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DIGESTIVE DISORDER

GENERAL CLINICAL MANIFESTATIONS CONDITIONS EMERGENCY MANAGEMENT PRIORITY NURSING


DIAGNOSIS

Pain • Caused by abdominal cramping • Acute and Chronic • Assess client for pain, • Acute pain related to
Gastritis bleeding and dehydration gastric erosion
• Peptic Ulcer • Obtain vital signs for • Fluid volume deficit
Anorexia • loss of appetite Disease baseline data related to
• Gastric Cancer • Prepare client for IV insertion vomiting/diarrhea/
for immediate re-hydration bleeding
Nausea • increased tension on the walls of the • Provide pain medications as
stomach, duodenum or lower end prescribed
of the esophagus
• If the client is showing signs
of bleeding, shock must be
Vomiting • caused by stimulation of the emetic prevented.
center • The nurse or the physician
may insert an NGT to
Bleeding • erosion or ulceration of the GIT measure the extent of
mucosa bleeding
• If bleeding is severe, prepare
client for Blood Transfusion
Diarrhea • Increase peristalsis from an effort of
or for surgery.
the stomach and intestine to
• Explain all procedures to the
eliminate a local irritant.
client and relatives to
Belching and minimize confusion and
Flatulence • Swallowed air anxiety.

Indigestion or • Chewing inadequately, GIT disease,


Dyspepsia eating too rapidly, gas forming
foods, strong emotion and food
allergy.

INTESTINAL DISORDER

GENERAL CONDITIONS EMERGENCY MANAGEMENT PRIORITY NURSING


CLINICAL DIAGNOSIS
MANIFESTATIONS

• Hemorrhage • Gastroenteritis • Check the client’s vital signs. Monitor for • Acute pain related to
• Pain • Parasitic Infection increase in temperature and change in pulse inflammation of the
• Nausea and • Appendicitis and blood pressure intestinal mucosa
vomiting • Peritonitis • Assess client for bleeding and pain • Fluid volume deficit
• Distention • Inflammatory Bowel Disease • IV insertion for immediate re-hydration related to
• Diarrhea 1. Chron’s disease (regional enteritis) • Anti-diarrheal medications may be vomiting/bleeding
• Constipation 2. Ulcerative colitis administered as prescribed • Alteration in
• Abnormalities in • Neoplastic Disorders • For GI trauma, stop external bleeding thermoregulation
fecal content 1. Benign Tumors of the bowel • Prepare client if the client is scheduled for related to
• fever 2. Cancer of the small bowel surgery bacterial/parasitic
3. Colorectal cancer • Explain briefly every procedure to decrease infection
• Hernia anxiety
• Diverticular disease
• Intestinal Obstruction
• Irritable bowel syndrome
• Hemorrhoids
• Anal fissure
• Anal fistula
• Anorectal abscess
• Blunt or penetrating trauma
URINARY DISORDERS

GENERAL CLINICAL CONDITIONS EMERGENCY MANAGEMENT PRIORITY NURSING


MANIFESTATIONS DIAGNOSIS

• Burning pain on urination (dysuria) • Infectious and Inflammatory • Check the client’s vital signs. • Acute pain related to
• Frequency Disorders Monitor for increase in inflammation of
• Urgency 1. Cystitis temperature and change in urinary tract
• Voiding in small amounts 2. Urethritis pulse and blood pressure • Fluid volume deficit
• Inability to void 3. Ureteritis • Assess client for bleeding related to frequent
• Incomplete emptying of the bladder 4. Urosepsis and pain urination
5. Interstitial cystitis • Prepare client for collection • Fluid volume excess
• Cloud urine
• Obstructive Disorders of a urine sample related to urine
• nocturia
1. Bladder cancer • For urinary retention, an retention in the
• Hematuria 2. Ureteral tumors indwelling catheter may be bladder
• Lower back or supra pubic pain 3. Urinary calculi inserted to relieve •
• Malaise 4. Urinary reflux distention
• Abdominal distention • Voiding Disorders • Record output, its amount
• Nausea 1. Urinary retention and characteristics.
• diarrhea 2. Urinary Incontinence • IV insertion for immediate re-
3. Neurogenic bladder hydration
• Traumatic disorders • Administer pain medication
1. bladder trauma as prescribed.
2. urethral trauma • For traumatic and
3. ureteral trauma obstructive disorders
• Congenital anomalies prepare client for surgery.

RENAL DISORDERS

GENERAL CLINICAL MANIFESTATIONS CONDITIONS EMERGENCY MANAGEMENT PRIORITY NURSING


DIAGNOSIS

• acute distress/ pain • Check the client’s vital signs. • Acute pain related to
• abdominal mass • Acquired Disorders Monitor for increase in kidney edema and
• hematuria 1. Nephrolithiasis temperature and BP. distention
• flank pain 2. Pyelonephritis • Assess client for bleeding and • Fluid volume deficit related
• weakness • Renal Cancer pain to bleeding/vomiting
• anorexia • Glomerulonephritis • IV insertion for immediate re- • Fluid volume excess
• nausea and vomiting • Renal trauma hydration. related to sodium and
• generalized edema (anasarca) • Renal artery disease • Administer pain medication as water retention
• ascites • Renal vein disease prescribed.
• hemorrhage • Acute and chronic renal • Administer diuretics for edema as
failure prescribed
• absence of urine
• Congenital disorders • For traumatic and obstructive
disorders prepare client for
surgery.
• For patient’s with renal failure,
prepare client for dialysis

PANCREATIC AND BILIARY DISORDERS


GENERAL CLINICAL CONDITIONS EMERGENCY MANAGEMENT PRIORITY NURSING DIAGNOSIS
MANIFESTATIONS

• Abdominal pain • Acute and Chronic Pancreatitis • Assess client’s level of pain • Ineffective breathing pattern related
• Abdominal distention and • Pancreatic cancer • Obtain Vital signs and monitor to abdominal distention
tenderness • Pancreatic trauma • Prepare client for IV insertion if • Acute pain/Pain related to
• Fever • Cystic fibrosis for admission inflammation of the pancreas/ bile
• Administer pain medication as duct
prescribed • Risk for fluid volume deficit related
• Prepare client for laboratory to vomiting
• Jaundice • Cholelithiasis
• Chills • Acute and chronic cholecystitis examinations
• Fever • Acute acalculous cholecystitis • Prepare client for surgery
• RUQ pain • Choledocholithiasis and • NGT may be inserted
• Indigestion cholangitis
• Fat intolerance • Carcinoma of the gallbladder
• Heartburn
• Flatulence
• Nausea and vomiting

HEPATIC DISORDERS
GENERAL CLINICAL CONDITIONS EMERGENCY MANAGEMENT PRIORITY NURSING DIAGNOSIS
MANIFESTATIONS

• Jaundice • Hepatitis • Obtain Vital signs • Ineffective breathing pattern related to


• Clay colored feces • Cirrhosis • Request necessary laboratory increased intra-abdominal pressure on
• Tea-colored urine • Hepatic stenosis request the diaphragm
• Pruritus • Liver neoplasms • Provide Oxygenation if client • Impaired skin integrity related to
• Fatigue • Benign hepatic is having difficulty of pruritus
• Anorexia tumors breathing • Imbalanced nutrition less than body
• Hepatomegaly • Liver abscess • Prepare client for IV insertion requirements related to anorexia
• Ascites • Liver trauma • Monitor IV fluid
• Administer diuretics as
prescribed
• Prepare client for
paracentesis or surgery

DYSRHYTHMIAS
DEFINITION GENERAL CLINICAL CONDITIONS EMERGENCY PRIMARY NURSING
MANIFESTATION MANAGEMENT DIAGNOSIS

• Disorders of • Syncope ( loss of A. Sinus Node Dysrhythmia • Observe and assess • Alteration in comfort
the formation consciousness) • Sinus Bradycardia client’s level of related to dizziness
or conduction • Lightheadedness • Sinus Tachycardia consciousness • Risk for injury related to
of the • Dizziness • Sinus Arrhythmia • The nurse regularly loss of
electrical • Fatigue B. Atrial Dysrhythmia evaluates blood pressure, consciousness/dizziness
impulse • Chest discomfort/ • Premature Atrial Complex pulse rate, rhythm, rate
within the pain • Atrial Flutter and depth of respiration
heart • Palpitations • Atrial Fibrillation and breath sounds
C. Junctional Dysrhythmia • Obtain 12 Lead ECG
• Premature junctional complex • Prepare client for IV
• Junctional rhythm insertion
• Atrioventricular Nodal reentry • Administer anti arrhythmic
tachycardia medications as prescribed
D. Ventricular Dysrhythmias • Maintain a calm and
• Premature Ventricular Complex reassuring attitude to
• Ventricular tachycardia lessen anxiety
• Ventricular fibrillation • For uncontrolled and acute
dysrhythmia, defibrillation
• Idioventricular rhythm
may be done.
• Ventricular asystole
E. Conduction Abnormalities

CORONARY VASCULAR DISEASE

CLINICAL MANIFESTATION CONDITIONS EMERGENCY MANAGEMENT PRIMARY NURSING


DIAGNOSIS

• Coronary • •
Sudden onset of pain that
continues despite rest, location atherosclerosis
• blockages on
Assess client’s pain, level of
consciousness and vital
Ineffective breathing
pattern related to
narrow vessel by
may radiate to other parts of the signs decrease oxygen
fatty substances
body such as neck, jaw, • Evaluate blood pressure, supply in the blood
in a way that
shoulders and arms pulse rate, rhythm, rate and • Acute Pain related to
reduces blood
• Shortness of breath depth of respiration and decrease oxygen
flow to the
• Cool, pale and moist skin myocardium.
breath sounds every 15 supply in the heart
• Heart rate and respiratory rate minutes. muscles
may be faster than normal • Direct patient to rest in bed (myocardium)
• Palpitations
Angina Pectoris • episodes or in a semi-fowler’s position. • Ineffective
paroxysms of • Oxygen administration is cardiopulmonary
• Increase jugular venous
pain or pressure usually initiated at the onset tissue perfusion
distention
in the anterior of chest pain to relieve pain related to reduced
• Increase Blood pressure chest caused by and to assist during coronary blood flow
• Heart murmurs upon auscultation decrease oxygen respiratory distress. from thrombus
• Headache
• Nausea and vomiting • Prepare client for IV insertion
• Dizziness or lightheadedness • Obtain 12 Lead ECG
• Syncope • Blood oxygen saturation is
monitored by pulse oximetry
• Unusual fatigue
Myocardial • Myocardial cells • Administer pain/ thrombolytic
Infarction in the heart are medications as prescribed
permanently • Brief explanation for every
destroyed caused procedure to relieve anxiety
by reduce blood
flow in a coronary
artery

OTHER ER CASES
CONDITIONS DEFINITION CAUSES SIGNS AND EMERGENCY MANAGEMENT PRIORITY NURSING
SYMPTOMS DIAGNOSIS

ANAPHYLAXIS • A systematic, • Exposure to • Flushing of the • Oxygen is administered • Ineffective airway


potentially life- allergens skin • IV lines are inserted to provide clearance related to
threatening such as • Dyspnea access for administering fluids bronchospasm
hypersensitivity seafood, • Hypotension and medications • Ineffective tissue
reaction medicines, • Abdominal pain • Epinephrine and perfusion related to
dust, latex • Nausea, Diphenhydramine is decrease oxygen
vomiting, administered supply secondary to
diarrhea • Nebulized medications such bronchospasm
• Tingling of face, as Albuterol may be given to • Fluid volume deficit
mouth, pals and reverse histamine-induced related to vomiting
soles broncho spasm • Alteration in comfort
• Headache • If cardiac arrest and related to
respiratory arrest are headache.
imminent, cardiopulmonary
resuscitation is performed.
• Endotracheal tube or
tracheotomy may be
necessary to establish airway.

BURNS • Injury in the • Fires • red and painful For thermal Injuries: • Excessive fluid
soft tissue • Hot water or skin 1. Cool the area with cold volume related to
steam • blisters water resumption of
• Sun • charred, pale or 2. Gently debride and capillary integrity
overexposure brownish skin cleanse the wound and fluid shift from
• Electricity 3. Give analgesics for pain; the intestinal to
• chemicals IV medications for major intravascular
burns as prescribed compartment
4. Open blisters and excise
dead skin • Risk for infection
5. Cover with bacteriostatic related to loss of
cream and apply soft skin barrier and
bulky dressing. immune response
6. Review status of tetanus
prophylaxis and update • Impaired skin
For chemical burns: integrity related to
1. Remove patient’s open burn wounds
clothing
2. Irrigate area copiously • Acute pain related
with water, especially if to exposed nerves,
the eyes are involved. wound healing and
For electrical burns: treatments.
1. Because
cardiorespiratory arrest
is common, patient may
require CPR and
advanced cardiac life
support
2. Evaluate for other
entries
3. May need debridement
to assess the extent of
damage.
4. ECG monitoring

• • • •
FOOD
Food poisoning
results from the
• Bacterial

Vomiting
Bloody diarrhea
IV lines for replacement of
fluids and electrolytes
Fluid volume deficit
related to vomiting
POISONING pathogens,
ingestion of • Fever • Oxygen for respiratory • Poisoning related to
protozoan,
microorganism • Chills assistance ingestion of toxic
and algae are
s or toxins • Respiratory • Anti-emesis medication as contaminated food
responsible
found in failure prescribed • Alteration
for most food
contaminated • Dizziness • Gastric lavage of activated thermoregulation
poisoning.
food. charcoal related to increase
However, • Abdominal pain
poisonous • headache body temperature
components • Risk for injury
of plants and related to dizziness
animals are
also
responsible
for acute
food-borne
illness.

• Temporary • CNS infection • Abdominal pains • Oxygen administration • Risk for injury
SEIZURE neurological • Drug toxicity • Headache • Provide privacy and protect related to loss of
event that • Head trauma • Loss of the patient from curious on consciousness
results from • Electrolyte or consciousness lookers • Ineffective airway
abnormal, metabolic • Body muscle • Protect the head with a pad to clearance related to
hypersynchron derangement spasm prevent injury (from striking a muscle spasm
ous discharges s • Apnea hard surface)
from neurons in • High fevers • Cyanosis • Loosen constrictive clothing
the CNS • • Remove pillows and raise side
Tumors, • Dilated pupils
stroke that are rails

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