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I. II. III.
Client in Pain Perioperative Nursing Care Alterations in Human Functioning a. Disturbances in Oxygenation: Respiratory & Cardiovascular Functions
Disturbances in Musculoskeletal Functions Client in Biologic Crisis: Life threatening Conditions of the Human Body - Shock Emergency & Disaster - First-aid and Cardiopulmonary Support
b. c. d. e. f. g.
Disturbances in Metabolic and Endocrine Functions Disturbances in Elimination: Gastrointestinal Problems Disturbances in Fluids and Electrolytes: Renal & Genitourinary Functions Disturbances in Cellular Functioning: Cancer and Hematologic Problems Disturbances in Auditory & Visual Functions
-------------------------------------------------------------------------------------------------------------------------------------CLIENT IN PAIN
Pain – the fifth vital sign an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Basic Categories of Pain: 1. Acute Pain – sudden pain which is usually relieved in seconds or after a few weeks.
Chronic Pain (Non-Malignant) – constant, intermittent pain which usually persists even after healing of the injured tissue Cancer-Related Pain- May be acute or chronic; may or may not be relieved by medications
Pain Transmission: 1. Nociceptors are called pain receptors. These are the free nerve endings in the skin that respond to intense, potentially damaging stimuli. 2. Peripheral Nervous System 3. Central Nervous System 4. Descending Control System Factors Influencing Pain Response 1. Past Experience – e.g. trauma 2. Anxiety and Depression 3. Culture - beliefs
Age – infants are more sensitive Gender Placebo Effect
Characteristics of Pain 1. Intensity –mild, moderate, excruciating
4. 5. 6. 7.
Timing – morning or evening, duration may be longer or shorter Location Quality – burning, aching, stabbing Personal Meaning to pain – tolerance to pain may be different from one person to the other due to some personal reasons such as economic reasons, work condition, etc. Aggravating and Alleviating factors – patient’s environment 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. iii. 2.
Harmful effects of pain to the client Duration of the pain
Establish Nurse-Patient Relationship and Teaching a. Acknowledge the verbalization of pain by the client b. Relieve patient’s anxiety c. Teach measures how to relieve pain Provide Physical care a. Teach and assist in self-care b. Environmental conditions c. Application of ice/heat on painful area Manage anxiety related to Pain a. Teach about the nature of pain that may be felt by the client and reassure him/her b. Teach alternative measures to relieve pain c. Stay with the client/ frequent communication with the client Pain Medications may be administered as:
Balanced Anesthesia – given to avoid experiencing pain PRN – “Pro Re Nata” – as needed Preventive – taken before pain is felt Individualized Dosage Patient-Controlled Analgesia (PCA) – patient takes medication if pain felt is becoming intolerable
Non-pharmacologic Interventions a. Cutaneous Simulation and Massage b. Ice and heat therapies c. Transcutaneous Electrical Nerve Stimulation d. Distraction e. Relaxation Techniques f. Guided Imagery g. Hypnosis
PERIOPERATIVE CARE o Phases of Perioperative Nursing a.
Pre-operative Nursing Inraoperative Nursing Post-operative Nursing
Pre-operative Care Pre-admission and Admission Test 1. Psychological support 2. Client Education: a. Importance and practice of breathing exercises b. Location & support of wound c. Importance of early ambulation d. Inform and practice leg exercises, positioning, turning e. Anesthesia and analgesics f. Educate regarding drains and dressings to be received post-op g. Recovery room policies and procedures 3. Informed consent a. At least 18 years of age b. In sound mind- without psychologic disorder c. Not under the influence of drugs or alcohol d. Immediate relative over 18 years old Physical Assessment and preparation a. Physical Preparation – NPO, remove dentures, jewelries, clothesetc.
b. c. d. e. f.
Nutritional & Fluid Status – should be well hydrated Drug or alcohol Use – may experience delirium or intoxication to anesthetic drugs because ormal doses do not usually take effect to these patients and require heavier dose to achieve anesthetic effect. Respiratory Status - teach breathing exercises Cardiovascular Status – should have controlled and stable cardiovascular functioning before operation to prevent intraoperative problems Hepatic & Renal Functions – normal functioning is important in absorbing anesthetic drugs
g. h. i. j. 5. 6.
Endocrine Functions- important in monitoring to hypo/hyperglycemia, thyrotoxicosis, acidosis Immune Functions – allergies esp. to anesthetic drugs
Psychosocial Factors – emotional and psychological preparation to ensure cooperation fom the patient with the procedures Spiritual & Cultural Beliefs - blood transfusions, transplants, ligation, etc are against other culture & religion.
Pre-operative drugs – given 20-60 mins.pre-operative o Makes patient drowsy, keep siderails up Proper positioning HOB elevated at 30 degrees HOB elevated at 45 degrees Head injury, pot-op cranial surgery, post-op cataract removal, increased ICP, dyspneic patients Head injury, pot-op cranial surgery; post-op abdominal surgery; post-op thyroidectomy, post-op cataract surgery, increased ICP; dyspnea Pneumothorax, hiatus hernia Spinal cord injury, urinary catheterization Amputation of legs/feet, post lumbar puncture, post myelogram, post tonsillectomy & adenoidectomy (T&A) Post-abominal surgery, post tonsillectomy & adenoidectomy (T&A), post-liver biopsy ( right side down), post pyloric stenosis (right) Unconscious client
High-Fowler’s Supine/ Dorsal Recumbent
HOB elevated at 90 degrees Lying on back w/ small pillow under head Lying on abdomen with head turned to the side
Lateral / Side lying
Lying on side, weight on the lateral side, the lower scapula and lower iliac. Lying on side, weight on the clavicle, humerus and anterior aspect of the iliac. Lying on back with knees and legs bent and raised on a stir up
Perineal, rectal & vaginal procedures
Trendelenburg Reverse Tredelenburg Elevate extremity
Head & body lowered, feet elevated Head elevated , feet lowered Support with pillows
Shock Cervical traction Post-op surgical procedure on extremity, cast, edema, thrombophlebitis
Prone Supine Lateral Recumbent
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
Ensure safety of client in the operating table- prevent falls, drape the patient properly, provide warmth Stay with the client to relieve anxiety and support during anesthesia Anesthesia Administration:
a. b. c. d.
General Anesthesia via Inhalation General Anestheisia via Intravenous Regional Anesthesia - local anesthesia Conduction Blocks/ Spinal Anesthesia – Epidural & Spinal Block - for operation below the waist line - patient is awake during operation
4. 5. 6. 7. C.
Perform sponge count, instrument count and needle count Aseptic technique in handling and preparing all instruments and supplies Applies grounding device to prevent electrical burn during use of electrosurgical equipment Proper documentation Post-operative Care 1. Immediate assessment of VS, and Neuro VS, drainages, surgical dressing 2. Monitoring of vital signs q 15mins until stable 3. 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 pCO2 Measure of acidity or alkalinity Partial pressure of carbon dioxide parameter influenced by lungs only respiratory 7.35 – 7.45 35 -45
Partial pressure of oxygen; measure of amount oxygen delivered to lungs Bicarbonate, metabolic parameter influenced only by metabolic factors
Respiratory Acidosis pH pCO2 Normal Compensation HCO3
Normal Value 7.35 – 7.45 35 -45 22-26
a. Administer NaHco3 b. Get rid of CO2 c. Bronchodilators d. Monitor ABG
a. Breathe into paper bag or cupped hands b. Oxygen
Cigarette smoking Chronic respiratory infections Family history of COPD Air pollution Medical Management: 1.Metabolic Acidosis pH Normal Compensation pCO2 HCO3 a.increased mucus production that obstructs airway 3. Antihistamines 3. Antibiotics 5. Asthma Cause: 1. Promote good air exchange c. Diabetic acidosis. gastric suction. Expectorants 6. alkali ingestion. excessive exercise) b. Avoid allergens or other irritants 5. Cause: Cigarette Smoking.with or without sputum production CHRONIC BRONCHITIS “Blue Bloater” An inflammation of the bronchi which causes increased mucus production and chronic cough. diarrhea. Chronic Bronchitis. Adequate rests 4. Steroids 4. more tenacious mucus Slight gynecomastia Petechiae in midsternal area Dyspnea 120 . w/ chronic obstruction of airflow entering or leaving the lungs Major diseases 1. infection. Chronic condition is diagnosed if symptoms occur for 3 months and for 2 consecutive years. 4. 3. excessive diuretic Nursing Intervention CHRONIC OBSTRUCTIVE PULMONARY DISEASE - A group of conditions assoc. Oxygen therapy at 2LPM – use cautiously Nursing Management: 1. Pulmonary Emphysema – airway is obstructed due to destroyed alveolar walls 2. Psychological Support Clinical Manifestations: Few words between breaths Pursed-lip breathing Cyanosis Distended neck 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. Promote adequate activities to enhance cardiovascular fitness 3. Keratogenic diet. Bronchodilators 2. systemic infections. renal failure. Administer meds and O2 as ordered 2.45 Metabolic Alkalosis Normal Compensation 35 -45 22-26 Restore fluid loss which may be cause by vomiting. Give NAHCO3 via IV Normal Value 7. Treat underlying cause (Starvation.35 – 7. pollution Clinical Manifestations: Productive cough Thicker. 2.
expectorants 4. aerosol Complication: STATUS ASTHMATICUS . 3. combined immunologic and non-immunologic Nursing Management: Clinical Manifestations: Increased tightness of chest. 2. Stress Types: 1. Antibiotics 3. Increase humidity 3. mucoid sputum Treatment: 1. persistent cough (+) wheezes. Secondary smoke inhalation 4. 2.a life-threatening asthmatic attack in w/c symptoms of asthma continues and do not respond to treatment II. Promote pulmonary ventilation Facilitate expectoration Health teaching Breathing techniques Stress management Avoid allergens Chronic barrel chest. Tachypnea 3. Decreased exercise tolerance Wheezes Medical Management: see COPD Nursing Management: 1. Barrel-chest 4. Pinkish skin color 6. pollens. elevated shoulders distended neck veins orthopnea Tenacious. Reduce or avoid irritants 2. diaphoresis 1. O2. hacking. Wheezes 5. Family history of asthma 2. Allergens: dust. Immunologic asthma - occurs in childhood Non-immunologic asthma occurs in adulthood and assoc w/ recurrent resp infections. cyanosis. Chest physiotherapy 5. PARENCHYMAL DISORDERS: 121 . Alpha-anti-trypsin deficiency (an enzyme in the alveolar walls) Clinical Manifestations: 1. Promote Breathing techniques EMPHYSEMA “Pink Puffer” A disorder where the alveolar walls are destroyed causing permanent distention of air spaces. Dyspnea on exertion 2. 3. 2. Air pollution 5. (+) dead areas in the lungs that do not participate in gas or blood exchange Cause: Cigarette smoking. nebulization. tachypnea Dry. Shallow rapid respirations 7. Postural drainage 6. 3. Bronchodilators. Administer medications as ordered 4. Steroids. crackles Pallor. usually >35 y/o Mixed. Pursed lip breathing Nursing Management: Position: Sit up and lean forward Pulmonary toilet: Cough->Breathe deeply->Chest physiotherapy-> turn & position Frequent rest periods Nebulization IPPB – Intermittent Positive Pressure Breathing (aerosolized inhalation) O2 @ 2LPM Asthma -A condition where there is an increase responsiveness and/or spasm of the trachea and bronchi due to various stimuli which causes narrowing of airways Cause and Risk Factors: 1. dyspnea Tachycardia.
A chronic lung infection that leads to consumption of alveolar tissues Etiology: Mycobacterium tuberculosis. Aspiration 3. Monitor VS 4. URTI 4. Risk Factors: Poor living conditions. cyanosis Pathophysiology: Fluid accumulation in the alveolar sacs due to hypovolemia. overcrowded 1. Prolonged immobility: post-operative. bed-ridden patients Clinical Manifestations: 1. irritability. rusty/ yellowish/greenish sputum. hx of exposure Cough. Administer medications TUBERCULOSIS . w/ marked increase in alveolar and interstitial fluids Etiology: 1. Chest physiotherapy. apprehensiveness. IPPB Provide rest and comfort Prevent potential complications Health teaching: skin care. low sodium diet. anorexia. Tracheal intubation 6.positioning. sputum culture.often occurs when the left side of the heart is distended and fails to pump adequately o Clinical Manifestation: Constant irritating cough. influenza 2. Age: too young and elderly are most prone to develop 2. Diuretics. promote effective airway clearance. I&O 2. Altered conciousness 5. chest retration CXR. crackles. hygiene Drug therapy: o Antibiotics: penicillin. increased WBC. Poor nutritional intake 2. cephalosphorin. elevated sedimentation rate Nursing Management: Promote adequate ventilation. dyspnea. Inhalation of irritating fumes Risk factors: 1. nausea. Bacterial / Viral – streptococcus pneumoniae. air pollution 3. tetracycline.PNEUMONIA . Psychological support 5. Previous infection 122 . restlessness. 2. erythromycin o Cough suppressants o Expectorants Rest and adequate activity Proper Nutrition PULMONARY EDEMA . Blood culture. pseudomonas aeruginosa. splinting of affected side. 3. Smoking. Chest pain.productive .An inflammatory process of lung parenchyma assoc. alveoli are congested Nursing Management: 1. breathing patterns and ventilation 3. irritability. fluid congestions in the lungs.
8. Advise proper handwashing and use of mask for people in contact with infected persons who are not yet under treatment. CXR Sputum acid-fast Mantoux Test . 2. TB is infectious but can be cured 2. Regimen is usually 6 months. Infarction c. Clotting time – 10 mins. K.1 ml of PPD (Purified Protein Derivative) . 4. 2. Buerger’s Disease (Thromboangitis Obliterans) 6. e. Treatment: 1. vomiting Indigestion. Individual is generally considered not infectious after 1. Induration: 10mm – > positive exposure to TB bacillus 5 – 9 mm -> doubtful. .. c. Angina Pectoris Myocardial Congestive heart Valvular Stenosis AV Heart Block Pacemakers 123 . 6. Productive cough Hemoptysis Dypnea Rales Malaise Night Sweats Weight loss Anorexia. 3.Close contact with infected person 4. f. e. Ca. Rifampicin 3. Chloride .determine the ability of the heart to affect circulation and regulatory functions of fluids and electrolytes. Electrolytes – Na. d. Thrombophlebitis Varicose Veins Cardiac Disorders a. Aortic Aneurysm 5. Venous Disorders: 1. Diagnostic Procedure Laboratory Test Electrocardiogram Echocardiography Central Venous Pressure Pulmonary Artery Pressure/ Swan-Ganz Cardiac Catheterization II. Hypertension 2. Read after 48-72 hrs. Hypernatremia. Isoniazid 4. 2. Laboratory Tests Values / Description a. Transmitted by droplet infection and not carried on articles like clothing or eating utensils 3. 4. Streptomycin Client Education: 1. PT – 9-12 sec. b. Regular check-up to monitor progress should be done. 5. pallor 1. 7. Pyrazinamide 5. Mg (see fluids & electrolytes) b. may repeat the procedure > 4 mm -> Negative 3.2 weeks of medication. Cholesterol – 150-250 mg/dl . 3. Arteriosclerosis 3. 6.determines ability of the blood to form clot or thrombus Purpose Determines hyperkalemia. Diseases of the Vascular System: Arterial Disorders: 1. Inadequate treatment of primary infection Clinical Manifestations: Diagnostic Tests: 1. Failure d. Atherosclerosis 4. Medication regimen should be continuous and uninterrupted 5. Sputum samples are obtained first before drug therapy is started. 8. 7. PTT – 16-40 sec. DIAGNOSTIC PROCEDURES: Procedure 1. Raynaud’s Disease A. -------------------------------------------------------------------------------------------------------------------------------------------------------CARDIOVASCULAR SYSTEM THE HEART AND MAJOR VESSELS I. etc. Ethambutol 2. 9.
Right atrium Port d. TPN. determines tissue damage in the myocardium Determines the electrical impulse of the heart Normal impulses ensures adequate circulation to all body organs and tissues Procedure 3.I. Triglyceride – 50-250 mg/dl > LDL (bad cholesterol) – 60-180 mg/dl > HDL (good cholesterol) – 30-80 mg/dl g. Swan-Ganz Catheter / Pulmonary Artery Pressure (PAP) Measures the level of pressure in the left atrium 4 Ports: a. determines adequacy of circulation from the heart to the kidneys and its ability to excrete protein and urea h. .test of renal function. BUN – 6-20 mg/dl .) > LDH – 150-450 u/ml (rises 12 hrs after M.women.Jugular . Thermodilution port b.contraction of atrium until the beginning of the contraction of ventricles ST.Subclavian .determines the development of atherosclerosis which causes coronary artery disease .Femoral End of catheter or Tip – positioned at the right atrium or upper portion superior vena cava (for femoral insertion.Resting state of the ventricles PR interval. 124 . Electrocardiogram P. Obtain venous access when peripheral veins are inadequate To insert a temporary pacemaker Obtain central venous samples Monitor pressure in the ff: Right ventricle Pulmonary artery e. drug therapy. pericardial effusion. 2-Dimensional Echocardiography (2D Echo) Purpose Determines valvular deformities.Median .ventricles moves to a resting state Values / Description Ultrasound of the heart .30-135 ( rises 3-6 hrs after M.– also rises after MI 2. Pulmonary atrium port c.55-170 ..I. thickening of myocardium.etc Serves as guide for fluid replacement Monitor pressures in the right atrium and central veins Administer blood products.cardiac enzymes are present in high concentration in the myocardial tissues . Enzymes: > CPK – men.contraction of the atrium QRS complex. ESR.contraction of the ventricles T.Basilic . 4.) > SGOT – 5-40 u/ml i. tip is at the inferior vena cava) 5. Central Venous Pressure (CVP) Normal = 5 – 10 cm Water Measures the right atrial pressure or the pressure of the greater veins within the thorax by threading a catheter into a large central vein. Distal branches of the pulmonary artery Thermodilution Obtain blood for O2 saturation d. f.0-30. Balloon Port for inflating balloon used for placement of catheter c.
Trauma Pregnancy-Induced HPN Many others Signs & Symptoms Treatment BP=140/90 . Measure O2 concentration. Detect shunts c. To get blood samples d. Arteries . DM Neurologic Disorders – Brain tumors. Magnesium supplements (to balance sodium and other electrolytes) Pharmacologic: Calcium Agonist: Nifedipine. saturation. 1.carries unoxygenated blood Capillaries – allows the delivery of nutrients.most common . Determine need for bypass surgery Three types of Blood Vessels: 1. etc Regular exercise Salt restrictions Administer medications Teach risk factors 125 . 2. palpitations. heart and circulation a.carries oxygenated blood Veins .ARTERIAL DISORDERS HYPERTENSION persistent BP above 140 /90 Types of Hypertension Etiology: Essential hypertension unknown etiology . 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. DISEASES OF THE VASCULAR SYSTEM: B. hydrochlorothizide Adrenergic inhibitors: Propanolol. Calcium. 3. blurred vision and epistaxis Non-pharmacologic: Weight reduction Diet modification Alcohol & Smoking cessation Relaxation Techniques √ Sodium restriction √ Exercise √ Caffeine Restriction Potassium. stress. Nephritis Endocrine problems – Thyroid problem. fatigue. oxygen and fluids to the tissues B. weakness. dizziness. Methyldopa Nursing Interventions BP monitoring Correct cause: obesity. flushing.6. diet. tension and pressure in the chambers of the heart b. Determine cardiac output & pulmonary flow e. Verapamil Vasodilators: Hydralazine Diuretics: Aldactone. Clonidine.may be caused by an increase in cardiac output or increase in peripheral resistance Essential hypertension Genetic Obesity Stress Loss of elastic tissues Arteriosclerosis of aorta Secondary hypertension caused by other physiologic problems Types of Hypertension Risk Factors Secondary hypertension Renal problems – Renal Failure. headache.
c. As a result. When this happens.Arteriosclerosis occurs when lipids in the blood. d. e. interfering with the normal flow of blood and oxygen throughout the body. mainly cholesterol. Sometimes there aren't any noticeable symptoms until the condition has advanced to a very serious stage. Infections or a Congenital abnormality Signs & Symptoms: Thoracic Aortic Aneurysm Dyspnea Dysphagia voice hoarseness Treatment: Thoracic/chest pain cough Abdominal Aortic Aneurysm (AAA) Abdominal Pain Low back pain Pulsating Abdominal Mass Surgical Removal of Aneurysm a. The term atherosclerosis refers to a condition in which fatty deposits build up in and on the artery walls. b. the heart has to work harder to pump blood through the narrowed blood vessels.When the arteries become obstructed with plaque and cholesterol. d. and the circulation of blood through the vessels becomes difficult. often called angina. including cholesterol. one of the first symptoms is chest pain. Monitor patient for signs of rupture of aneurysm Nursing Intervention: 126 . and a heart attack or a stroke may result. b. When the arteries of the heart are affected. accumulate inside the walls of blood vessels and reduce the size of the veins or arteries through which blood flows. a. c. ATHEROSCLEROSIS “Thickening” . Medical & Surgical Interventions for Athero and Arteriosclerosis: Lifestyle Modification . Psychological support b. Reduce Risk Factors Coronary Artery Bypass Graft (CABG Percutaneous Transluminal Coronary Angioplasty (PTCA) Directional Coronary Atherectomy (DCA) Intracoronary Stents Nursing Intervention: Health Teaching Reduce Risk Factors Restore Blood Supply Pre & Post-op Care for Surgical Patients AORTIC ANEURYSM Types of Aneurysm: Thoracic or Abdominal Aortic Aneurysm Risk Factors: Presence of Atherosclerosis. 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.A degenerative condition of the arteries characterized by thickening due to localized accumulation of fats. e.ARTERIOSCLEROSIS “Obstruction” . . a. they harden and constrict. Predisposing factors: cigarette smoking high fat levels in the blood high cholesterol high blood pressure obesity Signs and symptoms: The symptoms of atherosclerosis depend on the part of the body where the condition is taking place. blood pressure becomes elevated. forcing the blood through narrower passageways.
heavy smokers.calf pain upon dorsiflexion of foot Nursing Intervention: a.2. Vasculitis of the veins and arteries in the upper & lower extremities Men -20-35 y/o.VENOUS DISORDERS: THROMBOPHLEBITIS Definition: Risk Factors: Signs & Symptoms: Clot disorder in the vein usually at the lower extremity Trauma of the blood vessels. Nursing Intervention: Health teaching on lifestyle modifications. stasis. women with Systemic Lupus Erythematosus (SLE) or rheumatoid arthritis hypersensitivity of fingers to colds. pain. Use of thromboembolytic (TED) stockings 127 . posterior tibial Reddish or Cyanotic extremity which may progress to ulceration or gangrene Treatment: Calcium Channel Blockers to promote vasodilation Rest. c. Post-operative care: monitor peripheral circulation BUERGER’S DISEASE a. Thromboangitis Obliterans (TAO) Definition: Risk Factors: b. Pain Relievers. smoking Ensure protection of extremities against cold Administration of medications as ordered Protect client from injury Assessment of extremities RAYNAUD’S DISEASE Definition: Risk Factors: Cause: Signs & Symptoms: Vasospasm of arteries in the hands (upper extremities only) Women. Pre-operative preparation d. Avoid exposure to cold Surgery: Amputation of extremity is delayed until conservative treatments fail to effect.a. e. local induration. pain in legs relieved by immobility.k. spec. Shock: Bp= >100 systolic. Heavy smokers. individuals spec. numbness and tingling of toes sensitivity to cold Weak or absent pulsations at the dorsalis pedis. (+) Homan’s sign . d. congenital vasospasm.Triad of manifestations for ruptured abdominal aneurysm: 1. redness. Back or Flank pain (scrotal pain may also occur) 3. Increased coagulability Edema of the extremity. Serotonin release Cyanosis/pallor of the fingers when exposed to cold environment or emotional stimuli Numbness and occasional pain Bilateral or symmetrical involvement Treatment: Nifedipine to decrease vasospasm Avoid exposure to cold and keep hands warm Avoid smoking Nursing Intervention Same as buerger’s disease B. Pulse Rate >100bpm c. hypersensitivity to intradermal injections Signs & Symptoms: a. Abdominal pain 2.
tortuous veins in the legs distention. but less than ordinary activity can cause symptoms). as ordered d. Radiation of pain in the arms. Regular but careful exercise of the legs to promote circulation – ambulate for short periods 24-48 hrs post-op c. for cosmetic purpose only) Nursing Intervention Elevate legs at least 30 mins. Class II – slight limitation of physical activity (ordinary physical activity does cause symptoms). Class III – moderate limitation of activity (patient is comfortable at rest. obesity. shoulders and the neck. hence. lengthening and totuosity of veins loss of valvular competence and constant elevation of venous pressure most commonly in the veins of the legs. Heparin therapy. Elevate legs c. heaviness. Pain in the epigastrium. infection. Signs and symptoms: Patient experiences retrosternal chest discomfort Pressing. After prolonged standing Wear thromoembolic stockings Teach client o avoid prolong sitting or standing Avoid cross-legs while sitting Post-op Care after Sclerotherapy: a.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. Assessfor complications such as bleeding. back neck jaw or in the shoulders. Not a treatment. nerve damage IV. Prolonged standing. Maintain firm elastic pressure over the whole limb b. Bed rest e. pregnancy Surgical Management: Sclerotherapy (injection of sclerosing agent to the vein. burning and choking sensation. therefore severe limitations (patient may be symptomatic even at rest). squeezing. 128 . It lasts only for 1-5 minutes and taking up of nitroglycerine will be beneficial for the client.b. Class IV – unable to perform any physical activity without discomfort. Warm compress VARICOSE VEINS Definition: Cause: Risk Factors: Signs & Symptoms: Treatment: Aching Heaviness Moderate swelling Enlarged. 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).
Coronary Angiography Medical Management: a. 5. Causes: 1. however. Coronary Artery Embolism Signs and symptoms: 1. 12. Opiate Analgesic – MoSo4 Vasidilators – Nitroglygcerin. Oliguria – urine less than 30 ml/hr Risk factors: 129 . Stress Test c. 6. avoid constipation.an irregular heart beat or pulse. Orthopnea – sense of suffocation Nausea and/or abdominal pain. Assess pain – location. 9. back.gas pains around the heart Anxiety.Nursing Interventions: a. 7. character. Dysrythmias . 3. crushing. or squeezing. Dyspnea. The rapid development of myocardial necrosis caused by imbalance between the oxygen supply and demand of the myocardium. Destruction of myocardial tissue due to reduced coronary blood flow. Pain may radiate to the jaw. Apprehension Light headedness with or without syncope Cough . chest pain – heavy (viselike. ECG (ST elevation). rest after meals. c. Radioisotope Imaging d. precipitating factors b. resulting in an acute reduction of blood supply to a portion of the myocardium. Atherosclerotic heart 2. Help client to adjust lifestyle to prevemt angina attack – avoid excessive activity in cold weather. The left arm is affected more frequently. arms. and epigastrium. Neck vein distention – represents right pump failure. pressure. Wheezing Nausea with or without vomiting Cold diaphoresis. c. ECG b. Weakness and altered mental status – common in elderly patients. Nifedipine Beta Blocking Agents –Propanolol MYOCARDIAL INFARCTION d. if still not relieved go to the hospital Diagnostic Assessment: a. 11. avoid overeating. Results from plaque rupture with thrombus formation in a coronaryvessel. Rales – may be present in congestive heart failure. exercise Teach patient how to cope with angina attack – nitroglycerin every 5 mins upto 3x. usually tachycardic. 2. squeezing) usually across the anterior pericardium typically is described as tightness. a patient may experience pain in both arms. neck. 10. b. 8. 13. Isosorbide Mononitrate/Dinitrate Calcium Channel Blockers – Dlitiazem. gray facial color. 4.
delayed enhancement (infarction). diet. T-wave inversion. Electrocardiogram (ECG) . hypertension. Drug of choice for patient with MI: Antithrombotic agents . Family history.can be administered sublingually by tablet or spray. Male gender. and wall motion abnormalities (ischemia). topically. (metoprolol) Platelet aggregation inhibitors – inhibits platelet aggregation clopidogrel (plavix) Analgesics – reduce pain which decreases sympathetic stress (morphine sulfate) 130 . or IV. Age . (nitroglycerine) Beta-adrenergic blockers .Opposes coronary artery spasm. intermediate probability of MI are ST-segment depression.can identify wall thinning. . which decreases myocardial oxygen demand. -heparin) Vasodilators . DM. heparin supplemental oxygen pulse oximetry – maintain oxygen saturation at >90% Immediate administration of aspirin en route Nitroglycerin for active chest pain. stress.reduce blood pressure.ST-segment elevation greater than 1 mm. which augments coronary blood flow and reduces cardiac work by decreasing preload and afterload . Type A personality DIAGNOSTICS: Lab studies: Creatine kinase–MB (CK-MB) Myoglobin CBC . scar. given sublingually or by spray ECG Treatment is aimed at: Restoration of balance between oxygen supply and demand to prevent further ischemia. CT scan Radionuclide Imaging Positron Emission Imaging Transesophageal Echocardiography Magnetic resonance imaging (MRI) .prevent the formation of thrombus and inhibit platelet function. Trponin Potassium and magnesium level Creatinine level C – Reactive protein (CRP) Erythrocyte sedimentation rate (ESR) Serum lactate dehydrogenase (LDH) - Imaging studies: Chest radiography or chest x-ray – reveals pulmonary edema secondary to heart failure. obesity. Immediate emergency intervention: IV access – thrombolytic agents e. Smoking. and other nonspecific ST-T wave abnormalities.the presence of new Q waves. Chest Pain relief Prevention and treatment of complications.g. (aspirin. Sedentary lifestyle.
All MI patients should be admitted in the ICU. aspirin Antihypertensives – propanolol. e. a. 131 . c. b.quinidine. CONGESTIVE HEART FAILURE (CHF) Definition: inability of the heart to meet oxygen and metabolic needs of the body 2.morphine Provide physical rest Administer O2 via cannula Frequent VS Nifedipine Propanolol HCL Emotional Support Later g. Sudden loss of visual function 2. 2. e. d. Early Treat arrythmias promptly – lidocaine Give analgesic. ruptured papillary muscles Pericarditis Recommendations: . raise arm. low sodium diet. low cholesterol. A warning sign of stroke especially in first 4 weeks after TIA Causes: 1. Psychological support g. -captopril(capoten) Complications of MI: Dysrhytmias Cardiogenic Shock Heart Failure Pulmonary Edema Pulmonary Embolism Recurrent MI Complications due to Necrosis – VSD. soft food Commode Self-care Plan for rehabilitation Exercise program Stress management Teach risk factors f. Atherosclerosis 2. etc. Post-op focus – assess neurologic deficits. Nursing interventions for MI 1. f. rupture of the heart. Sudden loss of sensory function 3. Microemboli from atherosclerotic plaque Manifestations: 1. Anticoagulant therapy: aspirin. Long-term drug therapy Antiarryhtmics. smile may indicate problem in the specific cranial nerve. Sudden loss of motor function Management: . Patient should remain on complete bed rest during his stay in the hospital and avoid straining activities. avoid flexing neck Inability to swallow. chlorathiazide TRANSIENT ISCHEMIC ATTACK (TIA) temporary episode of neurological dysfunction lasting only a few minutes or seconds (in a day/ 24hrs) due to decreased blood flow to the brain. Give stool softener Provide low fat. c. b. move tongue.Angiotensin converting enzyme (ACE) inhibitors – prevents conversion of angiotensin I to angiotensin II.Surgical Carotid Endarterectomy (bypass) 1. a potent vasoconstrictor. lidocaine Anticoagualnt – heparin. d. h. a.
Congenital defects. O2 4. Fatigue. Central Nervous System: Halo around lights Diarrhea. Dopamine & Dobutamine. abdominal cramps Bradycardia.Causes: 1. HPN. ventricular aneurysm Diseases that exacerbate or precipitate heart failure – Stress. pregnancy. High Peripheral Vascular Resistance 2. anorexia. cardiomyopathy. Rales. Reduce congestion and edema: meds. Improve oxygenation: proper positioning. genitals and trunk (Anasarca) f. vomiting. frequent PVC’s Headache . wheezing d. Par oxysmal Nocturnal Dyspnea f. Eyes: b. Cou gh. Management: Positioning – High fowler’s position to reduce pulmonary congestion O2 Administration Pharmacology: Digitalis. Orth opnea e. 3. fear and depression f. Renal Changes. pulmonary disease. Reduce pain and anxiety 3. positioning 132 . thyroid disorders. ACE inhibitors Digitalis: • increases ventricular contractility • Increases ventricular emptying • Increase Cardiac output • Watch out for Digitalis toxicity Signs of Digitalis Toxicity: a. Nocturia c. infection. Gastrointestinal Tract: c. yne’s Stroke Dys Che Right Ventricular Peripheral edema Venous congestion of organs Hepatomegaly Cyanosis of the nail beds Massive swelling of the legs. myocarditis. Sodium restriction 2. Patent Ductus Arteriosus. nutritional deficiency.Myocardial Infarction. Valvular stenosis. Anxiety. anemia. ventricular / atrial septal defect. Fati gue &muscular weakness i. hypervolemia Left Ventricular Failure Signs & Symptoms Causes Pulmonary Congestion: a. Lethargy Nursing Intervention: 1. Pul monary Edema g. dysrhythmia. pnea b. Cer ebral hypoxia h. Abnormal loading conditions . Cardiovascular: d. Abnormal muscle function .
temporary pacing . when traveling Care of Site: > wear loose-fitting around pace-maker > Encourage bath tubs rather than shower to protect incision site for the first 10 days > Explain that healing takes place within 3 months Treatment None Degree of Block First-degree AV Block Second-degree AV Block Atrophine Isoproterenol Ventricular Pacemaker Third-degree AV Block 133 . ask patient to move 4-6 feet away from source. heat. decreased cardiac output. heart failure Heart valve replacement. skin breakdown Avoid high-energy radar. transesophageal.external.Coumadin Management: low sodium. device can be held in a belt. transvenous. . transcutaneous. Check for signs of infection on the site: fever. Remind to wear ID-information bracelet at all times esp. television. d.inserted trans thoracic. sutured within the subcutaneous tissue. c. transesophageal b. b.used for emergency purposes. Nursing Intervention: a. device.operated) that produce electrical stimuli to the heart and controls heart rate a. Permanent Pacemakers – internal. mitral commisurotomy Pharmacology: Anti-coagulant. Temporary Pacemakers . low cholesterol diet Stenosed Nursing Intervention: same as CHF AV HEART BLOCK Definition: Altered transmission of impulse from SA node through AV node Description delayed transmission of impulse to AV node not all impulses pass through AV node No impulse pass through AV node PACEMAKERS Definition: Types: Electronic device (battery.VALVULAR STENOSIS Definition: Signs & Symptoms: Treatment: Narrowing of valve which prevents blood flow or impaired closure of the valves causing regurgitation Murmurs. pain. microwave: if dizziness or tachycardia occur.
jaw. neck >30 mins. tightness Substernal. radiates to one or both arms. heavy. burning Retrosternal. severe. substernal.--- External Pacemaker Internal Pacemaker (sutured subcutaneously) Appearance of a person w/ internal pacemaker -------------------------------------------------------------------------------------------------------------------------------------------------------------Comparison of Chest Pain Angina Pectoris Myocardial Infarction • • • • • Sudden. pressing. left of sternum. crushing. Oxygen. narcotics. radiates to the left arm Usually 3-5 mins duration <30 mins rest. not relieved by rest & nitroglycerin Type Location • • squeezing. nitroglycerin Duration Relief • • Comparison of other signs & symptoms Angina Pectoris Myocardial Infarction Transient Ischemic Attack 134 .
mouth breathing. Cal.Blockers 4. low cholesterol. diaphoresis Sudden loss of: • Visual fxn • Sensory fxn • Motor fxn Objective Data: • Tachycardia • Pallor • Diaphoresis • Restless Objective Data: Loss of functioning about and returns normal for to Nursing Care Management Arteriosclerosis Angina Pectoris Transient Ischemic Attack 1. K 3. anti-embolic stockings 3. exercise. fear of impending death • Nausea Objective Data: • Symptoms of shock • Cyanosis.etc. bedside commode Provide emotional support Promote sexual functioning discuss concerns include partner resume 5-8 wks after uncomplicated MI 5. 1. 3.operated 2. • 2.0 mEq/L ECG Diet: low calorie. Urine Output & ECG • Meds: Anti-arrythmics & anticoagulants • Check for edema. water Meds: vasodilators. • • • • Maintain fluid & electrolyte balance / Nutrition Keep IV open. avoid Valsalva. • • • • • 2. cyanosis. • • • • Provide relief from pain: Rest Nitroglycerin Lifestyle modification Vital signs Assist w/ ambulation Provide emotional support Health teaching Pain differentiation Medication Dx test Diet. Gland DISTURBANCES IN METABOLIC & ENDOCRINE FUNCTIONING Hormone Functions 135 . UO Lab data: Na+135-145. • 4. • 3. vasopressors. dyspnea. Bedrest (24-48 hrs). crackles • CVP: normal= 5-15cm H20 • ROM. • • 8.Subjective Data: Dyspnea Palpitation Dizziness Faintness Subjective Data: • Shortness of breath • Apprehens ion. CVP.5-5. Stents Health teaching Modifications. diet. • Monitor VS. • 6. Health teaching 2. Maintain adequate circulation. Assess neurologic status Administer meds Nursing Care Management Myocardial Infarction 1. CABG 1. habits Restore blood supply Anti-embolic stockings. anti-coagulants Pre & post-op care CABG. • • • • Decrease oxygen demand/ Promote oxygenation O2. low sodium.C. 7. stress mgt. rest periods Semi-fowler’s position Anticipate needs of client: call light. Semi-fowler’s position to improve ventilation battery. O2. VS. cough. 2. low fat Facilitate fecal elimination stool softener.PTCA. • Lifestyle Modification Diet. • Reduce pain & discomfort: Narcotics.
thus raising blood glucose levels Decreases secretion of insulin.Sex Medulla Epinephrine (Adrenalin)-80% Norepinephrine. increases cardiac contractility. thus decreasing urine output Stimulates ejection of milk 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 Increases metabolic activity of almost all cells. may affect pigmentation Posterior lobe Promotes reabsorption of water by the distal tubules and collecting ducts of the kidney. glucagons. SEX Parathormone (PTH) Glucocorticoids (primarily cortisol) -. increases tissue responsiveness to other hormones Tends to increase sodium retention and potassium excretion Governs certain secondary sex characteristics. growth hormone and several gastrointestinal hormones( gastrin. protein and fat thus decreasing blood glucose Mobilizes glycogen stores. effect repair of the endometrium after menstruation Essential for normal functioning of male reproductive organs. maturity and functioning of primary and secondary sex organs Stimulates steroid production by adrenal cortex May stimulate adrenal cortex. protein and fat catabolism. stimulates most aspects of fat.20% Ovaries Estrogens and progesterone Testes Testosterone Pancreas Islets of Langerhans Insulin Glucagon Somatostatin PITUITARY GLAND PROBLEMS 136 . opposite effect from that of PTH Increases calcium levels and decreases phosphate levels.Sugar Mineralcorticoids (Aldosterone) -. increases resorption of bones Promotes carbohydrate.Salt Androgens (male hormones) -. increases heart rate. secretin) Thyroid Gland Thyroxine (T4) Triiodothyronine (T3) Thryrocalcitonin Parathyroid Adrenal Cortex Controls SSS: SUGAR. vasopressin) Oxytocin Stimulates growth of body tissues and bones Stimulates mammary tissue growth & lactation Stimulates thyroid gland Affect growth. stimulates development of secondary sex characteristics Promotes metabolism of carbohydrates.Pituitary Gland Anterior Lobe Growth Hormone Prolactin Thyrotropic hormone (TSH) Gonadotropic hormones (LH & FSH) Adrenocorticotropic hormone (ACTH) Melanocyte-stimulating Hormone (MSH) Anti-diuretic hormones (ADH. all corticoids are important for defense against stress or injury Elevates blood pressure. converts glycogen to glucose when needed by muscles for energy. protein and carbohydrate metabolism Lowers serum calcium levels and elevates phosphate level. dilates bronchioles Stimulate development of secondary sex characteristics. SALT.
Lithium Carbonate c. Irradiation of pituitary with Bromocriptine to decrease secretion of growth hormone 2.Clinical Manifestations Acromegaly Growth Hormone IN ADULTS 1. Visual problems 6. Desmopressin Acetate nasal spray b. Intake & Output monitoring d. Lethargy. Vasopressin Tannate – IM injections c. Polydipsia 3. Assess ICP b. Maintain adequate fluids b. Fluid restriction 2. Premature body aging 3. Avoid coughing. Anorexia. Increased perspiration 5. Sodium Restriction c. weakness. Daily weights f. Elevate head of bed (HOB) 30 degrees c. Post-op Care: a. No increase in height and weight but hands and feet become bigger 4. Abdominal cramping 7. Pharmacology: a. Hyperglycemia/calcemia Management 1. Slow intellectual development 1. Polyuria 2. vomiting 1. Surgery: Hypophysectomy-removal of the pituitary gland 3. Hyponatremia 2. a. Specific gravity SIADH – Syndrome of Inappropriate secretion of ADH 1. Removal of cause : tumor 2. Same as acromegaly & gigantism Diabetes Insipidus Antidiuretic Hormone 1. Dehyration 1. Demeclocycline administration as ordered b. Nursing Interventions. headache 5. blowing nose Gigantism Overgrowth of all body tissues and bones Growth Hormone In CHILDREN Dwarfism Growth Hormone In CHILDREN 1. Weight gain 6. Human Growth Hormone Injection 3. Mental confusion 3. Protrusion of jaw and orbit 3. sneezing. Hypressin Nasal Spray 2. Treat underlying causes 3. Teach self-injection techniques e. nausea. Enlarged extremities 2. Retarded physical growth 2. Butorphanol Tatrate ADRENAL GLAND PROBLEMS 137 . Pharma: a. Personality changes 4.
back and leg pain Hyperpyrexia followed by hypothermia Peripheral vascular collapse Shock Renal Shutdown -> Death Glucocorticoids Mineralcorticoids Sex Hormones Cushing’s Syndrome Glucocorticoids 1. provide quiet environment Mineralcorticoids (Aldosterone) Pheochromocytoma Epinephrine/ Norepinephrine 1. WOF Signs of Addisonian Crisis: Addisonian Crisis: Sudden profound weakness Severe abdominal. 3. Amenorrhea 13. Nursing Mgt: > protect from infection > protect from accidents > health teaching on self-medication STEROIDS: Purpose: Anti-inflammatory and anti-allergy. 7. Hypokalemia 1. 8. Chemotherapy: Bromocriptine 3. administer meds. Take at the same time everyday b. Surgical Mgt: Adrenalectomy 2. HPN 12. Stress Tolerance Medication: a. Nursing Mgt: > High caloric diet > Adequate Rest THYROID GLAND PROBLEMS 138 . male characteristics appear in women 11. Vomiting. nausea. Loss of libido 8. Hyperglycema 1. Malaise and general weakness 2. Diet: high CHON. Hyperglycemia. Anorexia. Osteoporosis 1. 2. 9. low Na diet . hypovolemia 3. dexamethasone) 2. Medical Management: Symptomatic (Treat symptoms as it occurs) 3. 6.Clinical Manifestations Addison’s Disease 1. Thin scalp Moon Face Acne Increased body hair Buffalo hump Obesity Hyperpigmentation Thin extremities Easy Bruising Mood swings. Causes gastric upset Side effects: Cushingoid Appearance Conn’s Syndrome / Aldosteronism 1. Hypotension. Teach importance of lifelong medications 4. Hypoglycemia (60-70) 9. vomiting 5. Hypokalemia. Increased pigmentation of skin 4. potassium supplement 4. Treatment of hypertension 4. CHON diet 3. 10. HPN 2. Potassium replacement 3. 5. Follow regime and do not stop abruptly c. Diet: high CHO. Nursing Mgt: Monitor BP. Personality Changes Management 1. Tachycardia 7. Pharmacology: Steroids (Prednisone. Surgery: Removal of tumor 2. Nausea.Palpitations 5. 4.Apprehension 4. low CHO. Surgical Mgt: Removal o tumor 2. Increase Perspiration 3. Electrolyte Imbalance 6. Weight loss 7. Headache 6. Observe side effects of hormone replacement – Cushingoid Appearance 4. Monitor fluid & electrolyte 5. HPN 2.
Irritability Cretinism T3. Iodides: Lugol’s solution – strains teeth. Fluid retention. Dry. Radioiodine therapy 4. Dry skin 4. High caloric. Increase metabolism: weight loss. Thyroid Replacement (Desiccated thyroid) ** taken in empty stomach ** heart rate less than 100 bpm -ok PARATHYROID GLAND PROBLEMS Clinical Manifestations Hypoparathyroid Parathormone Management 1. Muscle weakness 8. lethargy Menorrhagia. Propyl. Thyrocalcitonin INFANTS 1. anorexia and constipation 2. Fever b. drink w/ straw Saturated Solution of Potassium Iodide (SSKI) d. HPN 9. Sensitive to cold 3. irregular menses Easy bruising Constipation Fatigue. T4. Thyrocalcitonin THYROID STORM: a. carbohydrate. Anxiety. diarrhea.Clinical Manifestations Grave’s Disease / Hyperthyroidism/ Thyrotoxicosis 1. Surgery: Thyroidectomy 2. Nursing Mgt: a. Liothyronine Sodium 2. Enlarged thyroid 1. intolerance to cold 3. WOF: Thyroid Storm T3. high protein. Methimazole b. Eye protection for xopthalmos e. Drug Therapy: a.protrusion of eyes 2. vitamins without stimulants c. Drug therapy: Levothyroxine. T4. Dry skin 5. Measure daily weights d. Levothyroxine b. Tachycardia c. Exopthalmos. Drug Therapy: a. edema 4. Avoid stimulus Bradycardia . Slow metabolism: decreased sweating. Thyrocalcitonin ADULT 1. Poor appetite and constipated Treatment: Hormone Replacement Myxedema T3. T4. Cardiac Arrythmias 6. Propanolol 3. Personality changes 5. Insomnia Management 1. Physical & mental retardation 2. Decreased libido. coarse skin. Delirium d. diaphoresis 4. Enlargement of the thyroid gland 3.Thyracil c. Adequate Rest b. 139 . Easy fatigability 7.
Skin rashes c. Nausea. hypoglycemic agent or insulin Cardinal Signs & Symptoms: 1. Polydipsia . Drug therapy: Prophylthiuracil Methimazole. Glyburide c.Hyperthyroid Parathormone Tachycardia Palpitations Increased persitalsis weight loss Heat intolerance Decreased libido Amenorrhea 1. GI disturbances d. Saturated solution of Potassium Iodide. exercise and insulin Juvenile DM Type II Non-Insulin Dependent DM (NIDDM) Adult DM >35 y/o but can occur in children Insidious 85-90% Below normal Normal or Above normal Necessary for only 20-30% of clients Unlikely to occur Usually Obese Diet.excessive hunger Weight Loss . Hypoglycemia b. Acetohexamide f. Oral hypoglycemics: a. Treatment: 1. Flushing e. Radioactive Iodine 2. Tolazamide e. Tolbutamide d. 4. high fiber 3. exercise.for IDDM Side effects: a. before meals to promote faster absorption of the meds 140 .frequent urination 2. 3. Glipizide b. Chlorpropamide Polyuria Polyphagia .excessive thirst . Diet: low calcium. vomiting Administration: > usually administered 30 mins. Force fluid PANCREATIC PROBLEMS DIABETES MELLITUS Type I Insulin Dependent DM (IDDM) Other Name Age of Onset Before 30 years old but may occur at any age Onset Abrupt Incidence 10% Insulin production Little or none Insulin Injections Required Ketosis May occur Body weight at onset Ideal body weight or thin Management Diet.
Insulin Injections: Action Appearance. Peak 2 – 4 hrs. 2 -12 hrs. Kussmaul resp. polyuria. 6 – 12 hrs. 18 – 24 hrs. Indurated areas on skin due to injections Skin indurations Teach client to rotate sites of injection Hyperglycemic Hyperosmolar Nonketotic Coma (HHNK) Cause: Signs & Symptoms: Extremely high glucose. sunken eyesballs. 14 – 24 hrs. abdominal discomfort. 1 – 3 hrs.70% NPH . abdominal rigidity Give regular insulin Nursing Interventions: c. no ketosis Polyphagia. hyperpyrexia. excessive insulin Diaphoresis. polydipsia. Insulin Nursing Interventions: 141 . let the patient eat Check sugar level b. hypotension. Nausea. 18 -26 hrs. 6 – 12 hrs. acetone odor of breath.30% regular Complications of DM: a. hyperventilation. 4 – 6 hrs. confusion Give candy. Tachycardia.Preparation Onset of Effect Short-Acting Clear Cloudy Intermediate Acting Long-Acting Cloudy Cloudy Cloudy Cloudy Pre-Mixed .Regular Insulin . 18.Protamine zinc . changes in sensorium.NPH . shock Fluid & electroluyte replacement. Duration of Effect 6 – 8 hrs. 1 – 2 hrs. 8 – 16 hrs 18 -26 hrs.Ultralente 30 mins. hypotension. 4 – 6 hrs. tremors. dry mucous membranes. Stress Polyuria.Semilente . dehydration. juice or softdrinks. coma. – 1 hr. less dietary intake. Lipodystrophy Cause: Signs & Symptoms: Nursing Interventions: d. vomiting. – 1 hr.24 hrs. 2 – 8 hrs. 30 mins. irritability.Lente . Diabetic Ketoacidosis Cause: Signs & Symptoms: Lack of insulin . 28 – 36 hrs. weakness. Cloudy .2. Infection. Hypoglycemia Cause: Signs & Symptoms: Nursing Interventions: Hunger. thirst. glucosuria. Coma. 30 mins. 36 hrs.
avoid administration within 1-2 hr of other oral meds . pc. Chronic Gastritis c. alcohol intake and spicy foods c. High fat. cigarette smoking. Small frequent meals c. Bland diet d. coffee. construction workers o Usually affects malnourished individuals Excessive smoking. spicy foods 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. severe nausea. Eliminate caffeine.**inhibits the enzyme that produces gastric acid H Pylori – Metronidazole Omeprazole Tetraycline/Clarithromycin Cytoprotective – binds with Cause: Acid production: Location of Ulcer Pain: Stress. vomiting and sometimes hematemesis Increased hydrochloric acid. o Usually in a wellnourished individual Gastric Ulcer Nursing Intervention: > 50 yrs. Acute Gastritis b. intolerance to spicy or fatty foods No increase in hydrochloric acid Duration: Clinical Manifestations: Short Epigastric discomfort. Inflammatory and Neoplastic Disorders a. old o Type A personality (leaders. Relaxation techniques o Most common in persons like farmers. vague epigastric pain. May prescribe anticholinergics in chronic gastritis Nursing Interventions/ Health Teaching: -Avoid spicy foods -Avoid alcohol intake -Frequent small meals Incidence: o Common in age 50-60 years old o Frequent in male than female o Greater incidents in heavy drinkers and smokers Cause: Helicobacter Pylori Medicines: Aspirin. salicylates intake Normal to hyposecretion Lesser curvature o Experienced ½ to 1 hour after meal o Ingestion of FOOD DOES NOT RELIEVE PAIN b. hs H2 Antagonists .frequent administration – ac. Acid production: Duodenal Ulcer Occurrence: o 25-50 yrs. Antacids b. high carbohydrate Medical Treatment: Antacids . NSAIDS. Duodenal Ulcer d. old a. belching. cramping. N/V. steroids Food: Alcohol. Gastric Cancer Acute Gastritis Chronic Gastritis o Same in Acute Gastritis Treatment Medical Management: a.with meals/pc Anticholinergics Prostaglandin Analogs **misoprostol** & ACID PUMP INHIBITORS .1. Gastric Ulcer e. DISTURBANCES IN ELIMINATION 3.4. Poor food habit Hypersecretion Pylorus o Experienced 2-3 hrs after meal o Ingestion of FOOD RELIEVES PAIN 142 . executives). Abdominal pain. chemo drugs.
Clostriduum difficile from antibiotics) o o o o Risk Factors: Poor food handling Poor sanitary conditions Overcrowding Food remaining on high temperature making organisms incubate and colonize easily. Bactrim) Nursing Intervention: o Measure intake and output o Administer medications o Replace fluids APPENDICITIS o Inflammation of the vermiform appendix Incidence: Common between 20-30 yrs. g. Indigestion and anorexia f. live in urban area Exposure to radiation or trace metals in soil Cause: Helicobacter Pylori Clinical Manifestations: a. Disorders of the Large and Small Bowel VIRAL AND BACTERIAL GASTROENTERITIS/ DYSENTERY Gastroenteritis Inflammation of stomach and intestine usually the small bowel.2. mild to severe temperature Cause: Viral Dysentery Inflammation in the colon S/S: severe bloody diarrhea and abdominal cramping. S/S: abdominal cramps. Gastric ResectionGastroduodenostomy. Palpable mass b. j. Dysphagia e. salmonella. radiation therapy. Weight loss d. pre and post-operative health teaching 3. Metronidazole spec for amoebiasis. mild to severe temperature Cause: Bacterial ( E. Gastrojejunostomy Malignancy: Possible GASTRIC CANCER Incidence: f. Management: o Replace fluid loss o Anti-infective Agent (e. gastric resection Nursing Intervention: Same as with patient’s with ulcer. (+) high lactate dehydrogenase level in gastric juice Diagnosis: GIT x-ray. h. severe fluid and electrolyte loss. diarrhea. Ascites c.Bleeding Melena is more common than hematemesis Not possible diseased tissue and provides a protective barrier to acid Hematemesis is more common than melena Surgical Treatment 1.g.coli nd/or shigella. i. Vagotomy 2. old 143 . fever. vomiting. Common in men than women History or presence of Pernicious Anemia Often develops with the occurrence of atrophic gastritis Low-socio economic status. gastroscopy Treatment: Chemotherapy. severe fluid and electrolyte loss. emotional support.
dilation and edema of intestines revealed in GIT x-ray Medical Management: NGT: Lavage to relieve pressure in the abdomen Fluid & electrolyte replacement Surgical Treatment: Appendectomy or Exploration of the abdomen with drainage Nursing intervention: Careful assessment of history.-> Kinking of the appendix -> 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. (+) pain at Mc Burney’s point (RLQ) Treatment: Appendectomy Nursing intervention: Assess the VS and pain scale carefully Observe for symptoms of peritonitis . loss of apetite. vomiting (N/V) Absence of bowel sounds Shallow respirations Increased WBC . fluid & electrolytes Pre & Post-operative Care o o o c. low grade fever. Pre & post-operative care PERITONITIS o o Inflammation of the peritoneal membrane Cause: Gangrenous cholecystitis Ruptured gallbladder Perforated gastric cancer Perforated Peptic ulcer Ruptured spleen Acute pancreatitis Penetrating wound Ulcerative colitis Gangrenous obstruction of the bowel Perforated diverticulum o Ileitis Appendicitis with perforation Ruptured retroperitoneal abscess Strangulated hernia Salpingitis Septic Abortion Ruptured bladder Puerperal infection Iatrogenic Cause Signs and Symptoms: Localized pain Abdominal rigidity Increased pain upon movement Nausea. V/S. coated tongue and halitosis Diagnosis: Increased WBC. Inflammatory Bowel Disease: ULCERATIVE COLITIS & CHRON’S DISEASE CHRON’S DISEASE Pathology & Anatomy Involves primarily the ileum & right colon Distribution of d’se is segmental Malignancy is rare May be genetic Usually in the 30’s Remissions and relapses Course of Disease Slowly progressive Common ULCERATIVE COLITIS 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) Onset Etiology 144 .Cause: Fecalith (stone or calculus in the appendix) Fibrous condition in the bowel wall .
Make sure the client voids after surgery. flatulence. emotional stress. diarrhea (20 stools/day or more). cramping. Pain LLQ.Rectal bleeding Anorectal fistula Other S/S: Occasional Rare Common Abdominal pain Weight loss Diarrhea – soft or semi-liquid Pain in RLQ. Ileostomy Assess Intake and output. Incisional Hernia Medical Treatment: Use of TRUSS if hernia is not strangulated or incarcerated. abdominal distention. weight Emotionla support Client teaching regarding surgery Post-op intervention: Observation of the stoma Teach client re: self-care Same as Chron’s D’se HERNIA -An abnormal protrusion of an organ or tissue through the structure that contains it. Umbilical Hernia 5. Femoral Hernia 4. Nursing Intervention: Pre & Post-operative Care Post-op Care: a. Ice pack over the incisional site to control pain and swelling d. Stools may occur with blood or pus. Loperamide HCL (Imodium) Total Parenteral Nutrition Bowel Resection. weight loss Urgency. Direct Inguinal Hernia 3. . tenderness.Frequently a congenital occurrence or acquired weakness of the abdominal muscles Types: Indirect Inguinal Hernia 2. Instruct patient to avoid heavy lifting from 4-6 weeks post surgery DIVERTICULUM Diverticulum – an outpouching of intestinal mucosa through the muscular coat of the large intestine (most commonly the sigmoid colon) Diverticulosis – refers to the presence of non-inflamed out pouching of the intestine Diverticulitis – inflammation of a diverticulum Incidence: Etiology: > 45 yrs. cramping. Ileostomy Rectal bleeding. urinary retention is common after herniorrhaphy b. Male & Female Lower fiber diet which causes bulk in stools which may cause intraluminal pressure in the bowel causing diverticula Chronic Constipation Anorexia Low grade fever Risk factors: S/S: Left Quadrant Pain Increased flatus 145 . Same as Chron’s D’se Medical Treatment Surgical Treatment Nursing interventions: Bowel Resection. nausea (mimics Appendicitis) Replacement of fluid loss Anti-diarrheal: Diphenoxylate HCL (Lomotil) . Resume diet as tolerated by the patient c. Surgical Treatment: Herniorrhaphy 1. old .
ribbon-like stool. o Colon resection with colostomy Indications Colostomy o Involves the large bowel (colon) o stool is semi-formed Inflammatory / obstructive process of the lower intestinal tract Trauma Rectal or sigmoid cancer Diverticulum o Chron’s Disease Ulcerative Colitis Nursing Intervention 1. emesis w/ bile stain Treatment: a. Colostomy b. Emotional support 2. Bowel Resection c. e. Avoid activities that may increase abdominal pressure (bending. abscess. Heath Education regarding: a. Intake of 6-8 glasses of water a day c. perforation and obstruction. etc) b. 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. 10-11 yr. Teach colostomy care. Cleansing Enema Post-op Nursing Intervention.(+) rectal mass on digital rectal examination Medical Intervention: High-fiber diet and laxatives NGT insertion to relieve pressure Control inflammation through antibiotics and advise patient to: a. Avoid incision by keeping diapers low e. Internal – varicosities above the mucocutaneous border covered by the mucous membrane. Reduce weight if obese Indicated for those who developed complications as manifested by hemorrhage. Check dressing c.check color of stoma (should be bright leg) b. Psychological Support 3. lifting. a. 146 . Hemorrhoids o Peri-anal varicosities which is either internal or external o Types: a.surgery (ileostomy/colostomy) b. Self-care Surgical Intervention: Ileostomy o Involves the small bowel (ileum) o stool is in liquid form o o d. old child can already take care of his/her own stoma. chronic constipation. Monitor intake & output d. diarrhea.
5 – 5. Rubber band ligation. Regulates exchange of water between fluid compartments a.5 mEq/L 85-115 mEq/L 22-29 mEq/L Functions of the Fluid & Electrolytes in the Human Body: a.physiologic or over hydration as Fluid Volume Deficit fluids and/or electrolytes are loss physiologic or dehydration 147 . Actions of the Fluids & Electrolytes Diffusion – fluids move from area of higher concentration to an area of lower concentration Osmosis . Laser Surgery. Regulates acid-base balance in the body b.80% of body weight is water 47% of body weight is water - 135-145 mEq/L 3. Incidence: Risk factors: S/S: Both male and female aged 20-50 y/o. Pain Medical Intervention: a.b. Skin – means of elimination of fluid in the body through perspiration d. cryosurgery f. Pregnancy. Chloride (Cl) d. Infant d. CHF.3. Maintains fluid volume c. Blunt Trauma – injury like vehicular accident Penetrating Abdominal Trauma – stab wound DISTURBANCES IN FLUIDS AND ELECTROLYTES Fluid Content in the Human Body : a. bleeding and rectal itching External – enlarged mass at the anus Present symptoms in both internal & external: Bright red (blood) stain in stool or tissue. Abdominal Trauma : a. Lungs. b.3.45 NaCl System of Fluid Balance in the body: a. 5. portal hypertension Increased abdominal pressure. External Hemorrhoids.9 NSS. 0. tubular fibrous tract that extends into the anal canal May develop from trauma. . Fistula-in-ano Tiny. Relieve pain through heat application / Sith’s bath Surgical Intervention: Hemorrhoidectomy. D5W f.– varicosities below the mucocutaneous border covered by the anal skin. e. Elderly Electrolytes in the Human Body: a. Sclerotheraphy. Intravenous Solutions Used to correct imbalance: e. Men c. Endocrine –Controls hormones which regulates normal functioning of systems Imbalances in Fluids & Electrolytes Fluid Volume Excess Cause fluids exceeds the normal volume the body needs . straining during bowel Movement Internal – bleeding and renal prolapse. D50 g.fluids move from an area of lesser concentration to a higher concentration Filtration – fluids and substances moves from higher hydrostatic pressure to lesser hydrostatic pressure. Sodium (Na) b.g. Bicarbonate (HCO3 ) 50-55% of body weight is water 60-70% of body weight is water 75. fissures or regional enteritis Fistulectomy is recommended. Potassium (K) c. Women b. constipation. Kidneys – responsible in controlling the balance of fluid & electrolytes b.g. Hypertonic – has greater concentration of solis substances than the fluid substances e. Treat constipation b. b.Total Parenteral Nutrition. Hypotonic – has fewer solid and has higher fluid content. Prolonged sitting or standing. c. Isotonic – 0.controls the Carbondioxide levels in the body and water vapor c.
Fever.2. apricots.1.1. melon. urine collection) 4. Hematuria e.Coli Signs & Symptoms a. red meat. raisins. as ordered c. turkey Iodized or table Salt Peas. beans. (24 hr. Cloudy urine Nursing Considerations: a. vomiting Edema Oliguria 148 . proteinuria.3. Suprapubic pain d. Serum Creatinine. Rehydration Weight daily Administer medications as ordered ( depending on electrolytes loss) Encourage proper nutrition an fluid intake Sources of Electrolytes: Electrolyte Potassium Sodium Magnesium Calcium Food source Bananas. chills f.1 Genitourinary & Renal Problems Renal Function Tests Normal Values: a.500 ml/day Monitor vital signs Monitor I & O Fluid restriction Low sodium diet Weight daily Prevent skin breakdown. Antibiotic treatment. sardines. chills. Frequency & Urgency of urination b. prunes. nausea. fish 4. cheese. • • • Glomerulonephritis – inflammatory damage of the glomeruli – usually Streptococcus Signs & Symptoms: Hematuria. fever. weakness.in IV therapy Illness: Renal Disease Neurologic Diseases Congestive Heart Failure Addison’s Disease Renal Disease Diarrhea Post-operative conditions Burns Trauma GIT Suction/Drainage Weight loss Dry skin and mucous Membrane Tachycardia (same w/ excess) Poor skin turgor Decreased urine output Decreased Central Venous Pressure Increased hematocrit Urine output: < 30 cc/hr ( Normal Urine Output =30 cc/hr) Clinical Manifestations Weight gain Edema Flushed skin Tachycardia Increased BP.skin is fragile Keep client in Semi-fowler’s position to establish good gas exhange Administer Diuretics as orderedLasix (Furosemide) Nursing Interventions Monitor vital signs Monitor I & O Replace fluids. Force fluids d.5 -7. RR Rales Neck Vein distention Increased Central Venous Pressure Decreased Hct Urine output: > 1.8 mg/dL e. Blood Urea Nitrogen (BUN) – 10-20 mg/dl b. fruits Milk.0-1 mg/dL c. nuts. urine collection) d. Good hygiene 4. nuts & vegetables. Collect urine for testing b. Creatinine Clearance – 100-120 ml/ minute (24 hr. tomato. Serum Uric Acid -3. Cystitis / Urethritis/ Urinary Tract Infection –usually caused by E. Urine Uric Acid – 250-750 mg/ 24 hrs. Dysuria c. peaches.
• • • • • HPN Headache Increased Urea Nitrogen Flank Pain Anemia Nursing Considerations: a. high protein. Proteinuria b.1. vomiting. Administer meds as ordered 4. High CHO. DM. high fat. uncontrolled HPN Signs & Symptoms: a. b. Signs & Sypmtoms: a.urine is less than 400 cc in 24 hrs. allergies. (+) edema . Steroids. Administer meds as ordered: Diuretics. pyelopnephritis. bed rest b. Monitor I & O h. Sodium & fluid restriction d. Immunosuppresiove agents. Hematuria d. Maintain Fluid & electrolyte balance c. Protect from infection e. Proper diet : Oliguric – low CHON. Gastrointestinal symptoms d. fatigue b. UTI symptoms Nursing Considerations: a.stones in the urinary system Signs & Symptoms: a. stones or benign Prostatic hyperplasia Signs & Symptoms: 3 Phases a. Edema Nursing Considerations: a. Prevent hypokalemia d. Bed rest 4. Convulsions 149 . Acute Renal Failure –sudden and reversible malfunction of the kidney due to trauma. Oliguric Phase – sudden . anticoagulants 4. Urolithiasis . Nephrotic Sydrome – glomeruli disorder due to other diseases like DM.4. Dialysis if indicated i. etc. Psychological & emotional support 4. high calorie. high calorie. Chronic Renal Failure – progressive failure of kidney function which may result to death.7. less potassium Diuresis – high CHON. Administer insulin or IV glucose as ordered to promote potassium absorption e. Penicillin. Treat cause of sudden occurrence b.1. SLE.1. Proper dietary intake c. Strain Urine for stones c. Dull aching pain b. Period of Diuresis – urine is 1000 ml in 24 hrs and is diluted c. HPN e. Headache c.5. Irritability f. Hyperbilirubinemia d. Force fluids: at least 3L of water in a day b.6. as ordered b. Monitor I & O d. Recovery Period Nursing Intervention: a. Nausea.1. low sodium c. less fluid f. caused by chronic gomerulonephritis (CGN). Weigh daily g. diarrhea c. Hypoalbunimemia c.
dribbling sensation Surgical Treatment: Prostatectomy Post-operative Nursing Consideration: a. Benign Prostatic Hyperplasia – enlargement of the prostate with unknown etiology usually in older males Signs & Symptoms: Difficulty in urinating Nocturia. potassium Treatment: Dialysis Renal Transplant a. Nursing Considerations: Maintain fluid & electrolyte balance Bedrest Diet: low protein. Prostatectomy Nursing Interventions: Weigh daily . peritonitis. dyspnea. a. Nursing Interventions: Weigh daily Monitor vital signs Maintain asepsis at all times Record intake and output Monitor for complications: Bleeding.1. c. 4. 2.000 new cases of renal disease per year Affects all ages Adult: End-Stage Renal Disease (ESRD) 150 . monitor I&O Monitor vital signs Maintain asepsis at all times Monitor for complications: Bleeding. b. Avoid lifting heavy objects x 6 weeks and avoid strenuous activities d. high CHO and vitamins Control HPN WOF cerebral irritation e. Anemia h. c. sodium. Decrease pain. administer meds as odered TREATMENT FOR GENITOURINARY PROBLEMS: 1. abdominal pain. d. b. monitor bladder irrigation c. Dialysis a. Kidney Transplant KIDNEY DISEASE IN THE PHILIPPINE HEALTH SITUATION 6. Elevated BUN. bowel perforation Urinary Tract Surgery a.8. crea. Transurethral Removal of the Prostate b. Observe for shock and hemorrhage b. Bladder Drainage. Increase fluid intake e. low sodium.g. abdominal pain. e. Hemodialysis Process of cleansing the blood of waste products which the GUT is unable to eliminate Cathether inserted via a small incision on the neck (intrajugular). b. d. peritonitis. bowel Replace fluids Proper irrigation 3. arms or at the femoral area. Peritoneal Dialysis Use of peritoneum via a catheter for proper exchange of fluids and electrolytes and drainage of fluids Catheter inserted just below the umbilicus with small incision Continuous Ambulatory Peritoneal Dialysis c. hematuria. dyspnea.
Chronic Pyelopnephritis – 17% 3. Hypertensive Nephrosclerosis. N4 = increasing degree of abnormal regional lymph nodes Metastatic Development MO= no evidence of distant metastasis M1.13% 4. M2.cancer from blood-forming organs c.1. Colon Ca. 3. Sacrcoma. N2. Diabetes Mellitus. Routine screening for UTI. Prostate Ca Ex.Children and young: Chronic Glomrulonephritis Causes: 1.5% Kidney Disease Prevention: Good Nutrition 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. Renal Ca. T4 = progressive tumor in size and involvement TX = tumor cannot be assessed Involvement of Regional Nodes NO = regional lymph nodes not abnormal N1. Extent of Malignancy T0 = no evidence of primary tumor TIS= Carcinoma in Situ T1. diabetes and kidney disease DISTURBANCES IN CELLULAR FUNCTIONING CANCER o Abnormal growth of tissues a. Breast Ca. Hodgkin’s Lymphoma Ex. M3 = increasing degree of distant metastasis c. Increase awareness and prevent renal disease: • Adequate water intake • Balanced diet • Good personal hygiene • Regular exercise • Regular BP check-up • Complete immunization for infants and children • Proper management of throat and skin infections • Yearly urinalysis 2. Extent of tumor T= primary tumor N= regional nodes M= metastasis b. Leukemia . Increase awareness of signs & symptoms of kidney disease as edema and HPN 6. Lymphoma – cancer from reticulo-endothelial lymph node organs d.cancer from connective tissues o o Cancer in the Philippines: Ranks third in leading cause of morbidity and mortality 75% of cancers occur at age 50 y/o Staging of Tumors a.epithelial cells lining the internal and external surfaces of the body. Clinical Manifestations of Tumor Presence (based on Community Health Nursing Services in the Philippines by the DOH) C A U T I Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickening or lump in breast or elsewhere Indigestion or difficulty in Ex. Chronic Glomerulonephritis – 47% 2. Gastric Ca. Carcinoma . b. 6. Uterine Ca Ex. d. T3.N3. Rectal Ca . Laryngeal Ca Ex. T2. Esophageal Ca 151 .
Mammography: o Initially at age 40 and then 1-2 yrs thereafter o High risk women. indifference Make arrangements for spiritual consolation Assist in rehabilitation even before treatment and until she recovers and adjust to the society Collaborate with other health workers for the patient’s holistic needs 152 . Melanoma. Proper cavity and dental chewing No conclusive evidence for early prevention Early Detection Thorough dental check-up each year Breast Monthly self-exam and annual exam with physician. surgery or radiation therapy cannot assure treatment of the patient . Lung Ca Most Ca conditions Risk Factors Age Health Habits Sex Family History Race Socio-Economic Status Occupation Lifestyle Cancer Therapy a. d. Surgery b. c. Minimal alcohol intake.should consult a doctor before age 40 Lung Uterine / Cervix Avoid smoking Clean. yearly occult blood tests in stools.O N U S swallowing Obvious change in wart or mole Nagging cough or hoarseness Unexplained Anemia Sudden uexplained weight loss Ex. Radiation Therapy – electromagnetic rays destroys cancer cells Palliative/ Supportive Care. Avoid moldy foods Maintenance of a high fiber and low fat diet Avoid excessive sun exposure No conclusive evidence for early prevention Annual check-up Regular pap smear: Once sexually active then every 3 years if findings are normal None Liver Colon and Rectum Skin Prostate Regular medical check-up after 40 years. d. safe sex Single partner reduces risk Hepa.for end-stage or terminal stage . rectal exams and sigmoidoscopy Self skin assessment Rectal Exam Nursing Intervention a. vaccine.management o f care is geared towards a symptom-free individual with psychologic and spiritual support Cancer Prevention & Early Detection Type of Cancer Oral Cancer Early Prevention Avoid Smoking tobacco. Betel quid “Nganga” chewing. Squamous cell Ca Ex. e. Chemotherapy – chemical/ medication c. it is a holistic care for the patient and family . Assist the patient in maintaining self-dignity and integrity by continued and sustained communication and contact Allow patient to ventilate feelings such as fear. b. anger.given if chemo.
5 g/dL 36 – 48% 40 -52% WBC – white blood cells PC6. HEMATOLOGIC PROBLEMS Normal Values to Remember: Blood Component RBC – red blood cells Hgb . Hypoproliferation Anemia – bone marrow fails to produce adequate blood cells a. B12 and Folic acid deficiency in gastric juice Clinical Manifestations: Paresthesia Tingling or numbness of extremities Gait disturbances Behavioral Disturbances Nursing Intervention: Intake of Vit. drugs.4 x 106 4. Pallor. blood loss b. Dizziness.hemoglobin Hct . Indigent Cases d. then 153 .2 – 5.000/ mm3 150. Post-operative Cases c.5 g/dL 13. B12 following this regimen: o 3x a week for 2 weeks. 000 – 400. RBC fails to mature adequately Signs & Symptoms: Fatigue. b. or atrophy of the Megaloblastic Anemia – due to previous gastric surgery. a. c. ANEMIA Platelet count 4. Aplastic Anemia . Terminal Cases 6. Newly diagnosed cases b. hemoglobin & hematocrit Types of Anemia: a. Decreased RBC. Weakness. course of treatment and alternatives Priorities for Health Supervision: a.000 / mm3 Causes: Sudden or Chronic blood loss Abnormal bone marrow function c.2. 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.1.1 x 106 11.5 – 15.due to radiation.5 – 17. malabsorption gastric mucosa Pernicious Anemia – Vit.hematocrit Female: Male: Female: Male: Female: Male: Normal Values 4.7 – 6.500 – 11. Iron Deficiency Anemia – nutritional deficiency.2. Home visits and education about the client’s condition.f.
Increased Bleeding Tendencies LYMPHOMAS – neoplasm of lymphatic cells • Hodgkin’s Lymphoma • Non-Hodgkin’s Lymphoma 6. tinnitus.4. c. paresthesia. Reverse Isolation. Radiation therapy. Blood Transfusions.2. persistent increased can be malignant . o 2 x a week for 2 weeks. atherosclerosis THROMBOCYTOPHENIA . blurred vision. then o Once a month Protect lower extremities Rest in non-stimulating environment Hemolytic Anemia • Sickle Cell Anemia. turns to sickle cell when oxygen in venous blood is low • Thalassemia • Glucose-6 Phosphate Dehydrogenase Deficiency Clinical Manifestations: Thalassemia & G6PD – usually asymptomatic Sickle Cell Anemia: o Severe Pain o Swelling o Fever o Jaundice o Prone to infection Nursing Intervention: Proper oxygenation Hydration Analgesics Adequate Rest Refer to genetic counseling Avoid cold places to prevent sickle cell proliferation 6. Steroids Nursing Interventions: Emotional Support Reverse isolation Adequate Rest and Nutrition Strict Medication Regimen 154 . 6. LEUKOCYTOSIS & LEUKEMIA Leukocytosis Leukemia • • • – increase level of WBC.2.3. POLYCYTHEMIA – neoplasm of myeloid cells Clinical Manifestations: Dizziness.5. bleeding Management: Chemotherapy.2.defective hemoglobin.2. fatige. headache.2. • • Multiple Myeloma Thrombocytophenia – low platelet .proliferation of neoplastic white blood cells in the bone marrow affecting the different tissues and organs in the body Acute & Chronic Myeloid Leukemia (AML / CML) Acute & Chronic Lymphocytic Leukemia (ALL / CML) Angiogenic Myeloid Metaplasia (AMM) Clinical Manifestations: Fever Prone to Infection Pain Weight Loss Fatigue Nursing Interventions: Energy conservation Reverse Isolation Blood Transfusion 6.
sudden anxiety Diseases Transmitted through Blood Transfusion Hepatitis B or C . expiration. Types of Blood Components Transfused Whole Blood Packed Red Blood Cells Fresh Frozen Plasma/ Plasma Concentrate Transfusion Complications Non-hemolytic reaction. Check name.6. 2.5. 2. dyspnea. serial # Take baseline vitals signs Blood pack should be at room temperature Monitor for transfusion reaction Allergic (pruritus. ID. backpain. urticaria) Hemolytic (low back pain. orthopnea. blood type. 3. 155 . Cytomegalovirus Nursing Interventions: 1. if present – symptomatic treatment 5. chills) Treat transfusion reaction. itching Hypervolemia – neck vein distention. chills. nausea.Fever Hemolytic Reaction. fever. 4. flushing. BLOOD TRANSFUSION 1. chest tightness. tachycardia.2. AIDS / HIV. dyspnea and anxiety Allergic reaction –urticaria. respiratory distress. 3.life threatening: fear.
Eyelid reaction to stimulus Hearing Acuity Gag Response Ability to speak clearly Shoulder’s ability to resist against pressure Tongue at midline Neurologic Status: a. Autonomic Nervous System Sympathetic Nervous System Parasympathetic Nervous System The Cranial Nerves: Oh. b. Oh. c. Client identifies taste. Oh. Flexion: abnormal (decorticate) e. Coma. Extension: abnormal (decerebrate) f. Cranial Nerves – 12 pairs Spinal Nerves – 31 pairs Cervical – 8 Thoracic – 12 Lumbar – 5 Sacral – 5 Coccygeal . follows command. attentive. Localizes pain c. Obeys verbal commands b.arouses to vigorous and continuous stimulation -response may be an attempt to remove the painful stimulus. motor and verbal response Lowest score is 3 points . speaking ability and motor abilities in response to a stimuli. To pain d. but slowly and inattentively Stuporous . To Touch And Feel A Girls Veil So Heaven I II III IV V VI VII VIII IX X XI XII Olfactory Optic Oculomotor Trochlear Trigeminal Abducens Facial Auditory Glossopharyngeal Vagus Spinal Accessory Hypoglossal Smell Visual Acuity Pupil constriction and dilation Eye movement: Inferior and medial Jaw muscles Eye movement: Lateral directions Symmetrical facial movement.alert. d. To speech c. Peripheral Nervous System a.7. Central Nervous System: Brain Spinal Cord II. NEUROLOGIC DISTURBANCES I.1 c.Spontaneous/ Normal eye. – 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 . No response to pain on any limb Points 4 3 2 1 6 5 4 3 2 1 Moto r Response 156 .No response Eye Opening Response a. Spontaneous b.drowsy but awakens. Conscious. Perfect score is 15 points . No response a. and follows command Lethargic. b. Flexion: no withdrawal d.
HPN.occurs when a blood vessel bursts inside the brain and bleeds (haemorrhages). . aneurysm Signs & Syptoms: a. can look at surroundings. 3.total paralysis of the arm. Maintain fluid & electrolyte balance - 157 . When calling the nurse: can only say “ne…. extra damage is done to the brain tissue by the blood that seeps into it. Decreased awareness of body space Risks Factors: Types of stroke: 1. Cerebral thrombosis .a blood clot (thrombus) forms in an artery (blood vessel) supplying blood to the brain.e…e.blood clot that forms and then travel to the brain. Inappropriate speech d. No movement/response when skin is Pinched . Makes incomprehensible sound e. Cerebral embolism . Nursing Interventions: 1. and can express self through words.brain cells are starved of oxygen.” sound GCS Scoring: Eye opening Motor Response Verbal Response GCS Score = 3 = 1 = 2 = 6 CEREBROVASCULAR ACCIDENT (CVA) “Stroke” o A sudden disruption of blood supply to the brain which may lead to temporary or permanent dysfunction. Hemiplegia . With a hemorrhage. can raise hands when asked to. Hemiparesis. Transient Ischaemic Attack (TIA) short-term stroke that lasts for less than 24 hours ( seconds or minutes in a day) oxygen supply to the brain is restored quickly transient stroke needs prompt medical attention as it is a warning of serious risk of a major stroke. GCS Scoring: Eye opening Motor Response Verbal Response GCS Score = 4 = 6 = 5 = 15 Eye slightly opens when name is called . peripheral vascular disease. Monitor neuro vital signs: Vital signs and Glasgow coma scale including intake and output 3. obesity. Maintain adequate airway 2. Speech problem / Aphasia . leg and trunk on the same side f the body. Oriented b. 2. Obesity.weakness of one side of the body c.a loss or impairment of the ability to produce and/or comprehend language b. No response 5 4 3 2 1 Example: Patient s conscious. d. answer questions appropriately. Able to Converse c. Cerebral hemorrhage .Best verbal response a. Can tell where he is. coherent. 4.
Infection. Spinal Shock (Areflexia) 2. Tumor The Spinal Nerves: 1. biceps Wrist Extenders Triceps Hand Shoulder elevation possible. Bladder & Bowel conrol Hip adduction impaired Leg muscles Knee and ankle movement impaired Bladder & Bowel control Sexual Control Bladder/Bowel Incontinence. impaired breathing. upper arm. Violence. sexual dysfunction Cervical Nerve Injury causes Quadriplegia/ Tetraplegia Diaphragm Deltoid. Bladder & bowel management 4. Maintain respiratory function. Thoracic Nerve 3. Rehabilitation Nerves Level C1 C2 C3 C4 C5 C6 C7 C8 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 S1 S2 S3 S4 S5 Body part affected Head & Neck Spinal Cord Injury Effect Paralysis below neck. Cause: Vehicular accidents. Lumbar Nerve 4.etc Decrease sensation in the peineum 158 . Sacral Nerve Etiology: 1. ventilation support Elbow. Sports. bowel & bladder incontinence. wrist movement Thoracic Nerve Injury causes Paraplegia Loss of hand control. ABC 3. Cervical Nerve 2. Paralysis below waist Chest Muscles Abdominal Muscles Trunk and Abdominal control Lumbar Nerve Paralysis of legs. Falls. Immobilization specially after injury or trauma 2. loss of bladder and bowel control Sacral Nerve Sexual. sensory loss and altered activity.SPINAL CORD INJURY Definition: A damage in the nerve structure causing dysfunction resulting to paralysis. Autonomic Hyperreflexia Injury in T6 and above Life-threatening Nursing Interventions: 1.
c. 3. Severe weakness of the neuro functions most commonly affecting the Seventh cranial nerve. weakness.double-vision 3.PARKINSON’S DISEASE Definition: - A disorder affecting control and regulation of movement Unilateral flexion of arms. a. d. high CHON in PM High fiber foods to promote bowel elimination Prevent Injury – fall. Dyphagia Management: b. Phenylephrine Hydrochloride Vision w/ Cataract Vision w/ Cataract 159 .the eye lenses becomes thick and unclear or yellowish. b. d. Hazy vision / Yellowish haze Whitish to yellowish eyelense. Clinical Manifestations: 2. Mydriatrics . c. Ptosis. Pyridostigmine Bromine (mestinon) Ambenomium Chloride Steroids –Prednisone Atrophine Sulfate Nursing Interventions: Avoid fatigue Administer meds as ordered Avoi neomycin and morphine CATARACT Definition: . Gradual visual loss.Facial Nerve Clinical Manifestation: 1. Diplopia. disability Clinical Manifestations: Rigidity Involuntary body tremors Hips and knees flexion Masklike facial expression Slurred speech Drooling Constipation Depression Retropulsion.difficulty opening of the eye 4. shuffling gait. e. Atrophine Sulfate b.causes dilation of pupils. Surgical Treatment: Cataract extraction Drug: 1. Mask-like facial expression 2. difficulty in walking. Rehabiltation – exercise Speech therapy Diet: Low CHIN in am. propulsion Medical Management: Surgical Management: Nursing Interventions: a. etc Anti-parkinsonian Agent: Anti-cholinergic: Levodopa Cogentin Stereotaxic Thalamotomy – surgery of the thalamus to treat disorder MYASTHENIA GRAVIS Definition: Severe weakness of one or ore groups of skeletal muscles. 4. increases intraocular pressure (IOP) a.
2 types of Glaucoma: 1. coughing and sneezing as it may further increase IOP GLAUCOMA non-curable condition of the eye due to increase in intraocular pressure causing deterioration of the optic nerve. Nausea & vomiting e. Tired feeling in the eye d. Rainbow around lights b. can also be involved:heart and lung (as in rheumatic heart disease) Chronic disease. high fiber diet 8. Monitor BP. ulnar. Slowly diminishing peripheral vision Surgical Management: 1. Post-op intervention: keep eye covered head of bed elevated at 30-45 degreed. Teach client that glaucoma can be controlled but not curable (even surgery can’t cure the disease) 3. Administer drugs as ordered 2. Cloudy and blurred vision d. Progressive loss of vision c. common in women OSTEOARTHRITIS Degeneration of the articular cartilage Wear & Tear of joints Weight-bearing joints: knees. Iridenclesis Drugs: Miotics – causes constriction of pupils -A Vision w/ Glaucoma 1. 3. Trabeculectomy 2. Thermosclerectomy 3. Halo around lights b. Pilocarpine hydrochloride . increase BP Nursing Intervention: 2. Acute or Closed. Cervical. Pain around the eye c. finger joints.2.Drains aqueous humor Acetazolamide – decreases production of aqueous humor Mannitol – reduces IOP Isosorbid – also decreases production of aqueous humor Nursing Intervention: 1. 2. Cyclopegics – decreases ciliary muscle accomodation Side effects: blurred vision. 4.Angle Glaucoma a. Dilation of pupils 2. hips. MUSCULOSKELETAL DISTURBANCES RHEUMATOID ARTHRITIS A systemic inflammatory disorder of connective tissues and/ or joints characterized by exacerbation & remission. supine position Avoid bending or lifting heavy objects. avoid use to patients with HPN Teach client that blurring of vision may be experienced. 4. Encourage low residue. Encourage moderate exercise 4. spine JOINT DISORDERS Definition Kinds of Joints Incidence Clinical Manifestations Older women Pain felt after activity • • Synovitis Pain relieved with rest 160 . Avoid straining of bowel 5. early to mid-adulthood. 3. Chronic or Open-Angle Glaucoma a.
middle-aged and elderly. Cyclophosphamide Nursing Intervenions: Avoid exposure to sunlight because symptoms aggravate symptoms or wear hats. exercise. Bedrest during attacks b. Children.granulation of tissue causing destruction of adjacent cartilage. rest and exercise Stress management. sardines .food with high purine / uric acid content Systemic Lupous Erythematosus (SLE) Definition: Risk factors: Diffuse connective tissue disease affecting skin. Severe pain. Balance rest and exercise. if possible avoid stress Fractures Definition: A break in the continuity of the bones Clinical Manifestations: 161 .Azathioprine. b. Avoid eating organ meats.• Intermittent bone pain. Heat or cold compress c. . heat Balanced rest and activity. Indomethacin Probenecid Colchicine Sulfinpyrazone Drugs: Nursing Management: a. swelling. most common in men A salt of uric acid (Urate) crystallizes in soft and bony tissues causing local inflammation and irritation. Phenylbutazone Nursing Intervention Maintain body alignment. shellfish. NSAIDs. fingers.. steroids in joist only Drug: Steroid. proper diet Gout / Gouty Arthritis Defintion: Risk Factors: Clinical Manifestations painful metabolic disorder due to inflammation of the joints due to high uric acid Hereditary. umbrella or sunscreen Adequate nutrition. c. joints. malaise. ASA. Increase fluid intake to flush out uric acid d. joints and bones • fatigue. lymph nodes and GI tract. warm feeling due to vasodialtion and increased blood flow • Pannus formation. redness. hereditary Clinical Manifestations: “Butterfly rash” in the face ( across both cheeks and nose) Manifests symptoms same as that of arthritis and Raynaud’s Management: NSAID’s Steroids Cytotoxic drugs a.. kidney. ASA. serous membranes of the heart and lungs. anorexia. weight loss Management Rest. Indomethacin. heat packs. earlobes Allopurinol NSAID’s – Ibubrofen . Steroids. painful and swollen joints Tophi (crystal formation in joints) are palapated around great toes. usually in great toe Red.
For patients who have lower pain tolerance (elderly. fascia.internal manipulation of bones requiring surgical operation . subcutaneous tissue Epidermis. pins. Splint limb Bring to nearest hospital/medical institution Traction Closed Reduction -balanced pulling of the musculoskeletal structure to align bones. 4. 2. Head and Neck b. Pulselessness d. subcutaneous tissue. Pain b.Pain Loss of function Deformity False motion Edema Spasm Crepitus Hematoma around skin Breaks for penetrating bone fragments Management: First Aid 1. . children) reduction may be done under sedation anesthesia. Anterior Truck Full thickness - 9% 18% 162 . plates. skin is closed after the procedure. .applying nails and metal screws to bones through the skin surface Open Reduction Internal Fixation External Fixation Casts - -a rigid mold used to immobilize an injured structure to promote healing Nursing Management: 1. PAresthesia e. requires countertraction . fat. muscle and bone Superficial Superficial partial thickness. dermis. 3. painless.external manipulation such as manually aligning bones by pulling. Pallor c. with blisters (fluid formation) Reddish. dermis. 2. INTEGUMENTARY DISTURBANCES Burn Depth of Injury First-degree Second-degree Manifestation Painful. nails to align bones (opening of the skin and exposing bones affected). Deep partial thickness Full thickness Third. pink to reddish. Maintain airway and circulation Immobilize joints that may be affected.degree Fourth-degree Rule of Nines: a. Paralysis 9. 3. 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.surgically applying screws. subsides quickly Pain. pink to red. eschar formation (Leather-like skin) Level of Skin Affected Epidermis and part of dermis Epidermis and dermis hair follicle intact Epidermis. brownish or whitish.
Tetanus toxoid b. history of injury (time. Medical – Surgical Management: a.Body compensates Progressive Stage . severe dermatitis.Compensatory mechanism is not adequate .progressive Stage . 4.etc) 3. DIC Crystalloid loss: Dehydration. Ball thrombus 163 . Ruptured Aortic Aneurysm. Irreversible Stage . Disseminated Intravascular Coaguation Plasma loss: Burns. Hospital Interventions: 1. Types of Shock Cause Etiology Hypovolemic Shock due to inadequate circulating blood volume Blood loss: Massive Trauma. Check ABC. Erosion of Vessesl due to lesion. plus deficiency in removal of cellular wastes. Myocardial Contusion Cardiomypathies Valvular Disease or injury: Ruptured Aortic Cusp. resulting to cardiac failure I. Legs f. cause.burn patients are very prone to infections 4. tubes or other devices. Maintain asepsis.c. Mafenide acetate c. malnutrition. nasogastric suction Cardiogenic Shock 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. GI Bleeding. Assess client’s data. Rule of Nine’s Burning person: Ask person to stop. Debridement SHOCK Failure of the circulatory system to maintain adequate perfusion of vital organs. oxygen and electrolytes delivered to body tissues. Arms e. Topical Anti-microbial agent: Silver Nitrate. give oxygen and IV fluids 2. Ruptured Papillary muscle. Protracted Vomiting. Gentamicin Sulfate. Perineum - 18% 9% each = 18% 18% each = 36% 1% 100% Management: First-Aid: 1.Cardiac output is slightly decreased . drop and roll ( lie down and roll) Burning person: Stop burning process such as wrapping the burning part with wet towel or blanket Check airway First-degree burn: Run cool water to affected area for 10 minutes 2. Critically severe deficiency in nutrients.blood flow to the heart is not adequate thus heart begins to deteriorate 3. Accumulation of intraabdominal fluid. Diarrhea. 3. Surgery.Inadequate tissue perfusion . Stages of Shock Non.Cellular ischemia & necrosis lead to organ failure II. Posterior Trunk d. Silver Sulfadiazine.
External Pressure on the Heart interferes with heart filling or emptying: Pericardial Tamponade due to Trauma. oriented. massive pulmonary embolus. Nursing Care Management GOAL: Promote venous return. Adrenocorticoids Vasodilators (nitroprusside). U. wheezing (anaphylactic shock) Temperature: cold clammy skin. Anaphylactic Shock -severe hypersensitivity reaction resulting in massive systemic vasodilation c. aneurysm. Electromechanical dissociation 3. medicines.could be alert.hypotension Pulse – tachycardia. administer blood/plasma as ordered ( stop blood immediately in anaphylactic s.Swan Ganz Medications (depends on type) Antihypotensive (epinephrine. monitor respiration Fluids: IV. thready. cardiac surgery.) Vital signs: CVP. elevated in anaphylactic LOC . dopamine) Anti-arrythmics.Shock) Respiration: increased depth. tachypnea. circulatory perfusion Position: Feet elevated with head slightly elevated also Ventilation: loosen restrictive clothing. dye. Distributive Shock a. insect bites or stings b. Neurogenic Shock - interference with nervous system control of the blood vessels Spinal: Spinal anesthesia.above 15 cms (cardio & septic) IV. Cardiac Glycosides. irregular (Cardio. urticaria in anaphylactic shock Oliguria. O2. Slow capillary refill BP. Antibiotics. tension pneumothorax Cardiac Dysrhtymias: Tachyarrhythmias. unresponsive CVP – below 5 cm H20 (hypovolemic) . pericarditis. spinal cord injury Vaso-vagal reaction: Severe pain. severe emotional stress Allergy to food. Bradyarrythmias. Beta-adrenergic (dobutamine) Mechanical support : Military Anti-shock Trousers(MAST) Effects of Shock in Different Organs Respiratory System Cardiovascular System Neuroendocrine System Hypoxia Lactic acid accumulates tissue necrosis Myocardial deterioration Disseminated Intravascular Coagulation Stage of resistance o ADH is released causing kidneys to retain sodium and water o Increase in adrenocorticoid mineralcorticoid hormones 164 . Signs of Shock Anxiety Restlessness Dizziness Thirst Fainting Pale skin.O. Septic Shock systemic reaction vasodilation due to infection Gram-negative septicemia but also caused by other organisms III.. norepinephrine. ECG.
iodine or an iodine-containing cleanser. These guidelines can help you care for simple wounds: 1. 2. Cuts and scrapes: First aid*** Minor cuts and scrapes usually don't require a trip to the emergency room. but they can discourage infection and allow your body's healing process to close the wound more efficiently. Rinse out the wound with clear water. Don't move the joint. 5. Bandages can help keep the wound clean and keep harmful bacteria out. If they don't. 2. Minor cuts and scrapes usually stop bleeding on their own. Thorough wound cleaning reduces the risk of tetanus. exposure to the air will speed wound healing. There's no need to use hydrogen peroxide. These supplies generally are available at pharmacies. Hold the pressure continuously for 20 to 30 minutes. These substances irritate living cells. blood is pooled in the liver or portal bed Altered capillary blood pressure and glomerular filtration Renal ischemia GI System Renal System IV. apply a thin layer of an antibiotic cream or ointment such as Neosporin or Polysporin to help keep the surface moist. Put ice on the injured joint. Get medical help immediately. FIRST AID *** FIRST AID: Details from www. use soap and a washcloth. If dirt or debris remains in the wound after washing. Change the dressing at least daily or whenever it becomes wet or dirty. After the wound has healed enough to make infection unlikely. stop using the ointment. nerves or blood vessels. 4. use tweezers cleaned with alcohol to remove the particles.org Dislocation: First aid*** 1. Soap can irritate the wound. Yet proper care is essential to avoid infection or other complications. see your doctor. Don't try to move a dislocated joint or force it back into place. This can help reduce swelling by controlling internal bleeding and the buildup of fluids in and around the injured joint. Stop the bleeding. This can damage the joint and its surrounding muscles.Immune System Macrophages in bloodstream and tissues are depressed Increased susceptibility to shock GIT vagal stimulation stops/slow down no peristalsis Liver – ability to detoxify is lost. Don't keep checking to see if the bleeding has stopped because this may damage or dislodge the fresh clot that's forming and cause bleeding to resume. apply gentle pressure with a clean cloth or bandage. Change the dressing. 3. If the blood spurts or continues to flow after continuous pressure. don't apply them directly on the wound. ligaments. Clean the wound. so try to keep it out of the actual wound. The products don't make the wound heal faster. seek medical assistance. Certain ingredients in some ointments can cause a mild rash in some people. Cover the wound. After you clean the wound. Splint the affected joint into its fixed position. If debris remains embedded in the wound after cleaning. To clean the area around the wound. switch to adhesive-free dressings or sterile gauze held in place with paper tape. gauze roll or a loosely applied elastic bandage. If you're allergic to the adhesive used in most bandages. Apply an antibiotic. If you choose to use them. 165 . 3. If a rash appears.redcross.
7. If a Chemical burns: First aid*** chemical burns the skin. running water for 15 minutes or more. For major burns. Caution Don't use ice. such as increased pain. 4. Broken blisters are vulnerable to infection. Get a tetanus shot. Minor burns usually heal without further treatment. Wrap the gauze loosely to avoid putting pressure on burned skin. reduces pain and protects blistered skin. Bandaging keeps air off the burned skin. see your doctor as soon as possible. swelling or oozing. Until an emergency unit arrives. Avoid re-injuring or tanning if the burns are less than a year old — doing so may cause more extensive pigmentation changes. Take an over-the-counter pain reliever. warmth or swelling. muscle and even bone may be affected. Areas may be charred black or appear dry and white. Cooling the burn reduces swelling by conducting heat away from the skin. If there is no breathing or other sign of circulation. If this is impractical. 166 . Watch for signs of infection. Get the booster within 48 hours of the injury Burns: First aid*** For minor burns. Putting ice directly on a burn can cause frostbite. others). Watch for signs of infection. Don't use fluffy cotton. follow these steps: 1. Don't break blisters. Cover the area of the burn. fever. Proper closure within a few hours minimizes the risk of infection. Use sunscreen on the area for at least a year. Difficulty inhaling and exhaling. Cover the burn with a sterile gauze bandage. Motrin. Doing so could cause shock. Remove the cause of the burn by flushing the chemicals off the skin surface with cool. carbon monoxide poisoning or other toxic effects may occur if smoke inhalation accompanies the burn. do make sure the victim is no longer in contact with smoldering materials or exposed to smoke or heat. your doctor may recommend a tetanus shot booster. drainage. dial 911 or call for emergency medical assistance.6. However. 8. If the burning chemical is a powder-like substance such as lime. take the following action: Cool the burn. sterile bandage. coughing or movement). including second-degree burns limited to an area no larger than 2 to 3 inches in diameter. Don't remove burnt clothing. See your doctor if the wound isn't healing or you notice any redness. naproxen (Aleve) or acetaminophen (Tylenol. Don't immerse severe large burns in cold water. which may irritate the skin. or until the pain subsides. ibuprofen (Advil. others). A strip or two of surgical tape may hold a minor cut together. brush it off the skin before flushing. If your wound is deep or dirty and your last shot was more than five years ago. 3. clean. moist. Never give aspirin to children or teenagers. redness. Doctors recommend you get a tetanus shot every 10 years. Check for signs of circulation (breathing. Don't put ice on the burn. Use a cool. If infection develops. Get stitches for deep wounds. follow these steps: 1. seek medical help. A wound that cuts deeply through the skin or is gaping or jaggededged and has fat or muscle protruding usually requires stitches. Hold the burned area under cold running water for at least 5 minutes. moist cloth. immerse the burn in cold water or cool it with cold compresses. further damaging your skin. 2. They may heal with pigment changes. These include aspirin. but if you can't easily close the mouth of the wound. Fat. or moist towels. begin cardiopulmonary resuscitation (CPR). Third-degree burn The most serious burns are painless and involve all layers of the skin. meaning the healed area may be a different color from the surrounding skin.
2. Sometimes the jolt associated with the electrical burn can cause you to be thrown or to fall. 3. skunks. If you're unsure whether a substance is toxic. 5. and the resulting second-degree burn covers an area more than 2 to 3 inches in diameter. Bites from nonimmunized domestic animals and wild animals carry the risk of rabies. 2. such as a heart rhythm disturbance or cardiac arrest. move the source away from both you and the injured person using a nonconducting object made of cardboard. follow these guidelines: For minor wounds. Dogs are more likely to bite than cats. increased pain or oozing. see your doctor immediately. Check for signs of circulation (breathing. 4. Prevent shock. plastic or wood. Cover the affected areas. or over a major joint. redness. Minor chemical burns usually heal without further treatment. For deep wounds. Turn off the source of electricity if possible. The chemical burn occurred on the eye. Cat bites. For infection. If you notice signs of infection such as swelling. groin or buttocks. is confused. but the damage can extend deep into the tissues beneath your skin. follow these steps: 1. Rabbits. call the poison center. Don't use a blanket or towel. 167 . however. Apply an antibiotic cream to prevent infection and cover the bite with a clean bandage. heartbeat or consciousness. If the bite barely breaks the skin and there is no danger of rabies. Remove clothing or jewelry that has been contaminated by the chemical. If an animal bites you or your child. squirrels and other rodents rarely carry rabies. Lay the person down with the head slightly lower than the trunk and the legs elevated. such as fainting. hands. If not. resulting in fractures or other associated injuries. Wash the wound thoroughly with soap and water. Seek emergency medical assistance if: The victim has signs of shock. Touching the person may pass the current through you. dry cloth to stop the bleeding and see your doctor. sterile dressing or a clean cloth. face. feet. bats and foxes than in cats and dogs. The chemical burn penetrated through the first layer of skin. Dial 911 or call for emergency medical assistance if the person who has been burned is in pain. pale complexion or breathing in a notably shallow manner. treat it as a minor wound. If absent. Rabies is more common in raccoons. While helping someone with an electrical burn and waiting for medical help. apply pressure with a clean. if available. Wrap the burned area loosely with a dry. or a clean cloth. Electrical burns: First aid*** An electrical burn may appear minor or not show on the skin at all. cover any burned areas with a sterile gauze bandage. Look first. internal damage. The person may still be in contact with the electrical source. coughing or movement). Loose fibers can stick to the burns. If the animal bite creates a deep puncture of the skin or the skin is badly torn and bleeding. are more likely to cause infection. Don't touch. or is experiencing changes in his or her breathing. Animal bites: First aid*** Domestic pets cause most animal bites. begin cardiopulmonary resuscitation (CPR) immediately. If the person is breathing. 3. can occur. If a strong electrical current passes through your body.
If you suspect the bite was caused by an animal that might carry rabies — any bite from a wild or domestic animal of unknown immunization status — see your doctor immediately. Could your health conditions cause a fall? Your doctor likely wants to know about eye and ear disorders that may increase your risk of falls. especially those used to treat anxiety and insomnia. Fall prevention: 6 ways to reduce your falling risk*** Falls put you at risk of serious injury. Fortunately. age-related physical changes and medical conditions — and the medications you take to treat such conditions. 168 . Still. He or she may recommend carefully monitored exercise programs or give you a referral to a physical therapist who can devise a custom exercise program aimed at improving your balance. Buy properly fitting. he or she may also teach you balance retraining exercises (vestibular rehabilitation) — which involve specific head and body movements to correct loss of balance. Your odds of falling each year after age 65 are about one in three. along with the dosages. your doctor may recommend a booster. To help with fall prevention. floppy slippers and shoes with slick soles can make you slip. water workouts or tai chi — a gentle exercise that involves slow and graceful dance-like movements. including when. your health and your medications to identify situations when you're vulnerable to falling. Have you fallen before? Write down the details. Your doctor may then evaluate your muscle strength. Or bring them all with you. So can walking in your stocking feet. You needn't let the fear of falling rule your life. though. To improve your flexibility. Fall-prevention step 1: Make an appointment with your doctor Begin your fall-prevention plan by making an appointment with your doctor. balance. In order to devise a fall-prevention plan. If you have inner ear problems that affect your balance. You and your doctor can take a comprehensive look at your environment. Be prepared to discuss these and to tell him or her how you walk — describe any dizziness. Doctors recommend getting a tetanus shot every 10 years. falls are the leading cause of injury and injury-related death among older adults. You're more likely to fall as you get older because of common. If your last one was more than five years ago and your wound is deep or dirty. massage or ultrasound. Consider activities such as walking. For suspected rabies. Such activities reduce your risk of falls by improving your strength. muscle strength and gait. where and how you fell. joint pain. You should have the booster within 48 hours of the injury. Be sure to get your doctor's OK first. If you avoid exercise because you're afraid it will make a fall more likely. Your doctor can review your medications for side effects and interactions that may increase your risk of falling. sturdy shoes with nonskid soles. Here's a look at six fall-prevention approaches that can help you avoid falls. Prevent falls with these fall-prevention measures. numbness or shortness of breath that affects your walk. Instead: Have your feet measured each time you buy shoes. your doctor will want to know: What medications are you taking? Include all the prescription and over-the-counter medications you take. High heels. most of these falls aren't serious. the physical therapist may use techniques such as electrical stimulation. Fall-prevention step 2: Keep moving If you aren't already getting regular physical activity. stumble and fall. Many falls and fall-related injuries are preventable with fallprevention measures. Fall-prevention step 3: Wear sensible shoes Consider changing your footwear as part of your fall-prevention plan. balance and individual walking style (gait). bring this concern to your doctor. consider starting a general exercise program as part of your fall-prevention plan. Be prepared to discuss instances when you almost fell but managed to grab hold of something just in time or were caught by someone. coordination and flexibility. since your size can change. he or she may decide to wean you off certain medications.
Handrails on both sides of stairways. but so can the decorative accents you add to your home. magazine racks and plant stands from high-traffic areas. Others may require 169 . Make light switches more easily accessible in rooms. bathroom and hallways. bedroom. Secure loose rugs with double-faced tape. and keep the laces tied. Select footwear with fabric fasteners if you have trouble tying laces. tacks or a slip-resistant backing. If bending over to put on your shoes puts you off balance. Fall-prevention step 4: Remove home hazards As part of your fall-prevention measures. Shop in the men's department if you're a woman who can't find wide enough shoes. Repair loose. All sorts of gadgets have been invented to make everyday tasks easier. Ask your doctor for a referral to an occupational therapist who can help you devise other ways to prevent falls in your home. This might require installing switches at the top and bottom of stairs. Some solutions are easily installed and relatively inexpensive. Immediately clean spilled liquids. To make your home safer. take a look around you — your living room. you might try these tips: Remove boxes. too. Store flashlights in easy-to-find places in case of power outages. consider a long shoehorn that helps you slip your shoes on without bending over. Some you might consider: Grab bars mounted inside and just outside your shower or bathtub. Buy a hand-held shower nozzle so that you can shower sitting down. Move coffee tables. Fall-prevention step 5: Light up your living space As you get older. dishes. So keep your home brightly lit with 100-watt bulbs or higher to avoid tripping on objects that are hard to see. Turn on the lights before going up or down stairs. grease or food. newspapers. Don't use bulbs that exceed the wattage rating on lamps and lighting fixtures. Store clothing. wooden floorboards and carpeting right away. less light reaches the back of your eyes where you sense color and motion. Choose lace-up shoes instead of slip-ons. Use nonslip mats in your bathtub or shower. Also: Place a lamp near your bed and within reach so that you can use it if you get up at night. Avoid shoes with extra-thick soles. however. kitchen. A sturdy plastic seat placed in your shower or tub so that you can sit down if you need to. Nonslip treads on bare-wood steps. Clutter can get in your way. A raised toilet seat or one with armrests to stabilize yourself. food and other household necessities within easy reach. electrical cords and phone cords from walkways. since this can present a fire hazard. Place night lights in your bedroom. Consider installing glow-in-the-dark or illuminated switches. bathroom. Use nonskid floor wax. hallways and stairways may be filled with booby traps. Make a clear path to the switch if it isn't right near the room entrance. Fall-prevention step 6: Use assistive devices Your doctor might recommend using a cane or walker to keep you steady. Other assistive devices can help.
but these are generally milder. an investment in safety and fall prevention now may make that possible. A delayed reaction may cause fever. hornets. Wash the affected area with soap and water. yellow jackets and fire ants are typically the most troublesome. See your doctor promptly if you experience any of these signs and symptoms. have the person take an antihistamine pill if he or she is able to do so without choking. 170 . 2. Teldrin). Administer the drug as directed — usually by pressing the auto-injector against the person's thigh and holding it in place for several seconds. EpiPen). diarrhea or swelling larger than 2 inches in diameter at the site. Take an antihistamine containing diphenhydramine (Benadryl. apply a cold pack or cloth filled with ice. 3. If you plan on staying in your home for many more years. You might experience both the immediate and the delayed reactions from the same insect bite or sting. The severity of your reaction depends on your sensitivity to the insect venom or substance. Massage the injection site for 10 seconds to enhance absorption. doing so may release more venom. difficulty breathing and shock. Tylenol Severe Allergy) or chlorpheniramine maleate (Chlor-Trimeton. Bites from mosquitoes. Have the person lie still on his or her back with feet higher than the head. Insect bites and stings: First aid*** Signs and symptoms of an insect bite result from the injection of venom or other substances into your skin. To reduce pain and swelling. Apply 0. For mild reactions: Move to a safe area to avoid more stings. wasps. The venom triggers an allergic reaction. Scrape or brush off the stinger with a straight-edged object. hives. Most reactions to insect bites are mild. biting flies and some spiders also can cause reactions. Bites from bees. Check for special medications that the person might be carrying to treat an allergic attack.professional help and more of an investment. such as an auto-injector of epinephrine (for example. cramps and vomiting Take these actions immediately while waiting with an affected person for medical help: 1. After administering epinephrine. Don't try to pull out the stinger. causing little more than an annoying itching or stinging sensation and mild swelling that disappear within a day or so. Allergic reactions may include mild nausea and intestinal cramps. calamine lotion or a baking soda paste — with a ratio of 3 teaspoons baking soda to 1 teaspoon water — to the bite or sting several times a day until your symptoms subside.5 percent or 1 percent hydrocortisone cream. painful joints and swollen glands. such as a credit card or the back of a knife. Signs and symptoms of a severe reaction include facial swelling. Dial 911 or call for emergency medical assistance if the following signs or symptoms occur: Difficulty breathing Swelling of your lips or throat Faintness Dizziness Confusion Rapid heartbeat Hives Nausea. Only a small percentage of people develop severe reactions (anaphylaxis) to insect venom. ticks. For severe reactions: Severe reactions may progress rapidly.
6. 5. Strangulation Poisoning-Injection.redcross.Snakebite.chest compression not indicated because there is pulse rate METHODS IN GIVING ARTIFICIAL RESPIRATION 1. THREE (3) KINDS OF AIRWAY OBSTRUCTION Kind OF Airway Obstruction With Good Air Exchange With Poor Air Exchange Total Airway Obstruction with No Air Exchange Signs Victim can still TALK Victim produces wheezing sound Unconscious First Aid Observe the victim as he cough out obstruction Abdominal Thrust / Heimlich Maneuver 1. spiders Severe Bleeding Drowning Electrocution Suffocation Choking: Universal Sign of Choking. 5. 8. turn the person on his or her side to prevent choking. 3. jellyfish.palms guarding throat Disease 7. Rabies. Ingestion. 4. Artificial Respiration (AR) 2X 3. 2. 3. Artificial Respiration 2X if effective First Aid: Artificial Respiration (AR) – Giving of artificial air only either through a blow or ambubag . Repeat blind finger sweep 5. http://www. If there are no signs of circulation (breathing. 6.usual method Mouth to Nose . Listen & Feel (LLF) 4. bees. Mouth to Mouth . Check if Air is going backLook.if mouth is obstructed Mouth to Mouth & Nose – used in infants Mouth to Stoma . Loosen tight clothing and cover the person with a blanket. coughing or movement).like for patients with tracheostomy Mouth to Mask Ambu Bag to Mouth & Nose Ambu Bag.4.org RESPIRATORY ARREST Respiratory Arrest (-) RR (+) PR. 5. Scorpions. 4.a device used for artificial mechanical breathing unit 171 . Abdominal Thrust 10X Blind Finger sweep for adults 2. Don't give anything to drink. 6. Inhalation Injection. begin CPR. A condition of the victim wherein there is no breathing but pulse continues CAUSES: 1. 2. If there's vomiting or bleeding from the mouth.
usually occurs after 4-6 mins of cardiac arrest 1.start with 2 blows end with 2 blows 172 . 2. 5. 3. BIOLOGICAL DEATH.ADULT METHOD Manner of Breathing Rate of Blows Mouth TO Mouth Full and Slow 1 Blow every 5 secs 12 blows per min CHILD Mouth TO Mouth Regulated 1 Blow every 4 secs 15 blows per min INFANT Mouth TO Mouth & Nose Puff 1 Blow every 3 seconds 20 blows per min START WITH A BLOW AND END WITH A BLOW WHEN TO STOP 1. 4. 5.may occur if heart rate is not revived within 4-6 minutes 2.1 ½” 5ECC/1 blow 15X/min 80-100 ECC/min INFANT 2 Fingers (ring and mid finger) ½” – 1” 5ECC/1 blow 20X/min 100-120 ECC/min 5 ECC/1 blow CPR. 2. When the rescuer is exhausted When the victim is breathing on his own When the service of the physician is available When the pulse disappears. CLINICAL DEATH. ADULT. 6. Stroke Location Of Chest Compressions Danger of Failure to revive Patient: 1. Heart Attack. Don’t be a double crosser Don’t be a rocker Don’t be a jerker Don’t be a render Don’t be a bouncer Don’t be a massager CHILD 1 Heel of 1 hand 1”. 3. Intervention for Cardiac Arrest: CPR CPR.along nipple line ADULT Method Depth Rate Speed 2 Heels of 2 Hands 1 ½’.A combination of external chest compression and artificial ventilations to revive the heart and the lungs CAUSES All causes of Respiratory Arrest.Cardio Pulmonary Resuscitation . CARDIAC ARREST Condition of the victim when the pulse and breathing is absent.3 fingers above mid xiphoid INFANT. artificial respiration is stopped and cardiopulmonary rescucitation begins When another first aider takes over 4. 2.2” 15 ECC/2 blows 4X/min 60-80 ECC/min 12X/min 2 RESCUERS DON’T’S IN CPR: 1.
3. 7. Survey the scene “ the scene is safe” Check for responsiveness “ Hey 2X. etc. 6. then deliberate 11. 1002. After each cycle. Recovery Position 173 . 5. check pulse for 5 sec. R U Okay” Position the victim Open and Clear the airway (head tilt chin lift) “Mouth is clear” Check breathing for 3-5 seconds (LLF) 1001. 8. “Breathless” If Breathless. 2. Activate medical assistance “Arrange transfer facilities and I’ll do…AR or CPR” 10.SEQUENCE: 1. 4. give 2 blows Check for Pulse: Carotid 5-10 seconds State the condition of the victim “Victim is breathless with pulse” or “Victim is breathless & pulse less” 9.
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