. Pharmacologic:

Renal Failure, Nephritis Thyroid problem, DM Brain tumors, Trauma

. . . .

Calcium Agonist: Nifedipine, Verapamil Vasodilators: Hydralazine Diuretics: Aldactone, hydrochlorothizide Adrenergic inhibitors: Propanolol, Clonidine, Methyldopa

Nursing Interventions

ARTERIOSCLEROSIS Obstruction

- When the arteries become obstructed with plaque and cholesterol, they harden a nd constrict, and the circulation of blood through the vessels becomes difficult, forcing the blood through narrower passageways. As a result, blood pressure becomes elevated.

1. 2. 3. 4. 5. 6.

BP monitoring Correct cause: obesity, diet, stress, etc Regular exercise Salt restrictions Administer medications Teach ris factors

- Arteriosclerosis occurs when lipids in the blood, including cholesterol, accum ulate inside the walls of blood vessels and reduce the size of the veins or arteries through which blood flows.

ATHEROSCLEROSIS Thic ening

- A degenerative condition of the arteries characterized by thic ening due to lo calized accumulation of fats, mainly cholesterol. The term atherosclerosis refers to a condition in which fatty depos its build up in and on the artery walls, interfering with the normal flow of blood and oxygen throughout the body. When t his happens, the heart has to wor harder to pump blood through the narrowed blood vessels, and a heart attac or a stro e may result.

Predisposing factors:

Signs and symptoms:

. . . . .

cigarette smo ing high fat levels in the blood high cholesterol high blood pressure obesity

The symptoms of atherosclerosis depend on the part of the body where the conditi on is ta ing place. Sometimes there aren't any noticeable symptoms until the condition has advanced to a very serious stage . When the arteries of the heart are affected, one of the first symptoms is chest pain, often called angina. A person with clogged arteries of the heart may also have occasional difficulty in breathing and may experience unusual fatigue after short periods of exertion.

Medical & Surgical Interventions for Athero and Arteriosclerosis:

Nursing Intervention:

AORTIC ANEURYSM

Types of Aneurysm: Thoracic or Abdominal Aortic Aneurysm Ris Factors: Presence of Atherosclerosis, Infections or a Congenital abnormalit y

Signs & Symptoms:

Thoracic Aortic Aneurysm

a. b. c. d. e.

Health Teaching Reduce Ris Factors Restore Blood Supply Pre & Post-op Care for Surgical Patients

a. b. c. d. e.

Lifestyle Modification ; Reduce Ris Factors Coronary Artery Bypass Graft (CABG Percutaneous Transluminal Coronary Angioplasty (PTCA) Directional Coronary Atherectomy (DCA) Intracoronary Stents

Abdominal Aortic Aneurysm (AAA)

Dyspnea Thoracic/chest pain Dysphagia cough voice hoarseness Abdominal Pain

Pulsating Abdominal Mass

Treatment: Surgical Removal of Aneurysm

Nursing Intervention: a. Psychological support

b. Monitor patient for signs of rupture of aneurysm

Triad of manifestations for ruptured abdominal aneurysm: 1. Abdominal pain 2. Bac or Flan pain (scrotal pain may also occur) 3. Shoc : Bp= >100 systolic; Pulse Rate >100bpm c. Pre-operative preparation d. Post-operative care: monitor peripheral circulation

Low bac

pain

BUERGER S DISEASE a. .a. Thromboangitis Obliterans (TAO)

Definition: Vasculitis of the veins and arteries in the upper & lower extremitie s

Ris Factors: Men -20-35 y/o, Heavy smo ers, hypersensitivity to intradermal inj ections

Signs & Symptoms: a. pain in legs relieved by immobility, b. c. d. e. numbness and tingling of toes sensitivity to cold Wea or absent pulsations at the dorsalis pedis, posterior tibial Reddish or Cyanotic extremity which may progress to ulceration or gangrene

Treatment: . Calcium Channel Bloc ers to promote vasodilation

. Rest, Pain Relievers, Avoid exposure to cold . Surgery: Amputation of extremity is delayed until conservative treatments fail to effect.

Nursing Intervention:

RAYNAUD S DISEASE

Definition: Vasospasm of arteries in the hands (upper extremities only)

Ris Factors: Women, heavy smo ers, individuals spec. women with Systemic Lupus Erythematosus (SLE) or rheumatoid arthritis Cause: hypersensitivity of fingers to colds, congenital vasospasm, Serotonin rel ease Signs & Symptoms:

. Cyanosis/pallor of the fingers when exposed to cold environment or emotional s timuli . Numbness and occasional pain . Bilateral or symmetrical involvement

Treatment: . Nifedipine to decrease vasospasm . Avoid exposure to cold and eep hands warm . Avoid smo ing

. . . . . .

Health teaching on lifestyle modifications, spec. smo ing Ensure protection of extremities against cold Administration of medications as ordered Protect client from injury Assessment of extremities

Nursing Intervention . Same as buerger s disease

B.2.VENOUS DISORDERS:

THROMBOPHLEBITIS

Definition: Clot disorder in the vein usually at the lower extremity

Ris Factors: Trauma of the blood vessels, stasis, Increased coagulability

Signs & Symptoms: Edema of the extremity, redness, pain, local induration, (+) Homan s sign - calf pain upon dorsiflexion of foot Nursing Intervention: a. Use of thromboembolytic (TED) stoc ings b. Elevate legs c. Heparin therapy, as ordered d. Bed rest e. Warm compress

VARICOSE VEINS

Definition: distention, lengthening and totuosity of veins

Cause: loss of valvular competence and constant elevation of venous pressure most commonly in the veins of the legs.

Ris Factors: Prolonged standing, obesity, pregnancy

Signs & Symptoms: . . . . Aching Heaviness Moderate swelling Enlarged, tortuous veins in the legs

Treatment: . Surgical Management: Sclerotherapy (injection of sclerosing agent to the vein. Not a treatment, hence, for cosmetic purpose only)

Nursing Intervention . Elevate legs at least 30 mins. After prolonged standing . Wear thromoembolic stoc ings . Teach client o avoid prolong sitting or standing . Avoid cross-legs while sitting . Post-op Care after Sclerotherapy: a. Maintain firm elastic pressure over the w hole limb

b. Regular but careful exercise of the legs to promote circulation ambulate for short periods 24-48 hrs post-op

c. Assessfor complications such as bleeding, infection, nerve damage

IV.CARDIAC DISORDERS

ANGINA PECTORIS Chest pain

. insufficient coronary blood flow . inadequate oxygen exchange in the heart causing intermittent chest pain . can be relieved with rest. . It lasts only for 1-5 minutes and ta ing up of nitroglycerine will be benefici al for the client.

Signs and symptoms:

Precipitating factor: . . . . over exertion eating exposure to cold emotional stress

Classification of Symptoms:

Class I no limitations of physical activity (ordinary physical activity does not cause symptoms).

Class II slight limitation of physical activity (ordinary physical activity does cause symptoms).

Class III moderate limitation of activity (patient is comfortable at rest, but l ess than ordinary activity can cause symptoms).

. . . .

Patient experiences retrosternal chest discomfort Pressing, heaviness, squeezing, burning and cho ing sensation. Pain in the epigastrium, bac nec jaw or in the shoulders. Radiation of pain in the arms, shoulders and the nec .

Class IV unable to perform any physical activity without discomfort, therefore s evere limitations (patient may be symptomatic even at rest).

Nursing Interventions: a. Assess pain location, character, ECG (ST elevation), precipitating factors

b. Help client to adjust lifestyle to prevemt angina attac avoid excessive acti vity in cold weather, avoid overeating, avoid constipation, rest after meals, exercise

Diagnostic Assessment: a. b. c. d. ECG Stress Test Radioisotope Imaging Coronary Angiography

Medical Management:

MYOCARDIAL INFARCTION

a. b. c. d.

Opiate Analgesic MoSo4 Vasidilators Nitroglygcerin, Isosorbide Mononitrate/Dinitrate Calcium Channel Bloc ers Dlitiazem, Nifedipine Beta Bloc ing Agents Propanolol

c. Teach patient how to cope with angina attac 3x, if still not relieved go to the hospital

nitroglycerin every 5 mins upto

. Destruction of myocardial tissue due to reduced coronary blood flow.

. The rapid development of myocardial necrosis caused by imbalance between the oxygen supply and demand of the myocardium.

. Results from plaque rupture with thrombus formation in a coronaryvessel, resulting in an acute reduction of blood supply to a portion of the myocardium.

Causes: 1. Atherosclerotic heart 2. Coronary Artery Embolism

Left Ventricular Failure Right Ventricular

Signs & Symptoms

Causes Pulmonary Congestion:

a. b. c. d. e. f.

Dyspnea Cheyne s Stro e Cough, Rales, wheezing Orthopnea Paroxysmal Nocturnal Dyspnea Pulmonary Edema

g. Cerebral hypoxia h. Fatigue &muscular wea ness

i. Renal Changes, Nocturia

a. b. c. d. e.

Peripheral edema Venous congestion of organs Hepatomegaly Cyanosis of the nail beds Massive swelling of the legs,

genitals and trun (Anasarca) f. Anxiety, fear and depression f.

Description

Treatment

Degree of Bloc

delayed transmission of impulse to AV node

None

not all impulses pass through AV node

Atrophine Isoproterenol

No impulse pass through AV node

Ventricular Pacema er

Third-degree AV Bloc

Second-degree AV Bloc

First-degree AV Bloc

Comparison of Chest Pain

Angina Pectoris Myocardial Infarction Type

Location

Duration

Relief squeezing, pressing, burning

Retrosternal, substernal, left of sternum, radiates to the left arm

Usually 3-5 mins duration <30 mins

rest, nitroglycerin Sudden, severe, crushing, heavy, tightness

Substernal, radiates to one or both arms, jaw, nec

>30 mins.

Oxygen, narcotics, not relieved by rest & nitroglycerin

Comparison of other signs & symptoms

Angina Pectoris

Myocardial Infarction

Transient Ischemic Attac

Subjective Data: . . . . Dyspnea Palpitation Dizziness Faintness

Subjective Data: . Shortness of breath . Apprehension, fear of impending death . Nausea

Sudden loss of: . Visual fxn . Sensory fxn . Motor fxn

Objective Data: . Tachycardia . Pallor . Diaphoresis

Objective Data: . Symptoms of shoc . Cyanosis, diaphoresis . Restless

Objective Data: . Loss of functioning for about and returns to normal

Nursing Care Management

Arteriosclerosis

Angina Pectoris

1. Lifestyle Modification Diet, stress mgt, habits

2. Restore blood supply Anti-embolic stoc ings, anti-coagulants

3. Pre & post-op care CABG,PTCA, Stents

4. Health teaching Modifications, diet,etc.

1. Provide relief from pain: Rest Nitroglycerin Lifestyle modification Vital signs Assist w/ ambulation

Transient Ischemic Attac

2. Provide emotional support

3. Health teaching Pain differentiation Medication Dx test Diet, exercise, CABG

1. Assess neurologic status

2. Administer meds

Nursing Care Management

Myocardial Infarction

1. Reduce pain & discomfort: Narcotics, O2, Semi-fowler s position to improve ventilation battery- operated 2. Maintain adequate circulation. Monitor VS, Urine Output & ECG Meds: Anti-arrythmics & anticoagulants Chec for edema, cyanosis, dyspnea, cough, crac les CVP: normal= 5-15cm H20 ROM, anti-embolic stoc ings

3. Decrease oxygen demand/ Promote oxygenation O2, Bedrest (24-48 hrs), rest periods Semi-fowler s position Anticipate needs of client: call light, water Meds: vasodilators, vasopressors, Cal.C.Bloc ers

4. Maintain fluid & electrolyte balance / Nutrition Keep IV open; CVP, VS, UO Lab data: Na+135-145; K 3.5-5.0 mEq/L ECG Diet: low calorie, low sodium, low cholesterol, low fat

5. Facilitate fecal elimination stool softener, avoid Valsalva, mouth breathing, bedside commode

6. Provide emotional support

7. Promote sexual functioning discuss concerns include partner resume 5-8 w s after uncomplicated MI

8. Health teaching

DISTURBANCES IN METABOLIC & ENDOCRINE FUNCTIONING

Gland Hormone Functions

Pituitary Gland Anterior Lobe

Growth Hormone

Prolactin

Thyrotropic hormone (TSH)

Gonadotropic hormones (LH & FSH)

Adrenocorticotropic hormone (ACTH)

Melanocyte-stimulating Hormone (MSH)

Stimulates growth of body tissues and bones

Stimulates mammary tissue growth & lactation

Stimulates thyroid gland

Affect growth, maturity and functioning of primary and secondary sex organs

Stimulates steroid production by adrenal cortex

May stimulate adrenal cortex; may affect pigmentation

Posterior lobe

Anti-diuretic hormones (ADH, vasopressin)

Oxytocin

Promotes reabsorption of water by the distal tubules and collecting ducts of the idney, thus decreasing urine output

Stimulates ejection of mil from mammary alveoli into the ducts: stimulates uterine contractions may possibly

be involved in the transport of sperm in the reproductive tract of the female

Thyroid Gland

Thyroxine (T4)

Triiodothyronine (T3)

Thryrocalcitonin

Increases metabolic activity of almost all cells; stimulates most aspects of fat, protein and carbohydrate metabolism

Lowers serum calcium levels and elevates phosphate level; opposite effect from that of PTH

Parathyroid

Parathormone (PTH)

Increases calcium levels and decreases phosphate levels; increases resorption of bones

Adrenal Cortex

Controls SSS: SUGAR, SALT, SEX

Glucocorticoids (primarily cortisol) -- Sugar

Mineralcorticoids (Aldosterone) -- Salt

Androgens (male hormones) -- Sex

Promotes carbohydrate, protein and fat catabolism, increases tissue responsiveness to other hormones

Tends to increase sodium retention and potassium excretion

Governs certain secondary sex characteristics; all corticoids are important for defense against stress or injury

Medulla

Epinephrine (Adrenalin)-80%

Norepinephrine- 20%

Elevates blood pressure, converts glycogen to glucose when needed by muscles for energy; increases heart rate; increases cardiac contractility; dilates bronchioles

Ovaries

Estrogens and progesterone

Stimulate development of secondary sex characteristics, effect repair of the endometrium after menstruation

Testes

Testosterone

Essential for normal functioning of male reproductive organs; stimulates development of secondary sex characteristics

Pancreas Islets of Langerhans

Insulin

Glucagon

Somatostatin

Promotes metabolism of carbohydrates, protein and fat thus decreasing blood glucose Mobilizes glycogen stores, thus raising blood glucose levels Decreases secretion of insulin, glucagons, growth hormone and several gastrointestinal hormones( gastrin, secretin)

PITUITARY GLAND PROBLEMS

Clinical Manifestations

Management

Acromegaly

1. Enlarged extremities 2. Protrusion of jaw and orbit 3. No increase in height and weight but hands and feet become bigger 4. Increased perspiration 5. Visual problems 6. Hyperglycemia/calcemia

1. Irradiation of pituitary with Bromocriptine to decrease secretion of growth hormone

2. Surgery: Hypophysectomy-removal of the pituitary gland

3. Post-op Care: a. Assess ICP b. Elevate head of bed (HOB) 30 degrees c. Avoid coughing, sneezing, blowing nose

Gigantism

Overgrowth of all body tissues and bones

Dwarfism

1. Retarded physical growth 2. Premature body aging 3. Slow intellectual development

1. Removal of cause : tumor 2. Human Growth Hormone Injection 3. Same as acromegaly & gigantism

Growth Hormone IN ADULTS

Growth Hormone In CHILDREN

Growth Hormone In CHILDREN

Diabetes Insipidus

1. Polyuria 2. Polydipsia 3. Dehyration

1. Pharmacology: a. Desmopressin Acetate nasal spray b. Vasopressin Tannate c. Hypressin Nasal Spray IM injections

2. Nursing Interventions; a. Maintain adequate fluids b. Sodium Restriction c. Inta e & Output monitoring d. Teach self-injection techniques e. Daily weights f. Specific gravity

SIADH Syndrome of Inappropriate secretion of ADH

1. Hyponatremia 2. Mental confusion 3. Personality changes 4. Lethargy, wea ness, headache 5. Weight gain 6. Abdominal cramping 7. Anorexia, nausea, vomiting

1. Fluid restriction 2. Treat underlying causes 3. Pharma: a. Demeclocycline administration as ordered b. Lithium Carbonate c. Butorphanol Tatrate

Antidiuretic Hormone

ADRENAL GLAND PROBLEMS

Clinical Manifestations

Management

Addison s Disease

1. Malaise and general wea ness 2. Hypotension, hypovolemia 3. Increased pigmentation of s in 4. Anorexia, nausea, vomiting 5. Electrolyte Imbalance 6. Weight loss 7. Loss of libido 8. Hypoglycemia (60-70) 9. Personality Changes

1. Pharmacology: Steroids (Prednisone, dexamethasone) 2. Diet: high CHO, CHON diet 3. Observe side effects of hormone replacement Cushingoid Appearance 4. Monitor fluid & electrolyte 5. Teach importance of lifelong medications 4. WOF Signs of Addisonian Crisis:

Glucocorticoids

Mineralcorticoids Sex Hormones Addisonian Crisis:

1. Sudden profound wea ness 2. Severe abdominal, bac and leg pain 3. Hyperpyrexia followed by hypothermia 4. Peripheral vascular collapse 5. Shoc 6. Renal Shutdown -> Death

Cushing s Syndrome

1. Thin scalp 2. Moon Face 3. Acne 4. Increased body hair 5. Buffalo hump 6. Obesity 7. Hyperpigmentation 8. Thin extremities 9. Easy Bruising 10. Mood swings, male characteristics appear in women 11. Hypo alemia, Hyperglycemia, HPN 12. Amenorrhea 13. Osteoporosis

1. Surgical Mgt: Adrenalectomy 2. Chemotherapy: Bromocriptine

3. Diet: high CHON, low CHO, low Na diet , potassium supplement 4. Nursing Mgt: > protect from infection > protect from accidents > health teaching on self-medication

STEROIDS: Purpose: Anti-inflammatory and anti-allergy; Stress Tolerance Medication: a. Ta e at the same time everyday b. Follow regime and do not stop abruptly c. Causes gastric upset

Side effects: Cushingoid Appearance

Conn s Syndrome / Aldosteronism

1. HPN 2. Hypo alemia

1. Surgery: Removal of tumor 2. Potassium replacement 3. Treatment of hypertension 4. Nursing Mgt: Monitor BP, administer meds, provide quiet environment

Pheochromocytoma

1. HPN 2. Increase Perspiration 3.Apprehension 4.Palpitations 5. Nausea, Vomiting, Headache 6. Tachycardia 7. Hyperglycema

1. Surgical Mgt: Removal o tumor 2. Medical Management: Symptomatic (Treat

symptoms as it occurs) 3. Nursing Mgt: > High caloric diet > Adequate Rest

Glucocorticoids

Mineralcorticoids (Aldosterone)

Epinephrine/ Norepinephrine

THYROID GLAND PROBLEMS

Clinical Manifestations

Management

Grave s Disease / Hyperthyroidism/ Thyrotoxicosis

1. Exopthalmos- protrusion of eyes 2. Enlargement of the thyroid gland 3. Increase metabolism: weight loss, diarrhea, diaphoresis 4. Personality changes 5. Cardiac Arrythmias 6. Easy fatigability

7. Muscle wea ness 8. HPN 9. Anxiety, Insomnia

1. Surgery: Thyroidectomy 2. Drug Therapy: a. Methimazole b. Propyl- Thyracil c. Iodides:

Saturated Solution of Potassium Iodide (SSKI)

d. Propanolol 3. Radioiodine therapy 4. Nursing Mgt: a. Adequate Rest b. High caloric, high protein, carbohydrate, vitamins without stimulants c. Measure daily weights d. Eye protection for xopthalmos e. WOF: Thyroid Storm

Cretinism

Lugol s solution w/ straw

strains teeth, drin

1. Physical & mental retardation 2. Sensitive to cold 3. Dry s in 4. Poor appetite and constipated

Treatment: Hormone Replacement

Myxedema

1. anorexia and constipation 2. intolerance to cold 3. Slow metabolism: decreased sweating, edema 4. Dry s in 5. Enlarged thyroid

1. Drug Therapy: a. Levothyroxine b. Thyroid Replacement (Desiccated thyroid) ** ta en in empty stomach

T3, T4, Thyrocalcitonin THYROID STORM: a. b. c. d. Fever Tachycardia Delirium Irritability

** heart rate less than 100 bpm -o

T3, T4, Thyrocalcitonin INFANTS

T3, T4, Thyrocalcitonin ADULT

PARATHYROID GLAND PROBLEMS

Clinical Manifestations

Management

Hypoparathyroid

Bradycardia , Easy bruising Fluid retention, Constipation Dry, coarse s in, Fatigue, lethargy Decreased libido, Menorrhagia, irregular menses

1. Drug therapy: Levothyroxine, Liothyronine Sodium 2. Avoid stimulus

Hyperthyroid

Tachycardia Palpitations Increased persitalsis weight loss Heat intolerance Decreased libido Amenorrhea

1. Drug therapy: Prophylthiuracil Methimazole, Saturated solution of Potassium Iodide, Radioactive Iodine 2. Diet: low calcium, high fiber 2. Force fluid

Parathormone

Parathormone

PANCREATIC PROBLEMS

DIABETES MELLITUS

Type I Insulin Dependent DM (IDDM)

Type II Non-Insulin Dependent DM (NIDDM)

Other Name

Juvenile DM

Adult DM

Age of Onset

Before 30 years old but may occur at any age

>35 y/o but can occur in children Onset

Abrupt

Insidious Incidence

10%

85-90% Insulin production

Little or none

Below normal Normal or Above normal Insulin Injections

Required

Necessary for only 20-30% of clients

Ketosis

May occur

Unli ely to occur Body weight at onset

Ideal body weight or thin

Usually Obese Management

Diet, exercise and insulin

Diet, exercise, hypoglycemic agent or insulin

Cardinal Signs & Symptoms: 1. 2. 3. 4. Polydipsia - excessive thirst Polyuria - frequent urination Polyphagia - excessive hunger Weight Loss - for IDDM

Treatment:

Side effects:

Administration: > usually administered 30 mins. before meals to promote faster absorption of the meds

1. a. b. c. d. e. f.

Oral hypoglycemics: Glipizide Glyburide Tolbutamide Tolazamide Acetohexamide Chlorpropamide

2. Insulin Injections:

a. b. c. d. e.

Hypoglycemia S in rashes GI disturbances Flushing Nausea, vomiting

Action Appearance- Preparation

Onset of Effect

Duration of Effect

Short-Acting

Clear - Regular Insulin

30 mins.

Cloudy - Semilente

30 mins.

Intermediate Acting

1 hr. 4 hrs. 8 hrs. 1 hr. 8 hrs. 16 hrs

Pea

Cloudy - NPH

2 hrs.

12 hrs.

18 -26 hrs.

Cloudy - Lente

3 hrs.

12 hrs.

18 -26 hrs.

Long-Acting

Cloudy - Protamine zinc

6 hrs.

18

24 hrs.

28

36 hrs.

Cloudy - Ultralente

6 hrs.

14

24 hrs.

36 hrs.

Pre-Mixed

Cloudy - 70% NPH - 30% regular

30 mins.

2 -12 hrs.

18- 24 hrs.

Complications of DM:

a. Hypoglycemia

Cause: Hunger, less dietary inta e, excessive insulin

Signs & Symptoms: Diaphoresis, Tachycardia, tremors, wea ness, irritability, con fusion

Nursing Interventions: Give candy, juice or softdrin s, let the patient eat Chec sugar level

b. Diabetic Ketoacidosis

Cause: Lac of insulin , Infection, Stress

Signs & Symptoms: Polyuria, thirst, Nausea, vomiting, dry mucous membranes, Kuss maul resp, Coma, sun en eyesballs, acetone odor of breath, hypotension, abdominal rigidity

Nursing Interventions: Give regular insulin

c. Lipodystrophy

Cause: Indurated areas on s in due to injections

Signs & Symptoms: S in indurations

Nursing Interventions: Teach client to rotate sites of injection

d. Hyperglycemic Hyperosmolar Non etotic Coma (HHNK)

Cause: Extremely high glucose, no etosis

Signs & Symptoms: Polyphagia, polydipsia, polyuria, glucosuria, dehydration, abd ominal discomfort, hyperpyrexia, hyperventilation, changes in sensorium, coma,

Nursing Interventions: Fluid & electroluyte replacement, Insulin

3. DISTURBANCES IN ELIMINATION

3.1. Inflammatory and Neoplastic Disorders a. b. c. d. e. Acute Gastritis Chronic Gastritis Duodenal Ulcer Gastric Ulcer Gastric Cancer

hypotension, shoc

Acute Gastritis Chronic Gastritis Treatment

Incidence:

Cause:

Duration:

Clinical Manifestations:

Acid production:

o Common in age 50-60 years old o Frequent in male than female o Greater incidents in heavy drin ers and smo ers

Helicobacter Pylori

Medicines: Aspirin, NSAIDS, chemo drugs, steroids

Food: Alcohol, coffee, spicy foods

Short

Epigastric discomfort, Abdominal pain, cramping, severe nausea, vomiting and sometimes hematemesis

Increased hydrochloric acid.

o Same in Acute Gastritis

o History of or presence of peptic ulcer disease o Previous gastric surgery o Same as acute gastritis

Prolonged

o May be asymptomatic o Other symptoms include: o Dyspepsia, belching, vague epigastric pain, N/V, intolerance to spicy or fatty foods

No increase in hydrochloric acid

Medical Management: a. Antacids b. Small frequent meals c. Bland diet d. May prescribe anticholinergics in chronic gastritis

Nursing Interventions/ Health Teaching: -Avoid spicy foods -Avoid alcohol inta e

-Frequent small meals

Duodenal Ulcer Gastric Ulcer

Occurrence:

o 25-50 yrs. old

> 50 yrs. old

Nursing Intervention:

a. Relaxation techniques

Cause:

Acid production:

Location of Ulcer

Pain:

Bleeding

Malignancy: o Type A personality (leaders, executives);

o Usually in a wellnourished individual

Stress, Poor food habit

Hypersecretion

Pylorus

o Experienced 2-3 hrs after meal o Ingestion of FOOD RELIEVES PAIN

Melena is more common than hematemesis

Not possible

o Most common in persons li e farmers, construction wor ers

o Usually affects malnourished individuals

Excessive smo ing, salicylates inta e

Normal to hyposecretion

Lesser curvature

o Experienced to 1 hour after meal o Ingestion of

FOOD DOES NOT RELIEVE PAIN

Hematemesis is more common than melena

Possible

b. Eliminate caffeine, cigarette smo ing, alcohol inta e and spicy foods

c. High fat, high carbohydrate

Medical Treatment: Antacids - avoid administration within 1-2 hr of other oral meds - frequent administration ac, pc, hs H2 Antagonists - with meals/pc

Anticholinergics

Prostaglandin Analogs **misoprostol** & ACID PUMP INHIBITORS - **inhibits the enzyme that produces gastric acid

H Pylori . Metronidazole . Omeprazole . Tetraycline/Clarithromycin . Cytoprotective binds with diseased tissue and provides a protective barrier to acid

Surgical Treatment 1. Vagotomy 2. Gastric ResectionGastroduodenostomy; Gastrojejunostomy

GASTRIC CANCER

Incidence: f. g. h. i. j. Common in men than women History or presence of Pernicious Anemia Often develops with the occurrence of atrophic gastritis Low-socio economic status; live in urban area Exposure to radiation or trace metals in soil

Cause: Helicobacter Pylori

Clinical Manifestations:

a. b. c. d. e. f.

Palpable mass Ascites Weight loss Dysphagia Indigestion and anorexia (+) high lactate dehydrogenase level in gastric juice

Diagnosis: GIT x-ray, gastroscopy

Treatment: Chemotherapy, radiation therapy, gastric resection

Nursing Intervention: Same as with patient s with ulcer, emotional support, pre an d post-operative health teaching

3.2. Disorders of the Large and Small Bowel

VIRAL AND BACTERIAL GASTROENTERITIS/ DYSENTERY

Gastroenteritis - Inflammation of stomach and intestine usually the small bowel . S/S: abdominal cramps, diarrhea, vomiting, fever, severe fluid and electrolyte l oss, mild to severe temperature Cause: Viral

Dysentery - Inflammation in the colon S/S: severe bloody diarrhea and abdominal cramping, severe fluid and electrolyte loss, mild to severe temperature Cause: Bacterial ( E.coli nd/or shigella, salmonella, Clostriduum difficile from antibiotics)

o Poor food handling o Poor sanitary conditions o Overcrowding o Food remaining on high temperature ma ing organisms incubate and colonize easi ly.

Management: o Replace fluid loss o Anti-infective Agent (e.g. Metronidazole spec for amoebiasis, Bactrim)

Ris

Factors:

Nursing Intervention: o Measure inta e and output o Administer medications o Replace fluids

APPENDICITIS

o Inflammation of the vermiform appendix

Incidence: Common between 20-30 yrs. old

Cause: Fecalith (stone or calculus in the appendix) .-> Kin ing of the appendix Fibrous condition in the bowel wall -> Bowel adhesion

S/S: Pain starts in the epigastriium the shifts to the the right lower quadrant Guarding of painful area Keeps legs bent to relieve tension May have vomiting, loss of apetite, low grade fever, coated tongue and halitosi s

Diagnosis: Increased WBC, (+) pain at Mc Burney s point (RLQ)

Treatment: Appendectomy

Nursing intervention: Assess the VS and pain scale carefully Observe for symptoms of peritonitis , Pre & post-operative care

PERITONITIS

o Inflammation of the peritoneal membrane o Cause: Gangrenous cholecystitis Ileitis Ruptured gallbladder Appendicitis with perforation Perforated gastric cancer Ruptured retroperitoneal abscess Perforated Peptic ulcer Strangulated hernia Ruptured spleen Salpingitis

Acute pancreatitis Septic Abortion Penetrating wound Ruptured bladder Ulcerative colitis Puerperal infection Gangrenous obstruction of the bowel Iatrogenic Cause Perforated diverticulum

o Signs and Symptoms: Localized pain Abdominal rigidity Increased pain upon movement Nausea, vomiting (N/V) Absence of bowel sounds Shallow respirations Increased WBC , dilation and edema of intestines revealed in GIT x-ray

o Medical Management: NGT: Lavage to relieve pressure in the abdomen Fluid & electrolyte replacement

o Surgical Treatment: Appendectomy or Exploration of the abdomen with drainage

o Nursing intervention: Careful assessment of history, V/S, fluid & electrolytes Pre & Post-operative Care

c. Inflammatory Bowel Disease:

ULCERATIVE COLITIS & CHRON S DISEASE

CHRON S DISEASE ULCERATIVE COLITIS

Pathology & Anatomy

Etiology

Onset

Course of Disease

Rectal bleeding

Anorectal fistula

Other S/S:

Medical Treatment

Involves primarily the ileum & right colon Distribution of d se is segmental Malignancy is rare

May be genetic

Usually in the 30 s

Slowly progressive

Occasional

Common

Abdominal pain Weight loss Diarrhea soft or semi-liquid

Pain in RLQ, cramping, tenderness, flatulence, nausea (mimics Appendicitis)

Replacement of fluid loss Anti-diarrheal: Diphenoxylate HCL

Mucosal ulceration of lower colon and rectum Distribution of d se is continuous Malignancy may occur after 10 years

May be caused by infection or alteration in immunity

Young adults (20-40)

Remissions and relapses

Common

Rare

Rectal bleeding, diarrhea (20 stools/day or more); Stools may occur with blood or pus, weight loss Urgency, cramping, Pain LLQ, abdominal distention, emotional stress.

Same as Chron s D se

Surgical Treatment

Nursing interventions: (Lomotil) ; Loperamide HCL (Imodium)

Total Parenteral Nutrition

Bowel Resection, Ileostomy

Assess Inta e and output, weight Emotionla support Client teaching regarding surgery

Post-op intervention: Observation of the stoma Teach client re: self-care

Bowel Resection, Ileostomy

Same as Chron s D se

HERNIA

-An abnormal protrusion of an organ or tissue through the structure that contain s it. - Frequently a congenital occurrence or acquired wea ness of the abdominal muscl es

Types: 1. 2. 3. 4. 5. Indirect Inguinal Hernia Direct Inguinal Hernia Femoral Hernia Umbilical Hernia Incisional Hernia

Medical Treatment: Use of TRUSS if hernia is not strangulated or incarcerated.

Surgical Treatment: Herniorrhaphy

Nursing Intervention: Pre & Post-operative Care Post-op Care: a. Ma e sure the client voids after surgery, urinary retention is common

after herniorrhaphy b. Resume diet as tolerated by the patient c. Ice pac over the incisional site to control pain and swelling d. Instruct patient to avoid heavy lifting from 4-6 wee s post surgery

DIVERTICULUM

Diverticulum e large

an outpouching of intestinal mucosa through the muscular coat of th

intestine (most commonly the sigmoid colon) Diverticulosis ine Diverticulitis refers to the presence of non-inflamed out pouching of the intest inflammation of a diverticulum

Incidence: > 45 yrs. old ; Male & Female

which may cause intraluminal pressure in the bowel causing diverticula

Ris factors: Chronic Constipation

S/S: Left Quadrant Pain Anorexia Increased flatus Low grade fever (+) rectal mass on digital rectal examination

Medical Intervention: High-fiber diet and laxatives NGT insertion to relieve pressure

Etiology: Lower fiber diet which causes bul

in stools

Control inflammation through antibiotics and advise patient to: a. Avoid activities that may increase abdominal pressure (bending, lifting, etc) b. Inta e of 6-8 glasses of water a day c. Reduce weight if obese

Surgical Intervention: Indicated for those who developed complications as manife sted by hemorrhage, abscess, perforation and obstruction. o Colon resection with colostomy

Indications

Nursing Intervention

Colostomy o Involves the large bowel (colon)

o stool is semiformed

o Inflammatory / obstructive process of the lower intestinal tract o Trauma o Rectal or sigmoid cancer o Diverticulum

1. Emotional support 2. Psychological Support 3. Heath Education regarding: a.surgery (ileostomy/colostomy) b. Self-care Ileostomy o Involves the small bowel (ileum) o stool is in liquid form

o Chron s Disease o Ulcerative Colitis

d. Hirschprung s Disease and Megacolon

. Congenital absence of parasympathetic ganglion . Clinical Manifestations: o NB fail to pass meconium 24 hrs after birth o Older child recurrent abdominal distention, chronic constipation, ribbon-li e stool, diarrhea, emesis w/ bile stain

Treatment: a. Colostomy b. Bowel Resection c. Cleansing Enema

Post-op Nursing Intervention; a. Teach colostomy care- chec color of stoma (should be bright leg) b. Chec dressing c. Monitor inta e & output d. Avoid incision by eeping diapers low e. 10-11 yr. old child can already ta e care of his/her own stoma.

e. Hemorrhoids

o Peri-anal varicosities which is either internal or external

o Types: a. Internal

varicosities above the mucocutaneous border covered by the

mucous membrane.

b. External Hemorrhoidscovered by the anal s in.

varicosities below the mucocutaneous border

Incidence: Both male and female aged 20-50 y/o. Pregnancy, CHF, Prolonged sitting or standing, portal hypertension

Movement

Ris

factors: Increased abdominal pressure, constipation, straining during bowel

S/S: Internal External

bleeding and renal prolapse, bleeding and rectal itching

enlarged mass at the anus

Present symptoms in both internal & external: Bright red (blood) stain in stool or tissue, Pain Medical Intervention: a. Treat constipation b. Relieve pain through heat application / Sith s bath

Surgical Intervention: Hemorrhoidectomy, Sclerotheraphy, Rubber band ligation, Laser Surgery, cryosurgery

f. Fistula-in-ano . Tiny, tubular fibrous tract that extends into the anal canal . May develop from trauma, fissures or regional enteritis . Fistulectomy is recommended.

.3.3. Abdominal Trauma :

a. Blunt Trauma injury li e vehicular accident b. Penetrating Abdominal Trauma stab wound

4. DISTURBANCES IN FLUIDS AND ELECTROLYTES

Fluid Content in the Human Body : a. Women - 50-55% of body weight is water b. Men - 60-70% of body weight is water c. Infant - 75- 80% of body weight is water

d. Elderly - 47% of body weight is water

Electrolytes in the Human Body: a. Sodium (Na) - 135-145 mEq/L b. Potassium (K) - 3.5 5.5 mEq/L

c. Chloride (Cl) - 85-115 mEq/L d. Bicarbonate (HCO3 ) - 22-29 mEq/L

Functions of the Fluid & Electrolytes in the Human Body: a. Regulates acid-base balance in the body b. Maintains fluid volume c. Regulates exchange of water between fluid compartments

Actions of the Fluids & Electrolytes a. Diffusion fluids move from area of higher concentration to an area of lower c oncentration b. Osmosis - fluids move from an area of lesser concentration to a higher concen tration c. Filtration fluids and substances moves from higher hydrostatic pressure to le sser hydrostatic pressure.

Intravenous Solutions Used to correct imbalance: e. Isotonic 0.9 NSS, D5W f. Hypertonic has greater concentration of solis substances than the fluid subst ances

e.g.Total Parenteral Nutrition, D50 g. Hypotonic has fewer solid and has higher fluid content, e.g. 0.45 NaCl

System of Fluid Balance in the body: a. b. c. d. Kidneys responsible in controlling the balance of fluid & electrolytes Lungs- controls the Carbondioxide levels in the body and water vapor S in means of elimination of fluid in the body through perspiration Endocrine Controls hormones which regulates normal functioning of systems

Imbalances in Fluids & Electrolytes

Fluid Volume Excess Fluid Volume Deficit

Cause

fluids exceeds the normal volume the body needs - physiologic or over hydration as in IV therapy

fluids and/or electrolytes are loss physiologic or dehydration Illness:

Renal Disease Neurologic Diseases Congestive Heart Failure Addison s Disease

Renal Disease Diarrhea Post-operative conditions Burns Trauma GIT Suction/Drainage

Clinical Manifestations

Weight gain Edema Flushed s in Tachycardia Increased BP, RR Rales Nec Vein distention Increased Central Venous Pressure Decreased Hct Urine output: > 1,500 ml/day

Weight loss Dry s in and mucous Membrane Tachycardia (same w/ excess) Poor s in turgor

Decreased urine output Decreased Central Venous Pressure Increased hematocrit Urine output: < 30 cc/hr ( Normal Urine Output =30 cc/hr)

Nursing Interventions

Monitor vital signs Monitor I & O Fluid restriction Low sodium diet Weight daily Prevent s in brea down- s in is fragile Keep client in Semi-fowler s position to establish good gas exhange Administer Diuretics as orderedLasix (Furosemide)

Monitor vital signs Monitor I & O Replace fluids, Rehydration Weight daily Administer medications as ordered ( depending on electrolytes loss)

Encourage proper nutrition an fluid inta e

Sources of Electrolytes:

Electrolyte Food source Potassium Bananas, peaches, melon, prunes, raisins, apricots, tomato, nuts & vegetables, red meat, tur ey Sodium Iodized or table Salt Magnesium Peas, beans, nuts, fruits Calcium Mil , cheese, sardines, fish

4.1 Genitourinary & Renal Problems

Renal Function Tests Normal Values: a. b. c. d. e. Blood Urea Nitrogen (BUN) 10-20 mg/dl Serum Creatinine- 0-1 mg/dL Creatinine Clearance 100-120 ml/ minute (24 hr. urine collection) Serum Uric Acid -3.5 -7.8 mg/dL Urine Uric Acid 250-750 mg/ 24 hrs. (24 hr. urine collection)

4.1.2. Cystitis / Urethritis/ Urinary Tract Infection usually caused by E.Coli

Signs & Symptoms a. Frequency & Urgency of urination b. Dysuria c. Suprapubic pain d. Hematuria e. Fever, chills f. Cloudy urine

Nursing Considerations: a. Collect urine for testing b. Antibiotic treatment, as ordered c. Force fluids d. Good hygiene

4.1.3. Glomerulonephritis ccus

inflammatory damage of the glomeruli

usually Streptoco

Signs & Symptoms:

Nursing Considerations:

Signs & Sypmtoms: a. Proteinuria

4.1.4. Nephrotic Sydrome etc.

a. b. c. d.

Penicillin, as ordered Proper dietary inta e Sodium & fluid restriction Bed rest

glomeruli disorder due to other diseases li e DM, SLE,

. . . . . . . .

Hematuria, proteinuria, fever, chills, wea ness, nausea, vomiting Edema Oliguria HPN Headache Increased Urea Nitrogen Flan Pain Anemia

b. Hypoalbunimemia c. Hyperbilirubinemia d. Edema

Nursing Considerations: a. bed rest b. high calorie, high protein, low sodium c. Monitor I & O d. Protect from infection e. Administer meds as ordered: Diuretics, Steroids, Immunosuppresiove agents, anticoagulants

4.1.5. Urolithiasis - stones in the urinary system

Signs & Symptoms: a. Dull aching pain b. Nausea, vomiting, diarrhea c. Hematuria d. UTI symptoms

Nursing Considerations: a. Force fluids: at least 3L of water in a day b. Strain Urine for stones c. Administer meds as ordered

Signs & Symptoms: 3 Phases a. Oliguric Phase sudden , (+) edema

4.1.6. Acute Renal Failure sudden and reversible malfunction of the trauma, allergies, stones or benign Prostatic hyperplasia

idney due to

- urine is less than 400 cc in 24 hrs. b. Period of Diuresis c. Recovery Period Nursing Intervention: a. Treat cause of sudden occurrence b. Maintain Fluid & electrolyte balance c. Prevent hypo alemia d. Administer insulin or IV glucose as ordered to promote potassium absorption e. Proper diet : . Oliguric low CHON, High CHO, high fat, less potassium . Diuresis high CHON, high calorie, less fluid urine is 1000 ml in 24 hrs and is diluted

f. g. h. i.

Weigh daily Monitor I & O Dialysis if indicated Psychological & emotional support

by chronic gomerulonephritis (CGN), pyelopnephritis, DM, uncontrolled HPN

Signs & Symptoms: a. fatigue b. Headache c. Gastrointestinal symptoms d. HPN e. Irritability f. Convulsions g. Anemia h. Elevated BUN, crea, sodium, potassium

Treatment: . Dialysis . Renal Transplant

Nursing Considerations: a. Maintain fluid & electrolyte balance b. Bedrest

4.1.7. Chronic Renal Failure sult to death, caused

progressive failure of idney function which may re

c. Diet: low protein, low sodium, high CHO and vitamins d. Control HPN e. WOF cerebral irritation

older males Signs & Symptoms: . Difficulty in urinating . Nocturia, hematuria, dribbling sensation

Surgical Treatment: . Prostatectomy

Post-operative Nursing Consideration:

TREATMENT FOR GENITOURINARY PROBLEMS: 1. Dialysis a. Hemodialysis

a. b. c. d. e.

Observe for shoc and hemorrhage Bladder Drainage; monitor bladder irrigation Avoid lifting heavy objects x 6 wee s and avoid strenuous activities Increase fluid inta e Decrease pain, administer meds as odered

4.1.8. Benign Prostatic Hyperplasia ology usually in

enlargement of the prostate with un nown eti

. Process of cleansing the blood of waste products which the GUT is unable to el iminate . Cathether inserted via a small incision on the nec (intrajugular), arms or at the femoral area.

b. Peritoneal Dialysis . Use of peritoneum via a catheter for proper exchange of fluids and electrolyte s and drainage of fluids . Catheter inserted just below the umbilicus with small incision

c. Continuous Ambulatory Peritoneal Dialysis

Nursing Interventions: a. Weigh daily b. Monitor vital signs c. Maintain asepsis at all times d. Record inta e and output e. Monitor for complications: Bleeding, peritonitis, abdominal pain, dyspnea, bo wel

perforation 2. Urinary Tract Surgery a. Transurethral Removal of the Prostate b. Prostatectomy

Nursing Interventions: . Weigh daily , monitor I&O . Monitor vital signs . Maintain asepsis at all times . Monitor for complications: Bleeding, peritonitis, abdominal pain, dyspnea, bow el . Replace fluids . Proper irrigation

3. Kidney Transplant

KIDNEY DISEASE IN THE PHILIPPINE HEALTH SITUATION

. 6,000 new cases of renal disease per year . Affects all ages . Adult: End-Stage Renal Disease (ESRD)

Children and young: Chronic Glomrulonephritis Causes: 1. 2. 3. 4. Chronic Glomerulonephritis 47% Chronic Pyelopnephritis 17% Diabetes Mellitus- 13% Hypertensive Nephrosclerosis- 5%

Kidney Disease Prevention: 1. Good Nutrition

2. 3. 4. 5. 6. 7.

Clean Environment Early detection of of the disease Thorough urinary screening of asymptomatic children Increase casefinding and treatment for chronic glomerulonephritis Good glycemic control (w/ DM) Optimum Blood Pressure Control

Nursing Health Education:

1. Increase awareness and prevent renal disease:

3. Routine screening for UTI, diabetes and idney disease 5. DISTURBANCES IN CELLULAR FUNCTIONING

5.1. CANCER

o Abnormal growth of tissues a. Carcinoma - epithelial cells lining the internal and external surfaces of the body. b. Leu emia - cancer from blood-forming organs c. Lymphoma cancer from reticulo-endothelial lymph node organs d. Sacrcoma- cancer from connective tissues

2. Increase awareness of signs & symptoms of

. . . . . . . .

Adequate water inta e Balanced diet Good personal hygiene Regular exercise Regular BP chec -up Complete immunization for infants and children Proper management of throat and s in infections Yearly urinalysis

idney disease as edema and HPN

Cancer in the Philippines: o Ran s third in leading cause of morbidity and mortality o 75% of cancers occur at age 50 y/o

Staging of Tumors a. Extent of tumor

T= primary tumor N= regional nodes M= metastasis

b. Extent of Malignancy

T0 = no evidence of primary tumor TIS= Carcinoma in Situ T1, T2, T3, T4 = progressive tumor in size and involvement TX = tumor cannot be assessed

c. Involvement of Regional Nodes

NO = regional lymph nodes not abnormal N1, N2,N3, N4 = increasing degree of abnormal regional lymph nodes

d. Metastatic Development

MO= no evidence of distant metastasis M1, M2, M3 = increasing degree of distant metastasis

Clinical Manifestations of Tumor Presence (based on Community Health Nursing Services in the Philippines by the DOH)

C Change in bowel or bladder habits Ex. Gastric Ca, Colon Ca, Rectal Ca , Renal Ca, Prostate Ca A A sore that does not heal Ex. Laryngeal Ca U Unusual bleeding or discharge Ex. Uterine Ca T Thic ening or lump in breast or elsewhere Ex. Breast Ca, Hodg in s Lymphoma I Indigestion or difficulty in swallowing Ex. Esophageal Ca O Obvious change in wart or mole Ex. Melanoma, Squamous cell Ca N Nagging cough or hoarseness Ex. Lung Ca

U Unexplained Anemia

S Sudden uexplained weight loss Most Ca conditions

Ris Factors Age Health Habits Sex Family History Race Socio-Economic Status Occupation Lifestyle Cancer Therapy a. b. c. d. Surgery Chemotherapy chemical/ medication Radiation Therapy electromagnetic rays destroys cancer cells Palliative/ Supportive Care- for end-stage or terminal stage

- given if chemo, surgery or radiation therapy cannot assure treatment of the patient ; it is a holistic care for the patient and family - management o f care is geared towards a symptom-free individual with psychologic and spiritual support

Cancer Prevention & Early Detection

Type of Cancer

Early Prevention

Early Detection

Oral Cancer

Avoid Smo ing tobacco, Betel quid Nganga chewing, Proper cavity and dental chewing

Thorough dental chec -up each year

Breast

No conclusive evidence for early prevention

Monthly self-exam and annual exam with physician;

Mammography: o Initially at age 40 and then 1-2 yrs thereafter o High ris women- should consult a doctor before age 40

Lung

Avoid smo ing

Annual chec -up

Uterine / Cervix

Clean, safe sex

Regular pap smear: Once sexually active then every 3 years if findings are normal

Liver

Hepa. vaccine, Minimal alcohol inta e, Avoid moldy foods

None

Single partner reduces ris

Colon and Rectum

Maintenance of a high fiber and low fat diet

Regular medical chec -up after 40 years, yearly occult blood tests in stools, rectal exams and sigmoidoscopy

S in

Avoid excessive sun exposure

Self s in assessment

Prostate

No conclusive evidence for early prevention

Rectal Exam

Nursing Intervention

a. Assist the patient in maintaining self-dignity and integrity by continued and sustained communication and contact b. Allow patient to ventilate feelings such as fear, anger, indifference c. Ma e arrangements for spiritual consolation d. Assist in rehabilitation even before treatment and until she recovers and adj ust to the society e. Collaborate with other health wor ers for the patient s holistic needs f. Home visits and education about the client s condition, course of treatment and alternatives

Priorities for Health Supervision: a. b. c. d. Newly diagnosed cases Post-operative Cases Indigent Cases Terminal Cases

5.2. HEMATOLOGIC PROBLEMS

Normal Values to Remember:

Blood Component Normal Values

RBC

red blood cells

Female: 4.2 Male: 4.7

5.4 x 106 6.1 x 106

Hgb - hemoglobin

Female: 11.5 Male: 13.5

15.5 g/dL 17.5 g/dL

Hct - hematocrit

Female: 36

48%

Male: 40 -52%

WBC

white blood cells

4,500

11,000/ mm3

PC- Platelet count

150, 000

400,000 / mm3

5.2.1. ANEMIA

Causes: a. Sudden or Chronic blood loss b. Abnormal bone marrow function c. RBC fails to mature adequately

Signs & Symptoms: Fatigue, Wea ness, Dizziness, Pallor, Decreased RBC, hemoglobin & hematocrit Types of Anemia:

a. a. b. c.

Hypoproliferation Anemia bone marrow fails to produce adequate blood cells Iron Deficiency Anemia nutritional deficiency, blood loss Aplastic Anemia - due to radiation, drugs, toxin Anemia due to Renal Disease

Clinical Manifestations: . . . . Hypoxia Prone to infection Fatigue Easy bruising

Nursing Intervention: . Proper nutrition . Psychological support . Protect against infection and injury

b. Megaloblastic Anemia y of the gastric mucosa

. Pernicious Anemia

due to previous gastric surgery, malabsorption or atroph

Vit. B12 and Folic acid deficiency in gastric juice

Clinical Manifestations: . . . . Paresthesia Tingling or numbness of extremities Gait disturbances Behavioral Disturbances

Nursing Intervention:

. Protect lower extremities . Rest in non-stimulating environment

c. Hemolytic Anemia . Sic le Cell Anemia- defective hemoglobin, turns to sic le cell when oxygen in venous blood is low . Thalassemia . Glucose-6 Phosphate Dehydrogenase Deficiency

Clinical Manifestations:

Nursing Intervention:

. . o o o o o

Thalassemia & G6PD Sic le Cell Anemia: Severe Pain Swelling Fever Jaundice Prone to infection

usually asymptomatic

. o o o

Inta e of Vit. B12 following this regimen: 3x a wee for 2 wee s, then 2 x a wee for 2 wee s, then Once a month

. . . .

Proper oxygenation Hydration Analgesics Adequate Rest

. Refer to genetic counseling . Avoid cold places to prevent sic le cell proliferation

5.2.2. LEUKOCYTOSIS & LEUKEMIA

Leu ocytosis

increase level of WBC, persistent increased can be malignant

Leu emia - proliferation of neoplastic white blood cells in the bone marrow affe cting the different tissues and organs in the body

. Acute & Chronic Myeloid Leu emia (AML / CML) . Acute & Chronic Lymphocytic Leu emia (ALL / CML) . Angiogenic Myeloid Metaplasia (AMM)

Clinical Manifestations: . . . . . Fever Prone to Infection Pain Weight Loss Fatigue

Nursing Interventions: . Energy conservation . Reverse Isolation . Blood Transfusion

5.2.3. POLYCYTHEMIA

neoplasm of myeloid cells

Clinical Manifestations: . Dizziness, headache, tinnitus, fatige, paresthesia, blurred vision, atheroscle rosis

5.2.4. THROMBOCYTOPHENIA - Increased Bleeding Tendencies

5.2.5. LYMPHOMAS

neoplasm of lymphatic cells

Management: Chemotherapy, Blood Transfusions, Reverse Isolation, Radiation thera py, Steroids

Nursing Interventions: . . . . Emotional Support Reverse isolation Adequate Rest and Nutrition Strict Medication Regimen

5.2.6. BLOOD TRANSFUSION

Types of Blood Components Transfused

. . . .

Hodg in s Lymphoma Non-Hodg in s Lymphoma Multiple Myeloma Thrombocytophenia low platelet , bleeding

1. Whole Blood 2. Pac ed Red Blood Cells 3. Fresh Frozen Plasma/ Plasma Concentrate

Transfusion Complications 1. Non-hemolytic reaction- Fever 2. Hemolytic Reaction- life threatening: fear, chills, bac pain, nausea, chest t ightness, dyspnea and anxiety 3. Allergic reaction urticaria, flushing, itching 4. Hypervolemia nec vein distention, dyspnea, orthopnea, tachycardia, sudden an xiety

Diseases Transmitted through Blood Transfusion . Hepatitis B or C , AIDS / HIV, Cytomegalovirus

Nursing Interventions:

1. Chec name, ID, blood type, expiration, serial #

2. Ta e baseline vitals signs 3. Blood pac should be at room temperature 4. Monitor for transfusion reaction . Allergic (pruritus, respiratory distress, urticaria) . Hemolytic (low bac pain, fever, chills) 5. Treat transfusion reaction, if present

NEUROLOGIC DISTURBANCES

I. Central Nervous System:

a. Brain b. Spinal Cord

II. Peripheral Nervous System

a. Cranial Nerves

12 pairs

symptomatic treatment

b. Spinal Nerves . Cervical 8 . Thoracic 12 . Lumbar 5 . Sacral 5 . Coccygeal - 1

31 pairs

c. Autonomic Nervous System . Sympathetic Nervous System . Parasympathetic Nervous System

The Cranial Nerves: o Oh, Oh, Oh, To Touch And Feel A Girls Veil So Heaven

I Olfactory Smell II Optic Visual Acuity III Oculomotor

Pupil constriction and dilation IV Trochlear Eye movement: Inferior and medial V Trigeminal Jaw muscles VI Abducens Eye movement: Lateral directions VII Facial Symmetrical facial movement, Client identifies taste, Eyelid reaction to stimulus VIII Auditory Hearing Acuity IX Glossopharyngeal Gag Response X Vagus

XI Spinal Accessory Shoulder s ability to resist against pressure XII Hypoglossal Tongue at midline

Ability to spea

clearly

Neurologic Status:

a. Conscious- alert, attentive, and follows command b. Lethargic- drowsy but awa ens; follows command, but slowly and inattentively c. Stuporous - arouses to vigorous and continuous stimulation -response may be an attempt to remove the painful stimulus. d. Coma. no sounds, no movement

THE GLASGOW COMA SCALE

- An assessment tool measuring the individual s neurologic status specifically the spontaneity of the client s eye movement , spea ing ability and motor abilities in response to a stimuli.

Perfect score is 15 points - Spontaneous/ Normal eye, motor and verbal response Lowest score is 3 points - No response

Eye Opening Response

Points a. Spontaneous 4 b. To speech 3 c. To pain 2 d. No response 1

Motor Response

a. Obeys verbal commands 6 b. Localizes pain 5 c. Flexion: no withdrawal 4 d. Flexion: abnormal (decorticate) 3 e. Extension: abnormal (decerebrate) 2 f. No response to pain on any limb 1

Best verbal response

a. Oriented 5 b. Able to Converse 4 c. Inappropriate speech 3 d. Ma es incomprehensible sound 2 e. No response 1

Example:

Patient s conscious, coherent. Can tell where he is, can loo at surroundings, can raise hands when as ed to, and can express self through words, answer questions appropriately.

Eye slightly opens when name is called ; No movement/response when s in is Pinched ; When calling the nurse: can only say ne .e e. sound

GCS Scoring:

Eye opening = 4 Motor Response = 6 Verbal Response = 5

GCS Score = 15

GCS Scoring:

Eye opening = 3

Motor Response = 1 Verbal Response = 2

GCS Score = 6

CEREBROVASCULAR ACCIDENT (CVA) Stro e o

o A sudden disruption of blood supply to the brain which may lead to temporary o r permanent dysfunction.

Ris s Factors: HPN, Obesity, peripheral vascular disease, obesity, aneurysm

Signs & Syptoms: a. Speech problem / Aphasia - a loss or impairment of the ability to produce and/or comprehend language b. Hemiparesis- wea ness of one side of the body

c. Hemiplegia - total paralysis of the arm, leg and trun on the same side f the body. d. Decreased awareness of body space Types of stro e: 1. Transient Ischaemic Attac (TIA) - short-term stro e that lasts for less than 24 hours ( seconds or minutes in a day) - oxygen supply to the brain is restored quic ly - transient stro e needs prompt medical attention as it is a warning of serious ris of

a major stro e.

2. Cerebral thrombosis - a blood clot (thrombus) forms in an artery (blood vessel) supplying blood to the brain. - brain cells are starved of oxygen.

3. Cerebral embolism - blood clot that forms and then travel to the brain.

4. Cerebral hemorrhage - occurs when a blood vessel bursts inside the brain and bleeds (haemorrhages). With a hemorrhage, extra damage is done to the brain tissue by the blood that seeps into it.

Nursing Interventions:

1. Maintain adequate airway

3. Maintain fluid & electrolyte balance

2. Monitor neuro vital signs: Vital signs and Glasgow coma scale including inta e and output

SPINAL CORD INJURY

Definition: A damage in the nerve structure causing dysfunction resulting to par alysis, sensory loss and altered activity.

Cause: Vehicular accidents, Violence, Falls, Sports, Infection, Tumor

The Spinal Nerves: 1. 2. 3. 4. Cervical Nerve Thoracic Nerve Lumbar Nerve Sacral Nerve

Etiology: 1. Spinal Shoc (Areflexia) 2. Autonomic Hyperreflexia - Injury in T6 and above - Life-threatening

Nursing Interventions: 1. 2. 3. 4. Immobilization specially after injury or trauma Maintain respiratory function, ABC Bladder & bowel management Rehabilitation

Nerves

Level

Body part affected

Spinal Cord Injury Effect

Cervical Nerve

Injury causes Quadriplegia/ Tetraplegia

C1

Paralysis below nec ; impaired breathing, bowel & bladder incontinence, sexual dysfunction C2 C3 C4

Head & Nec

Diaphragm

Shoulder elevation possible, ventilation support C5 C6 Deltoid, biceps

Elbow, upper arm, wrist movement C7 Wrist Extenders C8 Triceps

Thoracic Nerve

Injury causes Paraplegia

T1

Hand

Loss of hand control, Paralysis below waist

T2 T3 T4

Chest Muscles T5 T6 T7

Abdominal Muscles

Trun and Abdominal control T8 T9 T10 T11 T12

Lumbar Nerve

Paralysis of legs; loss of bladder and bowel control

L1

Leg muscles

Hip adduction impaired L2

Knee and an le movement impaired L3 L4 L5

Sacral Nerve Sexual, Bladder & Bowel conrol

S1

Bladder & Bowel control

Bladder/Bowel Incontinence,etc S2 S3 S4 Sexual Control

Decrease sensation in the peineum S5

PARKINSON S DISEASE

PARKINSON S DISEASE

Definition: A disorder affecting control and regulation of movement - Unilateral flexion of arms, shuffling gait, difficulty in wal ing, wea ness, d isability

Clinical Manifestations:

Medical Management: Anti-par insonian Agent: Levodopa Anti-cholinergic: Cogentin

Surgical Management: Stereotaxic Thalamotomy sorder

Nursing Interventions: a. b. c. d. e. Rehabiltation exercise Speech therapy Diet: Low CHIN in am, high CHON in PM High fiber foods to promote bowel elimination Prevent Injury fall, etc

a. b. c. d. e. f. g. h. i.

Rigidity Involuntary body tremors Hips and nees flexion Mas li e facial expression Slurred speech Drooling Constipation Depression Retropulsion, propulsion

surgery of the thalamus to treat di

MYASTHENIA GRAVIS

Definition: Severe wea ness of one or ore groups of s eletal muscles; Severe wea ness of the neuro functions most commonly affecting the Seventh cranial nerve- Facial Nerve

Clinical Manifestation:

Management: a. Pyridostigmine Bromine (mestinon) b. Ambenomium Chloride c. Steroids Prednisone d. Atrophine Sulfate

Nursing Interventions: Avoid fatigue, Administer meds as ordered, Avoid neomycin

1. 2. 3. 4.

Mas -li e facial expression Diplopia- double-vision Ptosis- difficulty opening of the eye Dyphagia

and morphine

CATARACT

Clinical Manifestations: 2. Gradual visual loss. 3. Hazy vision / Yellowish haze 4. Whitish to yellowish eyelense.

Surgical Treatment: Cataract extraction

Vision w/ Cataract Drug: Vision w/ Cataract 1. Mydriatrics - causes dilation of pupils; increases intraocular pressure (IOP ) a. Atrophine Sulfate

Definition: - the eye lenses becomes thic

and unclear or yellowish.

b. Phenylephrine Hydrochloride

2. Cyclopegics

decreases ciliary muscle accomodation

Side effects: blurred vision, increase BP

Nursing Intervention: 1. Monitor BP; avoid use to patients with HPN 2. Teach client that blurring of vision may be experienced. 3. Post-op intervention:

. eep eye covered . head of bed elevated at 30-45 degreed, supine position . Avoid bending or lifting heavy objects, coughing and sneezing as it may furthe r increase IOP

GLAUCOMA

- A non-curable condition of the eye due to increase in intraocular pressure cau sing

deterioration of the optic nerve.

2 types of Glaucoma:

1. Acute or Closed- Angle Glaucoma a. Rainbow around lights b. Pain around the eye c. Cloudy and blurred vision

d. Nausea & vomiting e. Dilation of pupils

2. Chronic or Open-Angle Glaucoma a. Halo around lights b. Progressive loss of vision c. Tired feeling in the eye d. Slowly diminishing peripheral vision

Vision w/ Glaucoma Surgical Management: 1. Trabeculectomy 2. Thermosclerectomy 3. Iridenclesis

Drugs: Miotics causes constriction of pupils

1. 2. 3. 4.

Pilocarpine hydrochloride - Drains aqueous humor Acetazolamide decreases production of aqueous humor Mannitol reduces IOP Isosorbid also decreases production of aqueous humor

Nursing Intervention: 1. Administer drugs as ordered 2. Teach client that glaucoma can be controlled but not curable (even surgery ca n t cure the disease) 3. Encourage moderate exercise 4. Avoid straining of bowel 5. Encourage low residue, high fiber diet

6. MUSCULOSKELETAL DISTURBANCES

JOINT DISORDERS

RHEUMATOID ARTHRITIS

OSTEOARTHRITIS

Definition

A systemic inflammatory disorder of connective tissues and/ or joints characterized by exacerbation & remission.

Degeneration of the articular cartilage Wear & Tear of joints

Kinds of Joints

Cervical, finger joints, ulnar, can also be involved:heart and lung (as in rheumatic heart disease)

Incidence

Chronic disease; early to mid-adulthood, common in women

Older women

Clinical Manifestations

. Synovitis . Pain relieved with rest . Intermittent bone pain, swelling, redness, warm feeling due to vasodialtion and increased blood flow . Pannus formation- granulation of tissue causing destruction of adjacent cartilage, joints and bones . fatigue, anorexia, malaise, weight loss

Weight-bearing joints:

nees, hips, spine

Pain felt after activity

Management

Rest, exercise, ASA, NSAIDs, Steroids, heat

Balanced rest and activity, heat pac s, steroids in joist only

Drug: Steroid, ASA, Indomethacin, Phenylbutazone

Nursing Intervention

Maintain body alignment, Balance rest and exercise, proper diet

Gout / Gouty Arthritis

Defintion: painful metabolic disorder due to inflammation of the joints due to high uric acid

Clinical Manifestations A salt of uric acid (Urate) crystallizes in soft and bon y tissues causing local inflammation and

Ris

Factors: Hereditary, most common in men

irritation. Severe pain, usually in great toe Red, painful and swollen joints Tophi (crystal formation in joints) are palapated around great toes, fingers, earlobes Drugs: Allopurinol NSAID s Ibubrofen , Indomethacin

Probenecid Colchicine Sulfinpyrazone

Nursing Management: a. Bedrest during attac s b. Heat or cold compress c. Increase fluid inta e to flush out uric acid d. Avoid eating organ meats, shellfish, sardines - - - food with high purine / u ric acid content

Systemic Lupous Erythematosus (SLE)

Definition: Diffuse connective tissue disease affecting s in, joints, idney, se rous membranes of the heart and

lungs, lymph nodes and GI tract.

Ris factors: Children, middle-aged and elderly; hereditary

Manifests symptoms same as that of arthritis and Raynaud s

Management: NSAID s Steroids Cytotoxic drugs - Azathioprine, Cyclophosphamide

Nursing Intervenions: a. Avoid exposure to sunlight because symptoms aggravate symptoms or wear hats, umbrella or sunscreen b. Adequate nutrition, rest and exercise c. Stress management, if possible avoid stress

Fractures

Definition: A brea in the continuity of the bones

Clinical Manifestations:

Pain

Clinical Manifestations:

Butterfly rash

in the face ( across both chee s and nose)

Edema Loss of function Spasm Deformity Crepitus False motion Hematoma around s in Brea s for penetrating bone fragments

Management:

First Aid

1. Maintain airway and circulation 2. Immobilize joints that may be affected; Splint limb 3. Bring to nearest hospital/medical institution

Traction

-balanced pulling of the musculos eletal structure to align bones; requires countertraction

Closed Reduction

- external manipulation such as manually aligning bones by pulling. For patients who have lower pain tolerance (elderly, children) reduction may be done under sedation anesthesia.

Open Reduction

- internal manipulation of bones requiring surgical operation

Internal Fixation

- surgically applying screws, plates, pins, nails to align bones (opening of the s in and exposing bones affected); s in is closed after the procedure.

External Fixation

- applying nails and metal screws to bones through the s in surface

Casts

- -a rigid mold used to immobilize an injured structure to promote healing

Nursing Management: 1. 2. 3. 4. Mainatin positioning For tractionL maintaing weights and countertraction Clean wounds to prevent infection Assess for VASCULAR OCCLUSION

5 P s: 5 signs of Vascular Occlusion due to extremely tight casts / traction a. Pain b. Pallor c. Pulselessness d. PAresthesia e. Paralysis

7. INTEGUMENTARY DISTURBANCES Burn

Depth of Injury

Manifestation

Level of S in Affected

First-degree

Painful, pin to reddish, subsides quic ly

Epidermis and part of dermis

Superficial

Second-degree

Pain, pin to red, with blisters (fluid formation)

Epidermis and dermis hair follicle intact

Superficial partial thic ness; Deep partial thic ness

Third- degree

Reddish, brownish or whitish, painless, eschar formation (Leather-li e s in)

Epidermis, dermis, subcutaneous tissue

Full thic ness

Fourth-degree

Epidermis, dermis, subcutaneous tissue; fat, fascia, muscle and bone

Full thic ness

Rule of Nines: a. Head and Nec - 9%

b. Anterior Truc - 18% c. Posterior Trun - 18% d. Arms - 9% each = 18% e. Legs - 18% each = 36% f. Perineum - 1%

100%

Rule of Nine s

Management:

First-Aid:

Hospital Interventions: 1. Chec ABC, give oxygen and IV fluids 2. Assess client s data, history of injury (time, cause,etc) 3. Maintain asepsis- burn patients are very prone to infections 4. Medical Surgical Management: a. Tetanus toxoid b. Topical Anti-microbial agent: Silver Nitrate, Silver Sulfadiazine, Gentamicin Sulfate, Mafenide acetate c. Debridement

SHOCK

Failure of the circulatory system to maintain adequate perfusion of vital organs. Critically severe deficiency in nutrients, oxygen and electrolytes delivered to b ody tissues, plus deficiency in removal of cellular wastes, resulting to cardiac failure

1. Non- progressive Stage Cardiac output is slightly decreased

I. Stages of Shoc

1. 2. et 3. 4.

Burning person: As person to stop, drop and roll ( lie down and roll) Burning person: Stop burning process such as wrapping the burning part with w towel or blan et Chec airway First-degree burn: Run cool water to affected area for 10 minutes

Body compensates

2Progressive Stage Compensatory mechanism is not adequate

blood flow to the heart is not adequate thus heart begins to deteriorate

3. Irreversible Stage - Inadequate tissue perfusion - Cellular ischemia & necrosis lead to organ failure

Cause Etiology

due to inadequate circulating blood volume Blood loss: Massive Trauma, GI Bleeding, Ruptured Aortic Aneurysm, Surgery, Erosion of Vessesl due to lesion, tubes or other devices, Disseminated Intravascular Coaguation Plasma loss: Burns, Accumulation of intra-abdominal fluid, malnutrition, severe dermatitis, DIC

Hypovolemic Shoc

II. Types of Shoc

Crystalloid loss: Dehydration, Protracted Vomiting, Diarrhea, nasogastric suction

due to inadequate pumping action of the heart because of primary cardiac muscle dysfunction or mechanical obstruction of blood flow caused by MI or valvular insufficiency

Myocardial disease: Acute MI, Myocardial Contusion

Cardiomypathies Valvular Disease or injury: Ruptured Aortic Cusp, Ruptured Papillary muscle, Ball thrombus

External Pressure on the Heart interferes with heart filling or emptying: Pericardial Tamponade due to Trauma, aneurysm, cardiac surgery, pericarditis, massive pulmonary embolus, tension pneumothorax

Cardiac Dysrhtymias: Tachyarrhythmias, Bradyarrythmias, Electromechanical dissociation

a. Neurogenic Shoc

3. Distributive Shoc

Cardiogenic Shoc

b. Anaphylactic Shoc

- interference with nervous system control of the blood vessels

-severe hypersensitivity reaction resulting in massive systemic vasodilation

- systemic reaction vasodilation due to infection

c. Septic Shoc

Spinal: Spinal anesthesia, spinal cord injury Vaso-vagal reaction: Severe pain, severe emotional stress Allergy to food, medicines, dye, insect bites or stings

Gram-negative septicemia but also caused by other organisms

Anxiety BP- hypotension Restlessness

Dizziness Thirst Respiration: increased depth, tachypnea, wheezing (anaphylactic shoc ) Fainting Temperature: cold clammy s in, elevated in anaphylactic

LOC - could be alert, oriented, unresponsive Oliguria, Slow capillary refill CVP below 5 cm H20 (hypovolemic)

Pale s in, urticaria in anaphylactic shoc

Pulse

tachycardia, thready, irregular (Cardio.Shoc )

III. Signs of Shoc

- above 15 cms (cardio & septic)

IV. Nursing Care Management GOAL: Promote venous return, circulatory perfusion

1. Position: Feet elevated with head slightly elevated also 2. Ventilation: loosen restrictive clothing, O2, monitor respiration 3. Fluids: IV, administer blood/plasma as ordered ( stop blood immediately in an aphylactic s.) 4. Vital signs: CVP, ECG, U.O.,Swan Ganz 5. Medications (depends on type)

6. Antihypotensive (epinephrine, norepinephrine, dopamine) 7. Anti-arrythmics, Cardiac Glycosides, Antibiotics, Adrenocorticoids 8. Vasodilators (nitroprusside), Beta-adrenergic (dobutamine) 9. Mechanical support : Military Anti-shoc Trousers(MAST)

Respiratory System

Hypoxia Lactic acid accumulates tissue necrosis

Cardiovascular System

Myocardial deterioration Disseminated Intravascular Coagulation

Neuroendocrine System

Stage of resistance o ADH is released causing idneys to retain sodium and water o Increase in adrenocorticoid mineralcorticoid hormones

IV. Effects of Shoc

in Different Organs

Immune System

Macrophages in bloodstream and tissues are depressed

GI System

GIT vagal stimulation stops/slow down no peristalsis Liver ability to detoxify is lost; blood is pooled in the

liver or portal bed

Renal System

Altered capillary blood pressure and glomerular filtration Renal ischemia

V. FIRST AID

Increased susceptibility to shoc

*** FIRST AID: Details from www.redcross.org

Dislocation: First aid*** 1. Get medical help immediately. 2. Don't move the joint. Splint the affected joint into its fixed position. Don' t try to move a dislocated joint or force it bac into place. This can damage the joint and its surrounding muscles, ligament s, nerves or blood vessels. 3. Put ice on the injured joint. This can help reduce swelling by controlling in ternal bleeding and the buildup of fluids in and around the injured joint.

Cuts and scrapes: First aid***

Minor cuts and scrapes usually don't require a trip to the emergency room. Yet p roper care is essential to avoid infection or other complications. These guidelines can help you care for simple wounds: 1. Stop the bleeding. Minor cuts and scrapes usually stop bleeding on their own. If they don't, apply gentle pressure with a clean cloth or bandage. Hold the pressure continuously for 20 to 30 minutes. Don't eep chec ing to see if the bleeding has stopped because this may damage or dislodge the fresh clot that's forming and cause bleeding to resume. If the blood spurts or continues to flow after continuous pr essure, see medical assistance. 2. Clean the wound. Rinse out the wound with clear water. Soap can irritate the wound, so try to eep it out of the actual wound. If dirt or debris remains in the wound after washing, use tweezers cleaned with alcohol to remove the particles. If debris remains embedded in the wound after cleaning, see your doctor. Thorough wound cleaning reduces the ris of tetanus. To clean the area around the wound, use soap and a washcloth. There's no need to use hydrogen peroxide, iodine or an iodine-containing cleanser. These substances irritate living cells. If you choose to use them, don't apply them directly on the wound. 3. Apply an antibiotic. After you clean the wound, apply a thin layer of an anti biotic cream or ointment such as Neosporin or Polysporin to help eep the surface moist. The products don't ma e the wound heal faster, but they can discourage infection and allow your body's healing process to close the woun d more efficiently. Certain ingredients in some ointments can cause a mild rash in some people. If a rash ap pears, stop using the ointment. 4. Cover the wound. Bandages can help eep the wound clean and eep harmful bact eria out. After the wound has healed enough to ma e infection unli ely, exposure to the air will speed wound h ealing. 5. Change the dressing. Change the dressing at least daily or whenever it become s wet or dirty. If you're allergic to the adhesive used in most bandages, switch to adhesive-free dressings or sterile gauze held in place with paper tape, gauze roll or a loosely applied elastic bandage. These supplies generally are available at pharmacies. 6. Get stitches for deep wounds. A wound that cuts deeply through the s in or is gaping or jagged-edged and has fat or muscle protruding usually requires stitches. A strip or two of surgical t ape may hold a minor cut together, but if you can't easily close the mouth of the wound, see your doctor as soon as pos sible. Proper closure within a few hours minimizes the ris of infection. 7. Watch for signs of infection. See your doctor if the wound isn't healing or y ou notice any redness, drainage, warmth or swelling. 8. Get a tetanus shot. Doctors recommend you get a tetanus shot every 10 years. If your wound is deep or dirty and your last shot was more than five years ago, your doctor may recommend a tet anus shot booster. Get the booster within 48 hours of the injury

Burns: First aid***

For minor burns, including second-degree burns limited to an area no larger than 2 to 3 inches in diameter, ta e the following action: . Cool the burn. Hold the burned area under cold running water for at least 5 mi nutes, or until the pain subsides. If this is impractical, immerse the burn in cold water or cool it with cold compres ses. Cooling the burn reduces swelling by conducting heat away from the s in. Don't put ice on the burn. . Cover the burn with a sterile gauze bandage. Don't use fluffy cotton, which ma y irritate the s in. Wrap the gauze loosely to avoid putting pressure on burned s in. Bandaging eeps air off the bu rned s in, reduces pain and protects blistered s in. . Ta e an over-the-counter pain reliever. These include aspirin, ibuprofen (Advi l, Motrin, others), naproxen (Aleve) or acetaminophen (Tylenol, others). Never give aspirin to children or teenagers.

Minor burns usually heal without further treatment. They may heal with pigment c hanges, meaning the healed area may be a different color from the surrounding s in. Watch for signs of infection, su ch as increased pain, redness, fever, swelling or oozing. If infection develops, see medical help. Avoid re-injuring or tanning if the burns are less than a year old doing so may cause more extensive pigmentation changes. Use sunscreen on the area for at least a year. Caution . Don't use ice. Putting ice directly on a burn can cause frostbite, further dam aging your s in. . Don't brea blisters. Bro en blisters are vulnerable to infection. Third-degree burn The most serious burns are painless and involve all layers of the s in. Fat, mus cle and even bone may be affected. Areas may be charred blac or appear dry and white. Difficulty inhaling and exhaling, carbon monoxide poisoning or other toxic effects may occur if smo e inhalation accompanies the burn. For major burns, dial 911 or call for emergency medical assistance. Until an eme rgency unit arrives, follow these steps: 1. Don't remove burnt clothing. However, do ma e sure the victim is no longer in contact with smoldering materials or exposed to smo e or heat. 2. Don't immerse severe large burns in cold water. Doing so could cause shoc . 3. Chec for signs of circulation (breathing, coughing or movement). If there is no breathing or other sign of circulation, begin cardiopulmonary resuscitation (CPR). 4. Cover the area of the burn. Use a cool, moist, sterile bandage; clean, moist cloth; or moist towels. Chemical burns: First aid***

If a chemical burns the s in, follow these steps:

a powder-li e substance such as lime contaminated by the chemical. sterile dressing or a clean cloth.

Minor chemical burns usually heal without further treatment.

1. Remove the cause of the burn by flushing ith cool, running water for 15 minutes or more. If the burning chemical is , brush it off the s in before flushing. 2. Remove clothing or jewelry that has been 3. Wrap the burned area loosely with a dry,

the chemicals off the s in surface w

See emergency medical assistance if: . The victim has signs of shoc , such as fainting, pale complexion or breathing in a notably shallow manner. . The chemical burn penetrated through the first layer of s in, and the resultin g second-degree burn covers an area more than 2 to 3 inches in diameter. . The chemical burn occurred on the eye, hands, feet, face, groin or buttoc s, o r over a major joint. If you're unsure whether a substance is toxic, call the poison center.

Electrical burns: First aid***

An electrical burn may appear minor or not show on the s in at all, but the dama ge can extend deep into the tissues beneath your s in. If a strong electrical current passes through your body, inte rnal damage, such as a heart rhythm disturbance or cardiac arrest, can occur. Sometimes the jolt associated with the electrical burn can cause you to be thrown or to fall, resulting in fractures or other associated injuries. Dial 911 or call for emergency medical assistance if the person who has been bur ned is in pain, is confused, or is experiencing changes in his or her breathing, heartbeat or consciousness. While helping someone with an electrical burn and waiting for medical help, foll ow these steps: 1. Loo first. Don't touch. The person may still be in contact with the electric al source. Touching the person may pass the current through you. 2. Turn off the source of electricity if possible. If not, move the source away from both you and the injured person using a nonconducting object made of cardboard, plastic or wood. 3. Chec for signs of circulation (breathing, coughing or movement). If absent, begin cardiopulmonary resuscitation (CPR) immediately. 4. Prevent shoc . Lay the person down with the head slightly lower than the trun and the legs elevated. 5. Cover the affected areas. If the person is breathing, cover any burned areas with a sterile gauze bandage, if available, or a clean cloth. Don't use a blan et or towel. Loose fibers can stic to the burns.

Domestic pets cause most animal bites. Dogs are more li ely to bite than cats. C at bites, however, are more li ely to cause infection. Bites from nonimmunized domestic animals and wild animals carry the ris of rabies. Rabies is more common in raccoons, s un s, bats and foxes than in cats and dogs. Rabbits, squir rels and other rodents rarely carry rabies. If an animal bites you or your child, follow these guidelines: Animal bites: First aid*** . For minor wounds. If the bite barely brea s the s in and there is no danger of rabies, treat it as a minor wound. Wash the wound thoroughly with soap and water. Apply an antibiotic cream to prev ent infection and cover the bite with a clean bandage. . For deep wounds. If the animal bite creates a deep puncture of the s in or the s in is badly torn and bleeding,

apply pressure with a clean, dry cloth to stop the bleeding and see your doctor. . For infection. If you notice signs of infection such as swelling, redness, inc reased pain or oozing, see your doctor immediately. . For suspected rabies. If you suspect the bite was caused by an animal that mig ht carry rabies any bite from a wild or domestic animal of un nown immunization status see your doctor immediate ly. Doctors recommend getting a tetanus shot every 10 years. If your last one was mo re than five years ago and your wound is deep or dirty, your doctor may recommend a booster. You should have the boost er within 48 hours of the injury.

Fall prevention: 6 ways to reduce your falling ris ***

Falls put you at ris of serious injury. Prevent falls with these fall-preventio n measures.

Your odds of falling each year after age 65 are about one in three. Fortunately, most of these falls aren't serious. Still, falls are the leading cause of injury and injury-related death among older adults. You 're more li ely to fall as you get older because of common, age-related physical changes and medical conditions and the m edications you ta e to treat such conditions. You needn't let the fear of falling rule your life. Many falls and fall-related injuries are preventable with fall-prevention measures. Here's a loo at six fall-prevention approaches that can help you avoi d falls. Fall-prevention step 1: Ma e an appointment with your doctor Begin your fall-prevention plan by ma ing an appointment with your doctor. You a nd your doctor can ta e a comprehensive loo at your environment, your health and your medications to iden tify situations when you're vulnerable to falling. In order to devise a fall-prevention plan, your doctor will want to no w: . What medications are you ta ing? Include all the prescription and over-the-cou nter medications you ta e, along with the dosages. Or bring them all with you. Your doctor can review your medica tions for side effects and interactions that may increase your ris of falling. To help with fall preventio n, he or she may decide to wean you off certain medications, especially those used to treat anxiety and insomnia. . Have you fallen before? Write down the details, including when, where and how you fell. Be prepared to discuss instances when you almost fell but managed to grab hold of something just in tim e or were caught by someone. . Could your health conditions cause a fall? Your doctor li ely wants to now ab out eye and ear disorders that may increase your ris of falls. Be prepared to discuss these and to tell him or her how you wal describe any dizziness, joint pain, numbness or shortness of breath that affects your wal . Y our doctor may then evaluate your muscle strength, balance and individual wal ing style (gait). Fall-prevention step 2: Keep moving If you aren't already getting regular physical activity, consider starting a gen eral exercise program as part of your fallprevention plan. Consider activities such as wal ing, water wor outs or tai chi a gentle exercise that involves slow and graceful dance-li e movements. Such activities reduce your ris of falls by impr oving your strength, balance, coordination and flexibility. Be sure to get your doctor's OK first, though. If you avoid exercise because you're afraid it will ma e a fall more li ely, bri ng this concern to your doctor. He or she may recommend carefully monitored exercise programs or give you a referral to a phys ical therapist who can devise a custom exercise program aimed at improving your balance, muscle strength and gait. To i mprove your flexibility, the physical therapist may use techniques such as electrical stimulation, massage or ultrasou

nd. If you have inner ear problems that affect your balance, he or she may also teach you balance retraining exercises ( vestibular rehabilitation) which involve specific head and body movements to correct loss of balance. Fall-prevention step 3: Wear sensible shoes Consider changing your footwear as part of your fall-prevention plan. High heels , floppy slippers and shoes with slic soles can ma e you slip, stumble and fall. So can wal ing in your stoc ing feet. Instead: . Have your feet measured each time you buy shoes, since your size can change. . Buy properly fitting, sturdy shoes with nons id soles. . Avoid shoes with extra-thic soles. . Choose lace-up shoes instead of slip-ons, and eep the laces tied. . Select footwear with fabric fasteners if you have trouble tying laces. . Shop in the men's department if you're a woman who can't find wide enough shoe s. If bending over to put on your shoes puts you off balance, consider a long shoeh orn that helps you slip your shoes on without bending over.

Fall-prevention step 4: Remove home hazards As part of your fall-prevention measures, ta e a loo around you your living roo m, itchen, bedroom, bathroom, hallways and stairways may be filled with booby traps. Clutter can get in your w ay, but so can the decorative accents you add to your home. To ma e your home safer, you might try these tips:

Immediately clean spilled liquids, grease or food. Use nons id floor wax. Use nonslip mats in your bathtub or shower.

Fall-prevention step 5: Light up your living space As you get older, less light reaches the bac of your eyes where you sense color and motion. So eep your home brightly lit with 100-watt bulbs or higher to avoid tripping on objects that are hard to see. Don't use bulbs that exceed the wattage rating on lamps and lighting fixtures, however, since this can present a fire ha zard. Also: . Place a lamp near your bed and within reach so that you can use it if you get up at night. . Ma e light switches more easily accessible in rooms. Ma e a clear path to the switch if it isn't right near the room entrance. Consider installing glow-in-the-dar or illuminated switches. . Place night lights in your bedroom, bathroom and hallways. . Turn on the lights before going up or down stairs. This might require installi ng switches at the top and bottom of stairs. . Store flashlights in easy-to-find places in case of power outages. Fall-prevention step 6: Use assistive devices Your doctor might recommend using a cane or wal er to eep you steady. Other ass istive devices can help, too. All sorts of gadgets have been invented to ma e everyday tas s easier. Some you might cons ider: . Grab bars mounted inside and just outside your shower or bathtub. . A raised toilet seat or one with armrests to stabilize yourself. . A sturdy plastic seat placed in your shower or tub so that you can sit down if you need to. Buy a hand-held shower nozzle so that you can shower sitting down. . Handrails on both sides of stairways. . Nonslip treads on bare-wood steps. As your doctor for a referral to an occupational therapist who can help you dev

. . . . . . . . .

Remove boxes, newspapers, electrical cords and phone cords from wal ways. Move coffee tables, magazine rac s and plant stands from high-traffic areas. Secure loose rugs with double-faced tape, tac s or a slip-resistant bac ing. Repair loose, wooden floorboards and carpeting right away. Store clothing, dishes, food and other household necessities within easy reach

ise other ways to prevent falls in your home. Some solutions are easily installed and relatively inexpensive. Others may require professional help and more of an investment. If you plan on staying in your home for many more years, an inves tment in safety and fall prevention now may ma e that possible.

Insect bites and stings: First aid***

Signs and symptoms of an insect bite result from the injection of venom or other substances into your s in. The venom triggers an allergic reaction. The severity of your reaction depends on your sen sitivity to the insect venom or substance. Most reactions to insect bites are mild, causing little more than an annoying it ching or stinging sensation and mild swelling that disappear within a day or so. A delayed reaction may cause fever, hives, pa inful joints and swollen glands. You might experience both the immediate and the delayed reactions from the same insect bit e or sting. Only a small percentage of people develop severe reactions (anaphylaxis) to insect venom. Signs and symptom s of a severe reaction include facial swelling, difficulty breathing and shoc . Bites from bees, wasps, hornets, yellow jac ets and fire ants are typically the most troublesome. Bites from mosquitoes, tic s, biting flies and some spiders also can cause reactions, but these are gen erally milder. For mild reactions: . Move to a safe area to avoid more stings. . Scrape or brush off the stinger with a straight-edged object, such as a credit card or the bac of a nife. Wash the affected area with soap and water. Don't try to pull out the stinger; doing so m ay release more venom. . To reduce pain and swelling, apply a cold pac or cloth filled with ice. . Apply 0.5 percent or 1 percent hydrocortisone cream, calamine lotion or a ba i ng soda paste with a ratio of 3 teaspoons ba ing soda to 1 teaspoon water to the bite or sting several times a d ay until your symptoms subside. . Ta e an antihistamine containing diphenhydramine (Benadryl, Tylenol Severe All ergy) or chlorpheniramine maleate (Chlor-Trimeton, Teldrin). Allergic reactions may include mild nausea and intestinal cramps, diarrhea or sw elling larger than 2 inches in diameter at the site. See your doctor promptly if you experience any of these signs and symp toms. For severe reactions: Severe reactions may progress rapidly. Dial 911 or call for emergency medical as sistance if the following signs or symptoms occur: . . . . . . . . Difficulty breathing Swelling of your lips or throat Faintness Dizziness Confusion Rapid heartbeat Hives Nausea, cramps and vomiting

Ta e these actions immediately while waiting with an affected person for medical help: 1. Chec for special medications that the person might be carrying to treat an a llergic attac , such as an autoinjector of epinephrine (for example, EpiPen). Administer the drug as directed u sually by pressing the autoinjector against the person's thigh and holding it in place for several seconds. Massage the injection site for 10 seconds to enhance absorption. 2. After administering epinephrine, have the person ta e an antihistamine pill i f he or she is able to do so without cho ing. 3. Have the person lie still on his or her bac with feet higher than the head. 4. Loosen tight clothing and cover the person with a blan et. Don't give anythin g to drin .

5. If there's vomiting or bleeding from the mouth, turn the person on his or her side to prevent cho ing. 6. If there are no signs of circulation (breathing, coughing or movement), begin CPR.

http://www.redcross.org

RESPIRATORY ARREST

Respiratory Arrest (-) RR (+) PR.

. A condition of the victim wherein there is no breathing but pulse continues

CAUSES:

1. Strangulation 2. Poisoning-Injection, Ingestion, Inhalation . Injection- Sna ebite, Rabies, Scorpions, bees, jellyfish, spiders 3. 4. 5. 6. Severe Bleeding Drowning Electrocution Suffocation

7. Cho ing: Universal Sign of Cho ing- palms guarding throat 8. Disease

THREE (3) KINDS OF AIRWAY OBSTRUCTION

Kind OF Airway Obstruction

Signs

First Aid

With Good Air Exchange

Victim can still TALK

Observe the victim as he cough out obstruction

With Poor Air Exchange

Victim produces wheezing sound

Abdominal Thrust / Heimlich Maneuver

Total Airway Obstruction with No Air Exchange

Unconscious

1. Abdominal Thrust 10X

Blind Finger sweep for adults

2. Artificial Respiration (AR) 2X

Loo , Listen & Feel (LLF)

4. Repeat blind finger sweep

5. Artificial Respiration 2X if effective

First Aid: Artificial Respiration (AR) ugh a blow or ambubag

- chest compression not indicated because there is pulse rate

METHODS IN GIVING ARTIFICIAL RESPIRATION

1. Mouth to Mouth - usual method 2. Mouth to Nose - if mouth is obstructed

3. Chec

if Air is going bac -

Giving of artificial air only either thro

Ambu Bag- a device used for artificial mechanical breathing unit

ADULT

CHILD

INFANT

METHOD

Mouth TO Mouth

Mouth TO Mouth

Mouth TO Mouth & Nose

Manner of Breathing

Full and Slow

Regulated

Puff

3. 4. 5. 6.

Mouth to Mouth to Mouth to Ambu Bag

Mouth & Nose used in infants Stoma - li e for patients with tracheostomy Mas to Mouth & Nose

Rate of Blows

1 Blow every 5 secs 12 blows per min

1 Blow every 4 secs 15 blows per min

1 Blow every 3 seconds 20 blows per min

START WITH A BLOW AND END WITH A BLOW

WHEN TO STOP

1. When the rescuer is exhausted 2. When the victim is breathing on his own 3. When the service of the physician is available 4. When the pulse disappears; artificial respiration is stopped and cardiopulmon ary rescucitation begins 5. When another first aider ta es over

CARDIAC ARREST

. Condition of the victim when the pulse and breathing is absent.

Intervention for Cardiac Arrest: CPR

CPR- Cardio Pulmonary Resuscitation - A combination of external chest compression and artificial ventilations to revive the heart and the lungs

CAUSES Danger of Failure to revive Patient:

1. CLINICAL DEATH- may occur if heart rate is not revived within 4-6 minutes

2. BIOLOGICAL DEATH- usually occurs after 4-6 mins of cardiac arrest

. All causes of Respiratory Arrest, Heart Attac , Stro e

Location Of Chest Compressions

1. ADULT- 3 fingers above mid xiphoid 2. INFANT- along nipple line

ADULT

CHILD

INFANT

Method 2 Heels of 2 Hands 1 Heel of 1 hand 2 Fingers (ring and mid finger)

Depth

1 - 2

1 - 1

Rate

15 ECC/2 blows 4X/min

5ECC/1 blow 15X/min

5ECC/1 blow 20X/min

Speed

60-80 ECC/min 12X/min

80-100 ECC/min

100-120 ECC/min

2 RESCUERS 5 ECC/1 blow

DON T S IN CPR:

CPR- start with 2 blows end with 2 blows

SEQUENCE:

Victim is breathless with pulse Victim is breathless & pulse less

or

9. Activate medical assistance Arrange transfer facilities and I ll do AR or CPR 10. After each cycle, chec pulse for 5 sec. then deliberate 11. Recovery Position

1. 2. 3. 4. 5. 6. 7. 8.

Survey the scene the scene is safe Chec for responsiveness Hey 2X, R U O ay Position the victim Open and Clear the airway (head tilt chin lift) Mouth is clear Chec breathing for 3-5 seconds (LLF) 1001, 1002, etc. Breathless If Breathless, give 2 blows Chec for Pulse: Carotid 5-10 seconds State the condition of the victim

1. 2. 3. 4. 5. 6.

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