Surgery and Surgical Nursing

DEDICATION
With Great Thanks and Love
This SURGERY & SURGICAL NURSING booklet is dedicated to
My Lovely Auntie Mukwae Inonge Justina Kazembe Akashambatwa,
Sweet Parents Muwana Akashambatwa & Alice Nawa Kalaluka;
and
Beautiful Lovely Friend Kabwe Bwalya.
Love You All
AND
May God richly reward you all with his unending blessings
AKASHAMBATWA M. FREEBORN; akashambatwaf@yahoo.com LIVINGSTONE NURSING SCHOOL2009/12 page 1

TABLE OF CONTENTS
ITEM PAGE No:

1. Acknowledgement............................................................................................................................2
2. Dedication…………………………………………………………………………………………
3. Table of contents ………………………………………………………………………………….
4. A look at the surgery paper…………………………………………………………….……….....3
5. Cover sheet for paper two………………………………………....................................................5
6. Complete paper two set up……………………………...….……...................................................6
7. Answer booklet.………………………………………………......................................................12
8. Structuring of Questions……...……………………...…………...................................................14
9. Cholecystectomy.............................................................................................................................15
10. Enlarged prostate gland...................................................................................................................21
11. Acute abdomen.............................................................................................................................. 26
12. Head injury......................................................................................................................................31
13. Glaucoma........................................................................................................................................50
14. Corneal ulcers.................................................................................... ……………………………53
15. Retinal detachment.......................................................................... ……………………………. 56
16. Cataract...........................................................................................................................................59
17. Antenatal care.................................................................................................................................63
18. VVF................................................................................................................................................68
19. General pre op care.........................................................................................................................72
20. General post op care......................................................................... ……………………………. 77

LET’S LOOK AT PAPER TWO
SURGERY
Paper two also called the surgery paper is one of the two papers that lead to your qualification as a
registered nurse. This paper comprises all aspects of general surgery, surgical nursing, IRH, Ear Nose
and Throat conditions, orthopedics and ophthalmology.
This is usually your second paper after paper one or the medicine paper.
The paper has got 8 questions and you are expected to answer 5 questions only. The time given is 3
hours only for the whole paper. As you may see, you need just about 30 minutes for each question if
you have to complete all the five questions, with practice of course and a lot of concentration, this is
not impossible.
We can now take look at the breakdown of the paper.

The paper has three sections, A, B and C. in each of these sections there are some questions that you
will be expected to answer so you need to read each section instructions very carefully.
We will now look at each section one at a time so you can follow what needs to be done.
SECTION A
Section A. comprises all aspects of general surgery, surgical nursing.
There are three questions in this section. As indicated above there are all coming from the general
surgery and surgical nursing conditions that you have already studied in your surgery one course
lectures.
Out of the 3 questions that are asked, you are expected to choose only 2. The order of our selection
does not matter, for example you can start with question number 3 if you are more familiar to it then
go to any of the remaining two.. It’s a good idea to start with a question you clearly understand as the
first impression may have a lasting impression on your examiner.
When preparing for this section, you need to master a fairly large number of general surgical
conditions that you clearly understand during your course lectures.
You should also balance up the selection of your conditions to cover all the systems that you studied
during your course lectures in surgery one.
For example, you need to remember that we have about 8 major systems of the human body, try as
much as possible to pick conditions from each of these systems say, may be 5 conditions from each
and a little more from some of the more I what I would call vulnerable systems or interactive
systems that are more likely to altered physiology because of disease in other parts of the body, such
as the GIT.
Once you have picked your conditions try to study them under the following heading. This is like the
minimum information you need to know on each one of them, so it means you can actually study a
little further than what I have given you.
 The definition,
 Indications for surgery,
 Surgical approaches where applicable
 The causes or pre disposing factors,
 Presenting clinical signs and symptoms

 General investigations which should include focused history taking, physical examination,
laboratory tests, radiological tests, pathological tests if any etc.
 Surgical management which should include general investigations as above, non
pharmacological care and pharmacological care and operative procedures plus any
preventive measures where applicable.
 Nursing care
 Complications
Section B.
This section comprises all aspects of IRH.
These are Gynecological conditions and Obstetrical conditions which you studied in your course
lectures.
There not as many IRH conditions as you would find in General surgery and so this section will only have
2 questions from which you will be expected to choose only one question.
Very rarely will you be asked to draw some anatomical diagrams here. You will probably need about 8
questions covering both areas to be on a safe side. You need to follow the same layout of the content as
you study these questions as above.
Be mindful that some of the conditions may be obstetrical /Gynecological emergencies and so they have
to be managed as such.
Section C.
THIS SECTION COMPRISES ALL ASPECTS OF ENT, OPTHALMOLOGY AND

ORTHOPAEDIC CONDITIONS.
Probably the easiest of the three sections but poorly attempted, may be this time students realize that time
is not on their side and they end up hurrying through the questions. To avoid this occurrence, try to
allocate enough time to each question. We have already seen that each question needs about 30 minutes.
If you have taken well over 40 minutes stop that question and progress further to answer other question
There are 3 questions from this section. You need only to answer two questions from this section, it
does not matter which two you pick nor in which order
We will now try to familiarize ourselves with the presentation of paper two from the cover sheet up to the
instructions given then have a look at a complete set up of paper two has also been given as an example.

GENERAL NURSING COUNCIL OF ZAMBIA
(The Nurses and Midwives Act., 1997)
ZAMBIA REGISTERED NURSE FINAL EXAMINATION
CANDIDATE’S NO………………………………………………….
PAPER………………………………..
DATE………………………………….
No. Marks
WRITE No. OF QUESTIONS ANSWERED/ATTEMPTED
No. No. No. No. No.
No. No. No. No. No.

Total
NO…………………………

COVERING ALL ASPECTS OF GENERAL SURGERY AND SURGICAL NURSING, IRH, ENT,
OPTHALMOLOGY AND ORTHOPAEDIC CONDITIONS
INSTRUCTIONS TO CANDIDATES
1. Write your examination number on each page of the answer book and question paper,
which must be returned.
2. Start each question on a new page.
3. Write on both sides of paper.
4. On the front cover of answer book, write the numbers of questions you have answered on
the spaces provided.
5. Name of the school and candidate MUST NOT appear in the answer book.
6. NO form of identity or mark (other than the examination number) should appear on the
answer booklet.

COVERING ALL ASPECTS OF GENERAL SURGERY AND SURGICAL NURSING,
INTERGRATED REPRODUCTIVE HEALTH (IRH).ORTHOPEADICS, EAR NOSE THROAT
DISEASES AND OPTHALMOLOGY.
SECTION A
GENERAL SURGERY AND SURGICAL NURSING
ANSWER TWO (2) QUESTIONS ONLY FROM THIS SECTION.
QUESTION 1
CHOLECYSTITIS
A man in his middle age comes to your ward with complaints acute abdominal pains. The doctor
suspects that he could have Cholecystitis.
a) State three factors responsible for formation of cholesterol gall stones. 15%
b) Mention (5) Five clinical features of Acute Cholecystitis 15%
c) Post operative care in the first 48 Hours 50%
d) Mention (5) five possible complications following cholecystectomy and how they can be
prevented. 20%
BENIGN PROSTATIC HYPERTROPHY
Mr. Mwansa aged 52 years is admitted to the surgical ward with history of frequency and
difficulties in maturation. On examination, the diagnosis of benign prostatic hypertrophy is made
and he is to undergo prostatectomy
a) (i)Define the term benign prostatic hypertrophy 3%

(ii) List six (6) other obstructive symptoms that Mr. Mwansa may present with
Other than the one mentioned in the question 12%
b) Mention four (4) approaches that could be used to perform prostatectomy 10%
c) Discuss the pre-operative nursing care you would give to Mr. Mwansa 50%
d) Discuss (5)five points that you would include in your IEC to the
Patient discharge 25%
PROSTATECTOMY
Mr. Mugala an elderly man is readmitted to your surgical ward with a supra-pubic
catheter, following unrelieved urinary incontinence. He was earlier diagnosed with benign
prostatic hypertrophy and the surgeon believes that he can benefit from partial
prostatectomy.
a) Define prostatectomy (5 %)

b) Compare and contrast between characteristics of benign tumors and malignant tumors
(25%) (25%)
c) Mention four (4) surgical approaches that can be used to remove hypertrophic prostate
tissue (20%)
d) Discuss in detail the post operative care of the patient from day zero (0) to day four (4)
following surgery. (50 %)
QUESTION 3
APPENDECTOMY
Mrs. Mwanza has been complaining of chronic pain in the right Iliac fossa. After an abdominal
scan, The Dr suspects that she could have an inflamed Appendix and he decides to perform
appendectomy
a) Define Appendectomy (5 %)
b) List two types of abdominal incisions that a Dr can use to approach the appendix (6%)
c) Discuss in detail the pre op care of a patient going for appendectomy (50%)
d) Briefly discuss how you are going to manage the abdominal wound after surgery (20%)
Mention {4} four complications of abdominal surgery (15%)
STRANGULATED HERNIA
Mr. John nkoma is admitted to your ward with a history of sudden and severe pain in the
groin.The surgeon suspects that he could have a strangulated inguinal hernia and
immediately books him for an operation.
{a} Define Strangulated Hernia (5%)

{b} Draw a well diagram showing possible sites of abdominal hernia. (15%)
{c} Mention five {5} predisposing factors to abdominal hernia (10%)
{d} Discuss in detail the pre-operative nursing care that you are going to give to Mr. Nkoma.
(50marks)
{e} What IEC would you include to Mr. Nkoma on discharge (20%)
BURNS
Mrs. Mwanza presents to you a child who has sustained superficial 60% burns on the
entire abdomen. The child is taken to theatre for debridement.
{a} Define superficial burns (5%)

{b} Draw a well labeled diagram of the skin (15%)
{c} Explain three {3} classification of burns in terms of depth (15%)

{d} Given that the child weighs 20kgs on admission, calculate the fluid replacement in the first
24 hrs using the consensus formulae. (10%)
{e}Discuss the general post op care that you are going to give to this child (55%)
HEAD INJURY
Mr. Fuel Nyambe a 45 years old man is involved in a road traffic accident RTA along
Nakatindi road. He sustains head injuries with intracranial hemorrhage and brought to
hospital inn an unconscious state. A craniotomy is done.
a) Outline two 2 classifications of head injuries (6%)
b) State five signs and symptoms of head injuries (15%)
c) Discuss in detail the post operative care you would give Nyambe until discharge (55%)
d) Describe six 6 complications that may arise (24%)
THYROIDECTOMY
Miss. Milupi a 25 years old Miss Zambia is admitted to your ward with complaints of a
swollen goiter. Upon examination a diagnosis of cancer of the thyroid is made and elective
thyroidectomy is indicated.
a)
i. Define thyroidectomy (5%)
ii. Draw a well labeled diagram of the thyroid gland (15%)
b) Compare and contrast between benign tumours and malignant tumours (10%)
c) Discuss the post operative care you would give Milupi in the 1st 48 (50%)
d) Explain four (4) complications that Mrs. Milupi is likely to develop (20%)
HAEMORROIDECTOMY
Mr. Masialeti aged 45 years is a long distance truck driver. He has been admitted to your
ward after complaining of per rectal bleeding soon after passing stool. The doctor
schedules the patient for Haemorroidectomy
a) Define haemorrhoidectomy (3%)
b) List six 6 signs and symptoms of haemorrhoids other than the one mentioned above(20%)
c) Explain five 5 common causes of haemorrhoids (20%)
d) Describe the specific post operative management you give Mr. Masialeti (55%)

WOUNDS
Mrs. Mulenga a 35 years old house wife has been admitted to your surgical ward after
sustaining a deep cut wound and left hamstring muscle injury. This was following a road
Traffic accident.
a) Define a wound (6%)
b) Explain the following types of wound healing (24%)
I. First intention
II. Second intention
III. Third intention
c) Describe the nursing management you would give Mrs. Muleya during the first 24 hours
of stay in your ward (50%)
d) Outline five (5) factors that would affect the wound healing process (20%)
CHEST INJURIES
Mr. Kabunda has been involved in RTA and sustains severe chest injuries. He is rushed to
hospital where underwater seal drainage has been put to help evacuate hemorrhage in the
chest.
{a} Define under water seal drainage (5%)

{b} Mention five other indications of under water seal drainage other the one mentioned
(10%)
{c} Draw a well labeled diagram showing the mechanism of an under water seal drainage
(25%)
{d} Describe the nursing care you would give to a patient on the under water seal drainage
(40%)
{e}Mention five {5} points you would include in your IEC to your patient (20%)
INTESTINAL OBSTRUCTION
Zondani is rushed to theatre upon arrival at the casualty department with suspicion of a
Vovulus. Surgery was extensive and a temporal colostomy was performed.
a. Define Vovulus (5%)
b. Mention five {5} other causes of intestinal obstruction other than the one mentioned
above. (15%)
c. Discuss in detail the post - operative care of a patient who has undergone extensive bowel
surgery and has a colostomy in situ. (55%)
d. How would you manage the patient in the likely event that incisional site gets infected
(25%)

CHEST DRAINAGE
Mr. Mugabe, a 43 years old man who was retired on medical grounds, after working in a
mine chemical processing unit, and has been on treatment for lung malignancy, now comes
in your ward with a complication of Heamo-pneumothorax. The Dr decides to put up an
under water seal chest drainage system.
1. List five {5} occupational health hazards that could be found in a mining environment.
(5%)
2. Explain how four {4} other indications of chest drainage other than the one mentioned
above may occur. (20%)
3. Discuss in detail how you are going to manage the patient on ICD. (55%)
4. Identify four {4} potential complications that Mr. Mugabe is likely to present with and
how you can over come them. (20%)
SECTION B
INTERGRATED REPRODUCTIVE HEALTH (IRH)
ANSWER ONE (1) QUESTION ONLY FROM THIS SECTION.
QUESTION 4.
LABOUR
Mrs. Dinga Erickson aged 37years, gravid 12 is admitted to your labour ward complaining of show
and backache, on examination cervical dilation is 5cm; her last LMP was June 2010
a) Calculate
i. EED (5%)
ii. Gestation as of today (10%)
b) Explain how you would admit her to labour ward. (15%)
(i)Using a partograph record her observations and explain the findings. (15%)
c) Discuss the nursing care you would give her during the first of labour. (50%)
d) State (5) five complications. (5%)
CANCER OF THE BREAST
Kashibi Masaka a 30 year old lady Shuungu modeling centre was brought to gynae clinic with
history of feeling a growth in the left breast. A provisional disgnosis of breast cancer is made.
a) Give four clinical staging of cancer 8%

b) Draw a well labeled diagram of breast 22%
c) Describe the management of Masaka operatively 50%
d) Explain four (4) points that you would include in your information, education and communication
to Masaka regarding the care of the affected breast 20%

ABORTION
Mirinda aged 19years of highlands compound is brought to the Gynae ward with
complaints of sudden bleeding and severe abdominal pains her last normal menstrual
period being 10th November, 2009.
a) Define post abortal care (PAC) (5%)

b) Using a diagram illustrate the types of abortion (22%)
c) Mention elements of PAC (8%)
d) Describe the nursing care you will give Mirinda before the MVA is done (40%)
e) Explain five (5) possible complications of abortion (25%)
FAMILY PLANNING
Mary Mbangwete, a mother of seven (7) children, comes to your clinic for family Planning
services six (6) weeks after the last delivery.
a) Define family planning 5%
b) Explain the counseling you would give her during this visit 25%
c) Discuss some long term family planning methods that you would advise Mary to use
40%
d) Explain five (5) preventive measures that you can undertake during the provision of
family planning services 30%
PUEPERUIM
Mrs. Tebuno a 20 years old para 1 has been admitted to your ward post natal ward
following delivery of a live mature infant weighing 3.8kgs.
a) I) Define pueperuim 5%
ii) Describe the three types of lochia 12%

b) Discuss the management of Mrs. Tebuno in the first 48hrs 50%
c) What advice wound you give Mrs. Tebuno using the following headings
I. Hygiene
II. Diet
III. Care of the baby
IV. Immunization 28%
d) List five (5) complications of pueperuim 15%
SECTION C
EAR NOSE AND THROAT DISEASES, OPHTHALMOLOGY AND ORTHOPAEDICS.
ANSWER TWO (2) QUESTIONS ONLY FROM THIS SECTION.

ARTHRITIS
Mr. Monze, a famous cyclist, underwent knee surgery after suffering from acute septic arthritis
which developed after falling off his bicycle.
a) Define acute septic arthritis 5%

(i) List five{5} causes of arthritis 10%
b) Explain five {5} signs and symptom of acute septic arthritis. 10%
c) Discuss in detail the Pre operative care of a patient due for bone surgery 50%
d) Mention {4} four rehabilitative measures that you would inoperative in your teaching plan to
your patient 5%
CATARACT
Naomi a 65 years old woman is admitted to the eye ward with a complaint of poor visibility in both
eyes. After a thorough investigation the specialist decides that Naomi should undergo surgery in
one of the eyes to remove the lens
a) (i) List (5) five possible causes of cataracts in Zambia. 5%

(ii)Draw a well labeled diagram of the eye 10%
b) Discuss pre operative care would you give to your client 45%
c) Discuss the IEC that you would give you client upon discharge 15%
d) Mention five (5) Complication of contact extraction 15 %
OTITIS MEDIA
Given Hachundu has been complaining of pain the right ear after the swimming festival. Its 4
weeks now and the pain seems to be getting worse. You are the clinician at the health centre
attending to this client.
a) Define Otitis Media. 2%
b) Mention six (6) signs and symptoms your patient is likely to present with 24%
c) Discuss the Medical management of your client 50%
d) State six (6) complications that could occur if there is further delay in the management of this
client 24%
AMPUTATION
Mrs. Joyce Wenu aged 35 years; Married with five (5) children is admitted to your ward
complaining of tenderness in the left leg and general body malaise. After thorough
examination, a diagnosis of gas gangrene is made and a below knee amputation is
indicated.
a) Define gas gangrene 3%

b) What is the causative organism for gas gangrene 2%
c) List five (5) signs and symptoms Mrs. Wenu is likely to present with other than the ones
mentioned in the stem 15%
d) Identify five (5) problems Mrs. Wenu is likely to present with after the amputation and
using the nursing care plan, describe the management of client. 50%
e) Explain five(5) complications of gas gangrene 25%
AMPUTATION
Mrs. Simpaya aged 60yrs is admitted to your ward with an old wound on the left leg. A
diagnosis of gangrene is made and an above knee amputation is indicated
{a} Define gangrene (5%)

{b} State 3 {three} causes of gangrene (15%)
{c}Discuss the post op care you will give to Mr. Simpaya until discharge (50%)
{d} List four {4} complications of amputation and explain how they occur (30%)
AMPUTATION
Mr. Banda a taxi driver and a diabetic patient has the option of partial digital amputation
on the feet or a daily 4 hourly wound dressing
a. Define amputation (5%)

b. What option, giving reasons would you recommend Mr. Banda to take. (20%)
c. Using a nursing care plan to manage your patient , identify five {5} problems that Mr.
Banda is likely to present with and clearly show the interventions that you are going to
take (50%)
d. Discuss the rehabilitation of Mr. Banda should his option be amputation (25%)
CONJUCTIVITIS
Mbuyi Wamundila a 35 year old farmer comes to outpatient department with sunken red
eyes. A provisional diagnosis of conjunctivitis was made and he was admitted to the eye
ward.
a. Define conjunctivitis (3%)
b. Explain three (3) types of conjunctivitis common in Zambia (15%)
c. State five (5) principles of Primary Health care (25%)
d. Describe the management you would give to Mbuyi under the following headings
i. Investigations (8%)
ii. Medical management (15%)
iii. Nursing care (27%)
MASTOIDITIS
Mary Munsaka an 8 year old girl has been on treatment for chronic Otitis media. She later
develops a complication of mastoiditis because of frequent ear syringing procedures.
a)
i) Define mastoiditis (5%)
ii) Explain the relationship between mastoiditis and chronic Otitis media (8%)
b) Mention six (6) clinical manifestation of mastoiditis (12%)
c) Discuss the general pre operative care that you will give to the patient (50%)
d) Explain five (5) complications that may follow mastoidectomy (25%)
FRACTURES
Mrs. .Zulu an elderly woman living at old people’s home suddenly falls and sustains a
complete fracture of the head of femur. She is refereed to a specialist hospital where total
hip replacement will be done.
1. With the aid of a well labeled diagram draw the structure of a femur. (15%)
2. Explain the five {5} activities that take place at old peoples home (20%)
3. In the likely event that total hip replacement was done; draw up a rehabilitation plan for Mrs.
Zulu as she comes back to the old people’s home. (45%)
4. Outline five {5} complications of invasive orthopedic surgery and how they can be
minimized (20%)

We will now try to familiarize ourselves with the presentation of paper the answer booklet. This is the
booklet where you will be expected to answer your question
GENERAL NURSING COUNCIL OF ZAMBIA

(The Nurses and Midwives Act., 1997)
ANSWER BOOKLET
CANDIDATE’S NO………………………………………………….
PAPER………………………………..
No. Marks
WRITE No. OF QUESTIONS ANSWERED/ATTEMPTED
No. No. No. No. No.
No. No. No. No. No.

Total

Index No.

STRUCTURING AND ANSWERING OF QUESTIONS
We can now have a look at how most of the questions are asked and what you are expected to include as
you attempt the question.
1. Definitions
 Define………………….
 What is the definition of…………………….
 How do you define………………………….
Example 2 Define a fracture. (5%)
A fracture is the discontinuity of bone tissue as a result of direct or indirect trauma manifested by loss of
function, deformity, and severe pain
If you analyze the definition, it attempts to answer the following

 What it is
 How it is caused
 Some common characteristics or features of a fracture.
When defining a concept, try as much as possible to follow the above pattern. This of course is most
applicable to conditions/diseases. If you are trying to define a procedure, you can mention what it is and
one or two common indications.
2. MENTIONING
Example 3: Mention five (5) causes of unconsciousness

Here you are expected to itemize the causes with some justification, as below
1. Reduced blood flow to the brain tissue as in severe shock
2. Sudden compression of the brain due to hematoma
3. ………………………………….
4. ………………………………….
5. ………….....................................
3. LISTING.
Example 3: List five (5) causes of unconsciousness
Here you are also expected to itemize the causes as below

 …prolonged shock……………………………….
 …hematoma………………………………
 ………………………………….
 Identifying
Example 4: Identity five (5) causes of unconsciousness.

Here you are expected to itemize the causes, it quiet similar to mentioning as below
1. Reduced blood flow to the brain tissue as in severe shock

2. Sudden compression of the brain due to hematoma
3. ............................................................................

6. Indicating, Stating, outline
Example.5 State five (5) causes of unconsciousness
Here you are expected to make a brief statement, an outline or a short sentence line on the causes as
below
1. unconsciousness can be caused by prolonged hypoxia as a result of hypoventilation

2. unconsciousness can be caused by a sudden shake or movement of the brain as in concussion
3. …………………………
4. ………………………………….
5. …………………………………
7. Discuss, explain, describe
You are expected to give a detailed argument of action, plan of care etc. for example you need to some of
the following aspects
What, why where who and when etc,
You are going to do observations for example.
 What are you doing
 Why are you doing observations
 Where and on who are you doing observations
 When or how frequent are you going to do observations, that way you will be able to
comprehensively discuss or explain your action. Your discussion must be comprehensive.
PAPER TWO /SURGERY QUESTIONS
CHOLECYSTITIS
(a) State three (3) factors responsible for formation of cholesterol gall stones 15%
(b). List five clinical features of acute cholecystitis 15%
(c). Discuss in detail the post op nursing care you would give in the first 48hrs 50%
(d). Mention five (5) post operative complications and how you would prevent them. 20%
Suggested marking Key for cholecystitis

Definition
Cholecystitis is the nflammation of the gallbladder that occurs most commonly because of
obstruction of the cystic duct from cholelithiasis.
Pathophysiology
Acute calculous cholecystitis is caused by obstruction of the cystic duct, leading to distention of
the gallbladder. As the gallbladder becomes distended, blood flow and lymphatic drainage are
compromised, leading to mucosal ischemia and necrosis. A study by Cullen et al (2000)
demonstrated the ability of endotoxin to cause necrosis, hemorrhage, areas of fibrin deposition,
and extensive mucosal loss, consistent with an acute ischemic insult. Endotoxin also abolished
the contractile response to cholecystokinin (CCK), leading to gallbladder stasis.
Although the exact mechanism of a calculous cholecystitis is unclear, a couple of theories exist.
Injury may be the result of retained concentrated bile, an extremely noxious substance. In the
presence of prolonged fasting, the gallbladder never receives a CCK stimulus to empty; thus, the
concentrated bile remains stagnant in the lumen.
State three factors responsible for formation of cholesterol gall stones.

Cholesterol super saturation of bile
This can occur as a result of excess cholesterol secretion into bile due to an increase of
enzyme activities.
Crystallization- Promoting factors
Within bile there are a number of lipoproteins reported to be putative crystallizing factors.
Motility of the gall bladder Gall bladder stasis leads to cholesterol crystallization.
(Note three points for the first five correct answers /ticks)
 Five clinical features of Acute Cholecystitis ( 15 marks)
Colic pain that starts suddenly and persists for 1-4 hours.
Aching pain with sensation of pressure in the epigastric region.
Nausea and vomiting.
Low –grade fever.
Jaundice (Saver obstructive)
Right upper Quadrant guarding
Inability to take deep inspiration when examining finger are pressing below the hepatic
margin.
(Note three points for the first five correct answers /ticks)
TREATMENT
For acute cholecystitis, initial treatment includes bowel rest, intravenous hydration, analgesia,
and intravenous antibiotics. For mild cases of acute cholecystitis, antibiotic therapy with a single
broad-spectrum antibiotic is adequate. Some options include the following:
- Ampicillin
- For severe cases of acute cholecystitis, gentamicin (3-5 mg/kg/d) with clindamycin (1.8-
2.7 g/d) or metronidazole with a third-generation cephalosporin provides adequate
coverage
- Analgesics -- Pain is a prominent feature of cholecystitis. Classic teaching is that
morphine is not the agent of choice because of the possibility of increasing tone at the
sphincter of Oddi. Meperidine has been shown to provide adequate analgesia without
affecting the sphincter of Oddi and, therefore, is the DOC.
- Antiemetics – Such as Phenergan or Compazine. Patients with cholecystitis frequently
experience associated nausea and vomiting. Antiemetics can help to make the patient
more comfortable and can prevent fluid and electrolyte abnormalities.
 POST OPERATIVE CARE IN THE FIRST 48 HOURS :( 50 Marks)
OBJECTIVES (1 mark each)

 To return the physiological function back to normal as early as possible.
 To promote wound healing.
 To prevent post-operative complications and those specific on the gastrointestinal tract.
ENVIRONMENT (5 marks)
 Ensure postoperative equipment and tray is available for immediate access in case of the need
for resuscitation.
 The room should be well ventilated and clean to ensure a soothing environment and to prevent
cross infection
(Write at least five points here)
POSITION (5 Marks)
 Place the patient in low – fowler’s one side to allow easy flow of secretion, so as to prevent
choking and maintain patient airway for effective breathing.
This position will also promote easy observation of the patient
 Assist in regular change of position to encourage circulation of blood
OBSERVATION (5 Marks)
 Vital sign observation- Blood Pressure, Pulse, respiration and temperature, initially done at ¼
hourly, ½ hourly, 1 hourly, 2 hourly then 4 hourly if the general condition proves to be improving
progressively.
 Observe the wound for bleeding if it is evident, apply pressure.
 Low blood pressure may indicate internal bleeding – inform the surgeon.
 Observe the tubing’s for patency especially the T tube
 Observe the general condition of the patient.
INTRAVENOUS INFUSION (5 Marks)

 Ensure that the IV line is running well.
 Infuse as per Doctors orders
 Observe for fluid overload and stop drip if face looks puffy with breathing difficulties.
 Record intake and out on the fluid balance chart.
PHYSIOLOGICAL CARE (5 Marks)

 Explain to the patient to the patient the nature of the disease process to ally anxiety.
 Explain to her the treatment regime and expectations regarding the care.
 Reinforce on knowledge of the possible outcome of the surgery.
DRUG ADMINISTRATION AND PAIN RELIEF. (3 Marks)
 Give medications as ordered, such as prophylactic antibiotic and analgesics such as pethidine to
relieve pain.
 Observe relieving pain and any drug reactions
NUTRITION
 Patient is kept nil orally on zero day until bowl sound are head, flatus is passed and this is usually
by the 5th day post operatively and prevents paralytic ileus
 Ideally, the surgeon will order when to start sips of water. During this time, nutrition is by IV
fluids up to 2nd day post operative.
 The patient then progresses to free fluids the following day, soft food and then full diet according
to surgeon orders.
 Low fat diet is given because there is hardly bile to fats cholecystectomy as there is bile leakage
in the few days post operative give food rich in proteins and vitamins for wound healing.
 Asses for nausea and vomiting and administer antiemetic.
 Encourage a lot of fluid intake to replace discharged and leaking bile from the T-tube.
 Test food tolerance by clamping the T-tube when indicated.
Note that this part is specific and you need as many points as you can
BOWEL ELIMINATION (1 Mark)
 Patient should begin to open bowels soon after beginning to take normal diet above two days.
CARE OF NASO GASTRIC TUBE: (5 Marks)

 Mrs.Chanda will have a naso gastric tube, to relieve the complication of vomiting bile.
 Aspirations must be done in the 1st 24 hours.
 Care of the tube and nostrils as well as oral care must be done.
 Measure inspects and records the aspirate all these measures help to keep the\tube patent
Note that this part is specific and you need as many points as you can
CARE OF DRAINAGE TUBES (6Marks)

 Care and observation of the drainage tube in the sub hepatic pouch be done recode the
drainage.
 The purpose of the tube is to drain the oozing blood from the liver bed and leaking bile.
 It is also useful for revealing internal reactionary haemorrhage.
 It also helps to reveal reactionary haemorrhage.
 It is removed after 48 hours.
Note this part is specific and you need as many points as you can
T-TUBE FROM COMMON BILE DUCT (7Marks)

 Un clamp the tube immediately the patient is put on her bed.
 Measure and record the bile draining into a bag, specifying colour and amount at least every 2
hours.
 Administer replacement fluids if indicated.
 Clamp the Tube when indicated.
 Report any increase or decrease of drainage.
 Maintain patency of the tube.
 The tube may be removed on the 7th-10th day meaning it will be in situ in the 1 st 48 hours post
operatively.
WOUND CARE (5 Marks)
 Maintain a dry and intact dressing, usually drains that is working is left in situ.
 If wound is bleeding apply pressure.
 First dressing is removed by the surgeon.
 There after the wound is cleaned aseptically. Inspect for any swelling, discharging and gasping.
 Maintain skin integrity by adequate hydration, remove the soiled dressing around the T tube and
replace with the clean sterile one.
CATHETER CARE (2 Mark)

 Aseptic catheter toilet to be done to prevent urinary infection.
 Observe urine for colour, sediments and amount. Record findings.
EXERCISES AND EARLY AMBULATION (4 Marks)

 Breathing and coughing then exercises to prevent hypostatic pneumonia at regular intervals such
as 1-2 hourly.
 Passive exercises the actively to prevent deep vein thrombosis.
 Promote early ambulation to prevent respiratory leg and renal complications.

 Assist the patient to sit up in bed and to sit in chair when the doctor has ordered ambulatory
exercises.
OTHER ASPECTS OF GENARAL CARE (2 marks each)
 Bed baths to remove dirty on the body and maintain general hygiene
 Two hourly turnings to prevent pressure sore formation
 Hair care to improve hygiene self care image
 Nail care to improve hygiene and prevent infection
 Pressure area care to prevent pressure formation
 Oral toilet to improve oral hygiene and enhance appetite
HEALTH EDUCATION (2marks each)

 Low fat diet as there is little or no bile to help in the digestion
 To encourage weight loss as reduces the amount of fats to be deposited in the body
 Encourage rest.
 Care of the healing wound.
C) Five possible complications following cholecystectomy and how they can be prevented. (20
Marks)
 Pulmonary Embolism
o Give analgesics and anticoagulants as well as early ambulation coupled with breathing
exercises.
o
 Hemorrhage and leakage of bile
o From the gall bladder bed which may accumulate to cause abdominal distension and
peritonitis. It is necessary to ensure patency of sub hepatic drainage tube.
o
 Renal failure and liver failure
o In jaundiced patients, renal failure and liver failure may occur. This is prevented by post-
operative administration of IV fluids with osmotic diuretic during surgery.
o
 Recurrences
o Recurrence stones in the common bile duct. Endoscopic division of the splinter of oddi
will help prevent this.
o
 Backache
o Backache by use of bridge on the operation table. Avoid its use in early patients.
Four marks for each correct answer

Mr. Mwansa aged 52 years is admitted to the surgical ward with history of frequency and
difficulties in micturition. On examination, the diagnosis of benign prostatic hypertrophy is made
and he is to undergo prostatectomy
a) Define the term benign prostatic hypertrophy 3%

b) List six (6) other obstructive symptoms that Mr. Mwansa may present with other than the one
mentioned in the question. 12%
c) Mention two (2) closed and three (3) open approaches of prostatectomy 10%
d) Discuss the pre-operative nursing care you would give to Mr. Mwansa
50%
e) Mention 5 five complications PBH 25%
DEFINITION
 Prostatectomy refers to the surgical removal of part of the prostate gland or the entire prostate
(radical prostatectomy).
Indications
 Benign prostate enlargement.
Pathophysiology of benign disease

 When men rich their mid 40s.the prostate gland begins to enlarge. This condition, benign
prostatic hyperplasia (BPH) is present in more than half of men in their 60s and as many as 90%
of those over 90. Because the prostate surrounds the urethra, the tube leading urine from the
bladder out of the body, the enlarging prostate narrows this passage and makes urination difficult.
The bladder does not empty complete each time a man urinates, and as a result, he must urinate
with greater frequency, night and day. In time, the bladder can overfill, and urine escapes from
the urethra, resulting in incontinence. An operation called transurethral resection of the prostate
(TURP) relieves symptoms of BPH by removing the prostate tissue that is blocking the urethra.
No incision is needed. Instead a tube (retro scope) is passed through the penis to the level of the
prostate, and tissue is either removed or destroyed, so that urine can freely pass from the body
Pathophysiology of Malignant disease
 Prostate cancer is the single most common form of non –skin cancer in the United State and the
most common cancer in men over 50. Half of men over 70 and almost all men over the age of 90
have prostate cancer, and the American Cancer Society estimates that 198000 new cases will be
diagnosed in 2001. This condition does not always require surely, In fact, many elderly men
adopt a policy of watchful waiting “especially if their cancer is growing slowly. Younger men
often elect to have their prostate gland totally removed along with the cancer it contains- an
operation called radical prostatectomy. The two main types of this surgery, radical retro pubic
prostatectomy and radical pineal prostatectomy, are performed only patient whose cancer is
limiting to the prostate. If cancer has broken out of the capsule surrounding the prostate gland and
spread in the area to distant sites, removing the prostate will not prevent the remaining cancer
from growing and spread throughout the body.
GENERAL SURGICAL MANAGEMENT FOR PROSTATE CANCER
PRECAUTIONS BEFORE SURGERY.
 Open (incision) prostatectomy for cancer should not be done if the cancer has spread bound the
prostate, as serious side effects may occur with the benefit of removing all the cancer. If the
bladder is retaining urine, it is necessary to insert a catheter before starting surgery. Patients
should be in the best possible general condition before radical prostatectomy. Before surgery, the
bladder is inspected using instrument called a cyst scope to help determine the best surgical
technique to use and to rule out other local problems.

TYPES OF SURGERY THAT COULD BE PERFORMED
 TRANS _URETHRA RESECTON OF PROSTATE (TURP)
 This procedure does not require an abdominal incision. With the patient under either general or
spinal anesthesia, a cutting instrument or heated wire loop is inserted to remove as much prostate
tissue as possible and seal blood vessels. The excised tissue is washed into the bladder, and then
flushed out at the end of the operation. A catheter is left in the bladder for one to five days to
drain urine and blood. Advanced laser technology enables surgeons to five days to drain urine
and blood. Advanced laser technology enables surgeons to safely and affectively burn off exceed
prostate tissue blocking the bladder opening with fewer of the early and late complications
associated with other forms of prostate surgery. This procedure can be performed on an outpatient
basis, but urinary symptoms do not improve until swelling subsides several weeks after surgery.
 RADICAL RETROPUBIC PROSTATECTOMY
 This is a useful approach if the prostate is very large, or cancer is suspected. With the patient
under general or spinal anesthesia or an epidural, a horizontal incision is made in the center of the
lower abdomen. Some surgeons begin the operation by removing pelvic lymph nodes to
determine whether cancer has invaded them. But recent findings suggest there is no need to
sample them in patients whose like hood of lymph node metastases is less than 18%. A doctor
who removes the lymph nodes for examination will not continue the operation if they contain
cancer cells, because the surgery will not cure the patient. Other surgeons remove the glad before
examining the lymph nodes. A tube (catheter) inserted into the penis to drain fluid from the body
is left in place for 14-21 days.
 Originally, this operation also removed a thin rim of bladder tissue in the area of the urethra
sphincter- a muscular structure that keeps urine from escaping from the bladder. In addition, the
nerves supplying the penis often were damaged, and many men found themselves important
(unable to achieve erections) after prostatectomy. A newer surgical method called potency-
sparing radical prostatectomy preserves sexual potency in 75% of patients fewer than 5% become
incontinent following this procedure.
 RADICAL PERINAL PROSTATECTOMY
 This procedure is just as curative as radical retro public prostatectomy but is performed less often
because it does not allow the surgical to spar the nerves associated with erection or, or because
the incision is made above the rectum and below the scrotum, to remove lymph nodes. Radical
Perineal prostatectomy is sometimes used when the cancer is limited to the prostate and there is
no need spare nerves or when patient’s health might be compromised by the longer procedure.
The Perineal operation is less invasive than retro pubic prostatectomy. Some parts of the prostate
can be seen batter, and blood loss is limited. The absence of an abdominal incision allows
patients to recover more rapidly. Many urologic surgeons have not been trained to perform this
procedure. Radical prostatectomy procedure last one to four hours, with radical Perineal
prostatectomy taking less time than radical retro pubic prostatectomy. The patient remains in the
hospital three to five days following surgery and can return to work in three to five weeks.
 Ongoing research indicates that laparoscopic radical prostatectomy may be as effective as open
surgery in treatment of early- stage disease.
CRYOSURGERY

Also called cry therapy or cry ablation, this minimally invasive procedure uses very low
temperature to freeze and destroy cancer cells in and around the prostate gland. A catheter
circulates warm fluid through the urethra to protect it from the cold. When used in
connection with ultrasound imaging, cryosurgery permits very precise tissue destruction.
Traditionally used only in patients whose cancer had not responded to radiation, but now
approved by Medicare as a primary treatment for prostate cancer, cryosurgery can safely be
performed on older men, on patients who are not in good enough general health to undergo
radical prostatectomy, or to treat recurrent disease. Recent studies have shown that total
cryosurgery, which destroys the prostate, is at least as effective as radical prostatectomy
without the trauma of major surgery1
Pre-op care
{Objectives and care as discussed under major abdominal surgery}
As with any type of major surgery done under general anaesthesia, the patient should be in optimal
condition. Most patients having prostatectomy are in the age range when cardiovascular problems are
frequent, making it especially important to be sure that the heart is beating strongly, and that the patient is
not retaining too much fluid. Because long-standing prostate disease may cause kidney problems from
urine "backing up," it also is necessary to be sure that the kidneys are working properly. If not, a period of
catheter drainage may be necessary before doing the surgery.
POST-OPERATIVE CARE
{Objectives and care as discussed under major abdominal surgery} with he following points
Following TURP, a catheter is placed in the bladder to drain urine and remains in place for two to three
days. A solution is used to irrigate the bladder and urethra until the urine is clear of blood, usually within
48 hours after surgery. Whether antibiotics should be routinely given remains an open question. Catheter
drainage also is used after open prostatectomy. The bladder is irrigated only if blood clots block the flow
of urine through the catheter. Patients are given intravenous fluids for the first 24 hours, to ensure good
urine flow. Patients resting in bed for long periods are prone to blood clots in their legs (which can pass to
the lungs and cause serious breathing problems). This can be prevented by elastic stockings and by
periodically exercising the patient's legs. The patient remains in the hospital one to two days following
surgery and can return to work in one to two weeks.
Complications of surgery
 Infection,
 Reactions to general or local anaesthesia..
 Excessive bleeding, which in rare cases may require blood transfusion.
 Incontinence when, during retropubic prostatectomy, the muscular valve (sphincter) that keeps
urine in the bladder is damaged. Less common today, when care is taken not to injure the
sphincter.
 Impotence, occurring when nerves to the penis are injured during the retropubic operation.
Today's "nerve-sparing" technique has drastically cut down on this problem.

 Some patients who receive a large volume of irrigating fluid after TURP develop high blood
pressure, vomiting, trouble with their vision, and mental confusion. This condition is caused by a
low salt level in the blood, and is reversed by giving salt solution.
 A permanent narrowing of the urethra called a stricture occasionally develops when the urethra is
damaged during TURP.
 There is about a 34% chance that the cancer will recur within 10 years of the procedure. In
addition, about 25% of patients experience what is known as biochemical recurrence, which
means that the level of prostate-specific antigen (PSA) in the patient's blood serum begins to rise
rapidly. Recurrence of the tumour or biochemical recurrence can be treated with radiation therapy
or androgen deprivation therapy.2
Normal results
In patients with BPH who have the TURP operation, urination should become much easier and less
frequent, and dribbling or incontinence should cease. In patients having radical prostatectomy for
cancer, a successful operation will remove the tumour and prevent its spread to other areas of the
body (metastasis). If examination of lymph nodes shows that cancer already had spread beyond the
prostate at the time of surgery, other measures are available to control the tumour. Benign prostatic
hypertrophy (BPH) or enlarged prostate is enlargement or hypertrophy of the prostate gland.
(b) Obstructive symptoms
1. Hesitancy in starting urination

2. Increased frequency of urination
3. Nocturia
4. Urgency and abdominal straining
5. Decrease in size and force of urine stream.
6. Dribbling in which urine dribbles out after urination.
 Sensation of incomplete emptying of the bladder.
 Acute urinary retention (more than 60mls)
 Recurrent urinary tract infections
 Interruption of urinary stream
 Ultimately azotenia and renal failure can occur. 12%
(c) Mention two (2) closed and three (3) open approaches of prostatectomy 10%
Closed approaches
 Transurethral resection
 Transurethral incision
Open approaches
 Suprapubic prostatectomy
 Perineal prostatectomy
 Retropublic prostatectomy
Discuss the pre-operative nursing care you would give to Mr. Mwansa 50%
objectives
 To prepare Mr. Mwansa psychologically and physically for operation so as to withstand the
effects of anaesthesia.
2

 …………………………………………………………………………………………….
Admission
Preferably the patient will admitted 48 hrs before surgery. This will help in acquainting him to the new
environment
 Welcome Mr. Mwansa into the ward and introduce him to other members of staff and other
patients in the ward to familiarize the environment.
 Check Mr. Mwansa’s vital signs thus the pulse, respiration, temperature and blood pressure to
serve as baseline data and to assess any deviation. Record all readings for reference.
Environment
 Put him in a clean room to minimize the risk of infection
 Maintain a restful environment by keeping the rock clean and well ventilated and by minimizing
environmental irritants (e.g. noise, smoking)
Assessment.
 Assess Mr. Mwansa’s physical state to detect any abnormalities or deviate from normal which
may need to be corrected before surgery
 Assess the client’s nutritional status by checking hair texture, skin status and color of the mucous
membrane.
 Assess the respiratory status for optimal pulmonary function by checking for breathing pattern,
nail bed for pallor or cyanosis because ventilation is potentially compromised during all phases of
surgery.
Pre-operative medication
 Depending on the findings during assessment, give the prescribed medication and monitor him
for desired effects and side effects of the drug
 Atropine 0.5mg, pethedine and diazepam usually given.
Pre-operative education
 Teach Mr. Mwansa some deep breathing and coughing exercises to promote
lung expansion
 Teach him about mobility and active body movement to prevent post operative
complications like deep vein thrombosis
 Teach him also about cognitive coping strategies to relieve tension, overcome
anxiety and achieve relaxation
NURSING CARE
i. Psychological care
 Continue giving psychological support to allay anxiety

 Reinforce the doctors explanation on the kind of operation and outcome
 Encourage Mr. Mwansa to verbalize his concerns and ask questions. Answer honestly
or refer the question to the highest authority if you are not able to. This is done to
relieve tension due to worries
 Identify significant others of family members and involve the in planning care for
Mr. Mwamba
ii. Consent Form

 Before Mr. Mwansa signs the consent form, ensure that the surgeon has provided a sample and clear
explanation of what prostatectomy entails, expected outcomes and possible risks if operation is not
done.
 After being sure that Mr. Mwansa knows and understands what will happen, then witness the signing
of the consent form.
(iii) Investigations
1. Collect blood sample for
 Hemoglobin to rule out anemia

 Grouping and cross match in case blood transfusion will be needed
 Bleeding and clotting time to rule out the bleeding disorders which may have a negative
bearing in post operatively.
 Collect urine sample for urinalysis to rule out diabetes mellitus and renal disease which may have
negative bearing in post operative period.
 Chest X-rays or ultra sound to rule out chest infections
iv. Nutrition and fluids

 Mr. Mwansa will be starved for 6-8 hours prior to surgery
 For this reason, advise him after he has his super not to take anything by mouth such as solid
floods, juice and water fro midnight to prevent vomiting and aspiration during surgery.
v. Physical preparation
 Clean Mr. Mwansa’s abdomen from the umbilical line to the middle thigh with soap and water to
reduce on the number of micro-organisms. If he is hairy use a scissors to trim the hair.
 Give Mr. Mwansa another cleansing enema in the late evening to allow satisfactory visualizing
of the surgical site and prevent trauma to intestine
 Immediate Pre- operative care
 Give Mr. Mwansa another cleaning enema in the early hours of the morning of the operation,
around 04:00 hours for example
 Give him the morning bath in the morning to remove sweat and dead epithelial cell on the body
 Mr. Mwansa will be dressed in a fresh, clean theatre gown to prevent infection
 Advise Mr. Mwansa to take off any jewelry to prevent electrocution
 Insert an canular to keep the vein open for intravenous infusion
 Insert also urinary catheter to employ the bladder and prevent accidental injury when it is full
 Insert a naso gastric tube to aspirate the stomach
 To prevent mistaken operation, provide an identity band of Name, age, sex, ward, type of surgery
to be done
 Immediate preoperative observations
 Check vital signs i.e. temperature, pulse, respirations and blood pressure to act detect any
deviation from normal and act baseline date intra operatively
 Report and note on Mr. Mwansa s chart any observation that might have bearing on anesthesia or
surgery e.g. raised blood pressure.
Pre anesthetic medication
 As ordered, give pre-anesthetic medication to allay anxiety, decrease the flow

of pharyngeal secretions and to reduce the amount of anesthesia to be given,
and also create amnesia for the event that precede surgery

 Escorting the patient to the theatre
 Complete the pre-operative checking list to be sure that it bears information such as
clinical data patient preparation and communication assessment
 Attach together surgical consent form, all laboratory reports or results, X-ray and scan
films and other relevant documents
 Transfer Mr. Mwansa from bed to a stretcher covered with sufficient number of linen to
ensure warmth
 Once at the theatre, hand over Mr. Mwansa to the theatre nurse according to the hospital
policy
 After escorting Mr. Mwansa to the theatre, come back to the ward and continue
reassuring his family members
(d) Mention five (5) Complications of prostatectomy and state how each one can be prevented
1. Haemorrhage
2. Infections
3. Renal failure
4. Pulmonary complications
5. Epididymo-orchits
 Obstruction/ stenosis of urinary bladder neck
 Sexual dysfunction such as :
1. impotence due to damage to the pudendal nerves
2. retrograde ejaculation i.e. the seminal fluid goes into the bladder
during ejaculations due to anatomical changes in the posterior
urethra
ACUTE ABDOMEN
MARKING KEY FOR ACUTE ABDOMEN
Mrs. Margret Zulu, a 60 year old marketer is admitted to your ward with severe abdominal pains.
After thorough examination, a diagnosis of acute abdominal is made.
a. Define acute abdomen 5%

b. Explain five(5) common causes of acute abdomen 20%
c. Describe the pre-operative management you would give to Mrs. Zulu 50%
d. Explain five (5) points you would include in your information, education and
communication to Mrs. Zulu before discharge 25%
1. Definition of acute abdomen
 This is an acute intra-abdominal condition of abrupt onset, usually associated with

pain due to inflammation, perforation, obstruction, infarction or rupture of abdominal
organs and usually requiring emergency surgical intervention
 Acute abdomen refers to conditions that have a sudden onset and affect the
abdomen or abdominal organs and usually require immediate or urgent
surgical intervention.
 Any part of the lower GIT is susceptible to acute inflammation caused
bacterial, viral or fungal diseases.
 Some of the conditions of acute abdomen may not be diseases by
themselves, such as intestinal obstruction but would eventually lead to
inflammatory diseases such as peritonitis or appendicitis.

. Five (5) common causes of acute abdomen
 Inflammation e.g.:
 Acute appendicitis- where the appendix is inflamed. There is sudden severe

abdominal pain such that if inflammation continues without treatment the
appendix can rapture
 Acute diverticulitis- acute inflammation of the diverticulum (pouch or pocket of
any portion e.g. of the G.I.T). This commonly occurs in the large intestine. There
is severe pain and tenderness usually in the lower left part of the abdomen among
others
 Acute cholecystitis- acute inflammation of the gall bladder
 Acute salpingitis- acute inflammation of the fallopian tubes
1) Acute intestinal obstruction
 May be a mechanical obstruction where the blockage could completely stop or seriously impair
the passage of intestinal contents. The part above the obstruction may swell up when filled with
food, fluid, digestive secretions, etc. Mechanical obstruction is commonly caused by:
 Volvulus - This is the twisting of the intestine causing obstruction. In this case, blood
supply is cut off to the affected part and gangrene may occur if not managed properly
 Intussusceptions-prolapsed of one of the intestine into another part immediately adjacent
to the part
 Intestinal obstruction can be non mechanical called functional obstruction e.g. in paralytic ileus-
where the normal contractile movement of the intestinal wall temporarily stops.
3) Peritonitis- inflammation is usually caused by an infection or inflammation of the lining of the

abdominal cavity (peritoneum). Usually infection spreads from an infected organ in the abdomen.
Common sources are:
Perforation of the stomach / intestine (e.g. perforated peptic ulcers), gall bladder, appendix), also
perforation of the fallopian tube (e.g. ruptured ectopic pregnancy)
4) Ischemia- This is where there is deficiency in blood supply which could be as a result of:
 Strangulated hernia- This is a hernia of the bowel in which the neck of the sac containing the
bowel is so constricted that the blood supply is impeded and gangrene may result if not managed
promptly.
 Volvulus - the blood supply is cut off and gangrene may result if not managed promptly
 Torsion of the ovarian cyst- This is where the long pedicles of an ovarian cyst twists leading to
impaired blood supply to the affected part, gangrene may result if not managed promptly.
5) Ruptured arterial aneurysm

 This is the rupture of an aneurysm (bulge or dilatation in the wall of an artery) usually the
abdominal aortic aneurysm
 There is excruciating pain in the lower abdomen and back, also tenderness over the aneurysm
 With severe internal bleeding, a person may rapidly go into shock
A wide range of acute abdomen conditions are described below. Some of the most common
ones are;
 Appendicitis
 Ruptured ectopic pregnancy
 Peritonitis
 Diverticulitis
 Small bowel obstruction
 Large bowel obstruction
 Strangulated hernia
 Volvulus
 Intussusception
 Ruptured spleen
 PREOPERATIVE MANAGEMENT GIVEN TO ZULU
Emergency care
 The management is emergency pre-operative
 Patient should be nil orally because if patient eats may aspirate the food under the influence of
anesthesia
 Insert a nasal gastric tube in order to empty the stomach (especially if the patient has eaten within
4-6 hours.
 If there is blood loss, or if patient has vomited a lot ( causing circulatory failure or dehydration or
where these are anticipated), Intravenous fluids are given
 A fluid balance chart is monitored in all cases
 In case patient is in shock or urinary retention is suspected, a catheter is put up
 Vital signs are monitored regularly e.g. 2 hourly depending on condition, low Bp, fast and feeble
pulse indicate patient going in shock. High temperature will show that there is infection.
 Blood is collected for grouping and cross match since the patient may need blood transfusion.
GENERAL CARE
 Remove any dentures, jewellers, etc
 Will explain to the patient the type of operation and why is going to theatre
 Thereafter, patient will be asked to sign the consent form for operation
 The abdomen will be trimmed up to the vulva
 I will put an identification band on the wrist
 Theater nurse will be informed of the patient going for laparotomy
 When ready will take the patient and handover to the theatre nurse
 Will come back to the ward to prepare the environment including the post –operative bed.
Five (5) points that can be included in the IEC to Mrs. Zulu before discharge
 IEC is given on the importance of good nutrition; high protein and vitamin diet. Proteins help in
the building of worn out tissues, while vitamins help in healing of the wound and boosting of the
immunity. Also need roughage in the diet to help in making the stool bulk and promote peristalsis
thereby preventing constipation. Constipation leads to straining while opening bowels and this
would cause pressure on the incision site which may open up.
 The patient will also be given IEC on the importance of not touching the incision site with dirty
hands as they may introduce microorganisms which may cause infection
 She will also be advised on not lifting heavy objects as this can cause strain on the incision site
thereby on the importance of coming back to the hospital for review so that the progress could be
assessed. However, she would be told that in case of having problems. Should come back even
before the review date.
 Drug compliance - advise the patient on the importance of drug compliance
INTESTINAL OBSTRUCTION

Definition
Intestinal obstruction occurs when the contents of the intestines or the lumen of the intestines
blocks the normal flow of bowel contents
The obstruction can be partial or complete, with the severity depending on the degree of
obstruction, the degree to which vascular supply is disturbed and the lumen affected
It can also be temporal due to manipulation during surgery {paralytic ileus}
Most bowel obstruction occurs in the small intestines with adhesions as the top cause followed
by hernias and neoplasm.
Causes
There are basically two processes that can cause intestinal obstruction
 Mechanical obstruction
 Functional / Neurological obstruction
Mechanical obstruction
This occurs when there is an intraluminal or a mural obstruction from pressure on the intestinal
walls. This may cause constriction resulting in partial obstruction but may suddenly become
complete obstruction.
Examples of mechanical obstruction would result from
 Intussusception { invagination}
 Polypoid tumours and neoplasm
 Stenosis
 Strictures
 Adhesions may form after abdominal surgery due to the healing process that leaves
scars
 Hernias
 Abscess
 Volvulus
 Diverticulitis {crohns disease]
 Pressure from tumours outside the lumen like uterine fibroids
Functional obstruction
This is where the intestinal musculature cannot propel the contents along the bowel and could
be as a result of amylidosis, muscular dystrophy, endocrine disorders such as diabetes or
Neurological disorders such as Parkinson’s syndrome.
Paralytic ileus is the most common cause of paralysis.
Obstruction may be as a result of vascular obstruction to a segment of the bowel where blood
supply will be cut off and ischemia results followed by infarction, gangrene and total
obstruction. The vascular causes may be a result of embolism, arthromatous changes in blood
vessels and thrombosis
Pathophysiology of obstruction
The intestinal contents, fluid and gas accumulate above the intestinal obstruction. This causes
abdominal distension. Irritation of the nerves by the distension also causes acute abdominal
pains.
The abdominal distension and retention of fluid reduces the absorption of the fluids and thus
stimulate more gastric secretions.

With the Increase in distension, pressure within the intestinal lumen also increases thus causing
a decrease in the venous and arterial capillary pressure. This causes oedema congestion,
necrosis and eventually rapture or perforation of the bowel with resultant peritonitis.
Reflux vomiting may be caused by abdominal distension.
The vomiting causes loss of hydrogen ions and potassium from the stomach leading to a
reduction of chlorides and potassium in the blood and eventually metabolic alkalosis.
Dehydration and acidosis follows from loss of water and sodium. With all these fluid losses
hypovolaemic shock occurs
Clinical picture
The initial picture or symptom is usually

 Cramp pain that is wave- like and colicky.
 The patient may pass blood and mucous but no faecal matter or flatus
If obstruction is complete the peristaltic movements initially become very vigorous and
eventually assume a reverse direction where the intestinal contents propel towards the mouth
instead of the rectum if the obstruction is in the ileum.
 Faecal vomiting may occur. First the patient vomits the stomach contents then the bile-
stained contents from the jejunum and duodenum and finally the faecal like contents of
the ileum
 Dehydrations becomes evident
 There is intense thirsty
 Drowsiness
 Generalized malaise
 Aching and parched tongue
 Abdominal distension
 Hypovolaemic shock
Diagnosis
Based on the symptoms presented by the patient {subjective and objective history taking
 Physical examination of patient may review abdominal distension

 Abdominal X-ray findings show abnormal quantities of gases, fluid or both in the bowels
 Laboratory findings review electrolyte imbalances
 FBC plus a complete blood cell count needs to be done and these will review a picture of
dehydration
 Loss of plasma volume and possible infection with an increases
 ESR
 Barium meal/swallow/ enema
 Sigmoidoscopy
 Abdominal Scan
 Stool for occult blood
 Stool examination for worms
Medical Management
Objectives
 To correct the electrolyte imbalance
 To relieve abdominal distension
 To relieve pain
 To treat the cause
 Prevent complications
Decompression of bowel through a naso gastric tube is successful a most cases

 If obstruction is complete it will warrant surgical intervention.
The surgical intervention is mostly dependent on the cause of obstruction i.e. hernia or
adhesions will involve repairing the hernia or dividing the adhesions to which the intestine is
attached.
 In some cases a portion of the intestines will have to be removed and an anastomosis
done
NURSING CARE
Nursing Care Objectives
The objectives of nursing management are;
 Provide a safe and conducive environment for rapid recovery from the disease process
 Help to relieve discomfort and pain
 Prevent occurrence of complications.
Environment
 The patient with acute abdomen is nursed in a surgical ward preferable in a side
ward/or in an acute bay, for easy observations and away from routine ward traffic to
ensure maximum rest and comfort.
 The ward should be cleaned every day by thorough dump dusting, mopping and drying
all the wet surfaces. These measures prevent cross infection, provide a comfortable and
soothing environment.
 It should be well ventilated for easy circulation of air.
 All emergency equipment such as emergency trolley, Oxygen machine suction machine
etc should be within reach for easy management of emergencies
 It should have adequate light for easy observations.
Position
The patient is nursed in a position he finds more comfortable, preferably lying on the
unaffected side. As he may be restricted by treatment regimes, such as immobilization, he
should ensure frequent turnings {at least 2 hourly} to promote circulation and prevent
development of pressure sores.
Psychological care

 The patient may be apprehensive about the out come of the disease process and the
possibility of long term treatment or immobilization.
 His self concept is usually altered because of a number of uncertainties.
 Quickly help the patient resolve the anxieties in readiness for surgery
 Explain to the patient the disease process, its eventful outcomes without alarming the
patient. Focus on the positive outcomes but avoid giving false hopes.
 Patient should understand the need for urgent surgery /intervention.
 Ensure you obtain an informed consent
 Involve the significant others in the care of the patient as home care will be inevitable.
Rest and activity
Passive exercises are to be done when patient is still bed ridden. Early ambulation is
encouraged to stimulate blood circulation and prevent infections and deep vein thrombosis,
coughing and deep breathing exercises must be done 4 hourly in the acute phase when patient
is bed ridden to prevent hypostatic pneumonia and wound infection.
Pain relief
Pethidine 100mg tds PRN for 3 doses is given as ordered post operatively. After wards pains
is relieved by positioning the patient in most comfortable position and instructing the patient to
hold on the wound when coughing. Observe pain if it’s reducing or increasing. Increasing pain
on the wound may indicate infection.
Observations
 Vital signs of temperature and pulse rate, blood pressure and respirations are taken
every 15 minutes to monitor the condition or disease process.
 Monitoring of the neuromuscular function is cardinal to ensure that ischemia is not
developing.
 The general well being of the patient is frequently assessed,
 his reaction to pain,
 his nutritional status,
 Compliance to the treatment regimes such as immobilization and generally his reaction
to hospitalization.
 Any haemorrhages or bleeding are noted and recorded
Wound Care/Hygiene.

Daily wound care with the prescribed antiseptic solution should be done. This helps to halt the
infective process. Sterile equipment and material should be used each time dressings are done.
 Ensure all drainage tubes are patent and follow the Doctors orders to remove or change
them.
 Patient is taken through the process of wound care so that they would be able to
manage the wounds at home
 Patient is also encouraged to assume personal hygiene measures such as general body
hygiene oral care, nail care and hair care.
 The clothes worn should be clean
 And linen where patient is lying should be frequently changed.
Medications
Patient may be put on long term antibiotic therapy,
 Thus adherence to the therapeutic regime will be critical to avoid resistance developing.
 The nurse monitors the patient for super infection as a result of long term use of
antibiotics. These could be vaginal candidiasis, oral candidiasis or foul smelling stools
Patient teaching /IEC
 Patient’s relatives must learn and recognize the importance of adhering to therapeutic
regimes,
 Preventing falls and other injuries.
 Patient may need to know how to manage IV at home
 Identification of additional painful sites should be reported
 Report any elevation in temperature
COMPLICATIONS of acute abdomen
 Infection as a result of
 Hemorrhage as a result of
 Intestinal obstruction following intuccesption or Volvulus
 Peritonitis due overflow of infected contents in the abdomen
 Aneamia due to excessive loss of blood/bleeding
 Gangrene due to blood flow obstruction
 Hypovolaemic Shock due to hemorrhage

 Neurogenic shock due to pain
APPENDECTOMY
Mrs. Mwanza has been complaining of chronic pain in the right Iliac fossa. After an abdominal
scan, The Dr suspects that she could have an inflamed Appendix and he decides to perform
appendectomy
a) Define Appendectomy/Appendicitis 5%
b) List two types of abdominal incisions that a Dr can use to approach the appendix 6%
c) Discuss in detail the pre op care of a patient going for appendectomy 50%
d) Briefly discuss how you are going to manage the abdominal wound after surgery 20%.
e) Mention {4} four complications of abdominal surgery 15%
Definition
This is the inflammation of the vermiform appendix.
Incidence;
About 7% of the population has appendicitis within their lives. Males are affected more then
females and teenagers more than adults
It occurs more frequently between ages of 10 and 30. 3
Pathophysiology
The appendix becomes inflamed and oedematous as a result of either becoming kinked or
occluded by faecal matter {a harden mass of stool} It can also be occluded by foreign matter or
by mural causes such as tumours
The inflammatory process initiates a progressively severe generalized or upper abdominal pain
and becomes localized in the right lower quadrant of the abdomen within a few hours
eventually the inflamed appendix fills with pus.
Clinical Picture
 There is vague epigastric pain or peri umbilical pain which progress to the right lower
quadrant.
 The pain is usually accompanied by low-grade fever
 Nausea and vomiting sometimes occur
 Loss of appetite is common
 Local tenderness is elicited at Mc Burney’s point when pressure is applied
 Rebound tenderness
 Constipation/Diarrhoea
 Pain in the lumber if appendix curls along the caecum
 If the tip is in the pelvis theses signs may only be elicited on rectal examination
 Pain on defecation suggests that the tip is in the pelvis or resting against the rectum
 Pain on urination suggests that the tip is near the bladder or impinges the urethra
 Rovsing sing may be elicited by palpating the left lower quadrant. This paradoxically
causes pain to be felt on the right side
 Pain becomes more diffuse if appendix has ruptured followed by abdominal distension
3

 Patient’s condition deteriorates art this time 4.
Note;
 Rovsing’s sign is pain felt on the right lower quadrant when the left lower
quadrant is palpated
 The Mc Burney’s point is between the umbilicus and the anterior superior iliac
spine
Diagnosis
This is based on a complete
 History taking,
 Physical examination
 Laboratory examination
 X-ray findings
 Complete Cell count demonstratives an elevated white blood cell count
 The leukocyte count may exceed 10 000 cells/mm3
 The nuetrophil count may exees75%
 Abdominal examination/x-rays, C.T and ultra sound may reveal a right lower quadrant
density or localized distention of the bowel
MEDICAL MANAGEMENT
Objectives
 To ensure that Surgery is performed as soon as possible in order to decrease the risk of
perforation.
 To correct or prevent fluid and electrolyte imbalance and dehydration by giving
antibiotics and intravenous fluids before surgery
 To relieve pain by giving analgesia, as patient awaits surgery
 This means that surgery is needed and is {thus called urgent surgery} It should not be
confused to emergency surgery which means surgery should be done immediately, like
in the case where a perforation has occurred.5
SURGICAL MANAGEMENT
Objective.
perforation.
Appendectomy, which is a surgical removal of the appendix, is performed

This may be done as an abdominal operation or via a laparascopy
NURSING CARE
Pre and post op care
4
5

{As for Any acute abdominal condition}
Complications
The major complication is

 Perforation of the appendix {10% to 32%} This may occur about 24 hrs after the onset
of pain thus the need for urgent surgery
 Peritonitis
 Abscess
NEPHRECTOMY
Definition
Nephrectomy is the surgical procedure of removing a kidney or section of a kidney.
Indications
Nephrectomy, or kidney removal, is performed on patients
 With cancer of the kidney (renal cell carcinoma); a disease in which cysts (sac-like
structures) displace healthy kidney tissue (polycystic kidney disease);
 Serious kidney infections.
 It is also used to remove a healthy kidney from a donor for the purposes of kidney
transplantation.
Types of nephrectomy
Nephrectomy may involve removing a small portion of the kidney or the entire organ and
surrounding tissues.
 Partial Nephrectomy - In partial nephrectomy, only the diseased or infected portion of the
kidney is removed.
 Radical nephrectomy involves removing the entire kidney, a section of the tube leading to
the bladder (ureter), the gland that sits atop the kidney (adrenal gland), and the fatty
tissue surrounding the kidney.
 A simple nephrectomy performed for transplant purposes requires removal of the kidney
and a section of the attached ureter.
 A similar procedure is used to harvest cadaver kidneys, although both kidneys are
typically removed at once (bilateral nephrectomy) and blood and cell samples for tissue
typing are also taken.
 Laparoscopic nephrectomy is a form of minimally-invasive surgery that utilizes

instruments on long, narrow rods to view, cut, and remove the kidney. The surgeon views
the kidney and surrounding tissue with a flexible videoscope.
PRE-OPERATIVE CARE
Pre operative Objectives {Surgical Management}
complications.
 To correct or prevent fluid and electrolyte imbalance and dehydration by giving
antibiotics and intravenous fluids before surgery
 To relieve pain by giving analgesia, as patient awaits surgery
 To prepare the patient physically, emotionally, psychologically so a to enable him
withstand the effects of surgery and administration of anesthesia.
EXPECTED OUTCOME OF SURGERY
Normal results
Normal results of a nephrectomy are dependent on the purpose of the procedure and the type of
nephrectomy performed. Immediately following the procedure, it is normal for patients to
experience pain near the incision site, particularly when coughing or breathing deeply. Renal
function of the patient is monitored carefully after nephrectomy surgery. If the remaining kidney
is healthy, it will increase its functioning over time to compensate for the loss of the removed
kidney.
Length of hospitalization depends on the type of nephrectomy procedure. Patients undergoing a

laparoscopic radical nephrectomy may be released within two to four days after surgery.
Traditional open nephrectomy patients are typically hospitalized for about a week. Recovery
time will also vary, on average from three to six weeks.
Precautions
Because the kidney is responsible for filtering wastes and fluid from the bloodstream, kidney
function is critical to life. Nephrectomy candidates suffering from serious kidney disease, cancer,
or infection usually have few treatment choices but to undergo the procedure. However, if kidney
function is lost in the remaining kidney, the patient will require chronic dialysis treatments or
transplantation of a healthy kidney to sustain life.
NURSING CARE
OBJECTIVES
The objectives of nursing management are;
 Provide a safe and conducive environment for rapid recovery from the disease process
 Help to relieve discomfort and pain
 Prevent occurrence of complications.
Prior to surgery, {Specific issues}

 Blood samples will be taken from the patient to type and cross match in case transfusion is
required during surgery.
 A catheter will also be inserted into the patient's bladder.
 The surgical procedure will be described to the patient, along with the possible risks.
GENERAL CARE.
Environment.
The patient with renal stones tumours etc, is nursed in a surgical ward, preferable in a side
ward away from routine ward traffic to ensure maximum rest and comfort.
The ward should be cleaned every day by thorough dump dusting, mopping and drying all the
wet surfaces. It should be well ventilated with adequate light. These measures are taken to
prevent cross infection, provide a comfortable and soothing environment.
Position
The patient is nursed in a position he finds more comfortable, preferably lying on the
unaffected side. If he is restricted by treatment regimes, such as immobilization, you should
ensure frequent turnings {at least 2 hourly} to promote circulation and prevent development of
pressure sores.
Psychological care
The patient may be apprehensive about the out come of the disease process and the possibility
of long term treatment or immobilization.
His self concept is usually altered because of a number of uncertainties.
Quickly help the patient resolve the anxieties in readiness for surgery
Explain to the patient the disease process, its eventful outcomes without alarming the patient.
Focus on the positive outcomes but avoid giving false hopes. Patient should understand the
need for urgent surgery /intervention.
Ensure you obtain an informed consent
Involve the significant others in the care of the patient as home care will be inevitable.
Rest and activity
The patient should understand the rationale for the activity restrictions. The joints above and
below the affected part should be gently placed through a range of motions. The nurse
encourages full range of ADLs within the physical limitations to promote the general well being.
Pain relief

There may be need to immobilize the patient or the affected part is usually immobilized in a
split to decrease pain and muscle spasm.
The nurse monitors the neuromuscular status of the affected extremity. The wounds are usually
very painful thus they should be handled with care and gentleness.
Elevation reduces swelling and the associated discomfort while the pain can be controlled
prescribed analgesia.
Observations
Nephrectomy patients may experience considerable discomfort in the area of the incision.
Patients may also experience numbness, caused by severed nerves, near or on the incision. Pain relievers
are administered following the surgical procedure and during the recovery period on an as-needed basis.
Although deep breathing and coughing may be painful due to the proximity of the incision to the
diaphragm, breathing exercises are encouraged to prevent pneumonia.
Vital signs of temperature and pulse rate, blood pressure and respirations are taken every 15
minutes to monitor the condition or disease process.
Monitoring of the neuromuscular function is cardinal to ensure that ischemia is not developing.
The general well being of the patient is frequently assessed, his reaction to pain, his nutritional
status, compliance to the treatment regimes such as immobilization and generally his reaction
to hospitalization.
Any haemorrhages or bleeding are noted and recorded
Wound Care/Hygiene.
Daily wound care with the prescribed antiseptic solution should be done. This helps to halt the
Ensure all drainage tubes are patent and follow the Doctors orders to remove or change them.
Patient is taken through the process of wound care so that they would be able to manage the
wounds at home
Patient is also encouraged to assume personal hygiene measures such as general body hygiene
oral care, nail care and hair care.
The clothes worn should be clean and linen where patient is lying should be frequently
changed.
Medications

Patient may be put on long term antibiotic therapy, thus adherence to the therapeutic regime
will be critical to avoid resistance developing. The nurse monitors the patient for super infection
as a result of long term use of antibiotics. These could be vaginal candidiasis oral candidiasis or
foul smelling stools
Patient teaching /IEC
 Patient relatives must learn and recognize the importance of adhering to therapeutic
regimes, preventing falls and other injuries.
 Patient may nee to know how to manage IV at home
 Identification of additional painful sites should be reported
 Report any elevation in temperature
 Patients should not drive an automobile for a minimum of two weeks.
COMPLICATIONS
Possible complications of a nephrectomy procedure include
 Infection,
 Bleeding (haemorrhage),
 Post-operative pneumonia.
 There is also the risk of kidney failure in a patient with impaired function or disease in the
remaining kidney
POSTOPERATIVE CARE GASTRECTOMY

After surgery, most patients are taken to the post anesthesia care unit (PACU) and are closely
monitored by the nursing staff until the anesthesia wears off. They may spend several hours in
the PACU, depending on how quickly they recover from the surgery. When they are stable, they
are transferred to their room.
Some patients need closer monitoring and attention. Those who are having respiratory problems,
those who were very ill prior to the operation, and those who developed complications during the
procedure are taken to the surgical intensive care unit until they are stable enough to be
transferred to their hospital room.
Upon waking from anesthesia, patients have an intravenous line, a urinary catheter, and a
nasogastric tube. They are not allowed to eat or drink immediately following surgery. Oxygen
may also be delivered through a plastic mask that fits over the mouth and nose, or through nasal
prongs. Patients experience pain from the incision and medication is prescribed to provide relief.
Pain medication is usually delivered intravenously.

Intensive care patients are connected to a monitor that measures their heart rate and breathing.
Their blood pressure and blood oxygen level are continuously monitored. Some patients require
a respirator to breathe for them, and additional intravenous lines to deliver medication and fluids.
Recovery is a gradual process. The nasogastric tube is attached to intermittent suction to keep the
stomach empty. If the entire stomach has been removed, the tube goes directly to the small
intestine and remains in place until bowel function returns. This generally takes between 2 and 3
days and is determined by listening to the abdomen with a stethoscope for bowel sounds (the
passage of gas). A bowel movement also indicates healing.
When bowel sounds return, clear liquids are offered. If they are tolerated, the nasogastric tube is
removed and the diet is gradually advanced from liquids to soft foods, and then to more solid
foods. Dietary adjustments may be necessary, as certain foods may now be difficult to digest.
The urinary catheter is removed in a day or two, depending on recovery. When food and liquid
are tolerated, and urine output is normal, the catheter is removed. The intravenous may also be
removed, but it remains in longer if medications, such as antibiotics and painkillers, have been
prescribed.
The day after surgery, most patients can get out of bed. Getting up and moving around is one of
the best ways to prevent postoperative complications. Movement helps blood circulation return
to normal, decreases the risk for a blood clot, helps bowel function normalizes, and lowers the
risk for lung infection. Getting out of bed can be painful and puts pressure on the incision. Pain
medication is prescribed and can be given before the patient attempts to get up.
Diet may present a challenge, especially for those whose entire stomach was removed. Food and
liquids now enter the small intestine quickly, causing uncomfortable symptoms that can usually
be relieved by eating several small meals, eating more protein and less sugar, and making other
dietary changes. A nutritionist or dietician can help develop new eating habits. The dietary
changes may be temporary, until the digestive system adjusts, or they may be permanent.
Vitamin B12 is absorbed in the stomach and must be supplemented with regular injections by
patients who underwent a total gastrectomy. Absorption may be impaired in those who still have
part of their stomach, so it is necessary to have B12 levels checked periodically.
Supplementation with folate, iron, and calcium may also be necessary to correct deficiencies
caused by the surgery.
The length of hospitalization varies. Full recovery may take several weeks or a few months,
especially if the patient has gastrointestinal problems such as diarrhea, which can be debilitating.
Recovery may also be prolonged by other treatments, such as chemotherapy.
Postoperative Complications
Complications related to the surgical procedure or problems adjusting to an altered digestive

tract can occur.

Dumping syndrome is a common problem that occurs after gastrectomy. With all or much of
the stomach gone, food and fluids can pass too quickly into the small intestine, causing
symptoms including:
 Cramping
 Diarrhea
 Dizziness
 Nausea and vomiting
 Shortness of breath
 Sweating
Dumping syndrome may resolve on its own after a few months and is often be relieved by
dietary changes. Eating several small, frequent meals during the day, and eating foods higher in
HEAD INJURY
DEFINITION
This is injury that affects the scalp, skull and or brain.
CAUSES
 The main causes of head injury are forceful trauma to the head.
Clinical manifestation
 Loss of consciousness
 Severe headache
 Vertigo
 Altered respirations, temperature, BP,
 Confusion
 Vomiting
 Leakage of C SF from the nose ears, or throat
 Blurred vision
 Loss of various sensory perception
 Paralysis on one side of the body
Investigations
 history
 physical examination
 CT scan
 MRI
 skull xray
 PET scan
 EEG
NURSING CARE OF A PATIENT WITH A HEAD INJURY

OBJECTIVES
 Maintain a clear and patent airway

 To ensure that the patient remains safe and free from further damage/injury to the head.
 To reduce/prevent complications that could arise as a result of the injury
 To anticipate and timely begin to rehabilitate the patient in case of a life long disability.
A patient with a scalp/skull may have a minor injury. A thorough assessment needs to be to ascertain
this. The patient will therefore be admitted for observations close to 24hrs. during this time the nurse
needs to monitor the vital signs, signs of impending shock, worsening of pain and other neurological
signs.
A patient with brain injury is definitively in danger and the condition should be treated as an emergency.
ENVIRONMENT.
The patient should be admitted in an acute bay or preferably in ICU. This is to allow for close
observations. It should be clean enough and well dumped dusted to prevent infections. There should be
adequate light that will facilitate easy observations in case of change of condition. The environment
should be quiet to allow the patient to have enough rest. Visitors should be allowed to visit patent but
only for short periods of time and in fewer numbers to promote rest. The patient is better nursed in a rail
bed that will prevent accidental falls as the patient attempt to turn.
POSITION
All patients with a head injury should be treated with assumption that they also have cervical spinal injury
until proved otherwise. The patient is therefore nursed on a flat hard board with head and neck kept in
body alignment. Where cervical spinal injury has being ruled out, a 30 degree pillow may be put to
prevent increased intra cranial pressure. Generally main a clear and patent air way for adequate
ventilation. As patient may be unconscious ensure two hourly turnings to prevent pressure sore
development.
REST VS ACTIVITY
Initially the patient should given enough time to rest .This helps to reduce tension and ICP.
An unconscious patient need not to disturb so often unless indicated when doing certain procedures like
bed bath.
Attempt to do procedures in blocks so that you disturb patient little.
However passive limb exercises will greatly help the patient improve circulation.
OBSERVATIONS
The focus of your care should be aimed at thorough observations.
Initially quarter hourly observations for the vital signs should be done to monitor the progress of the
patient. Patient’s condition tends to deteriorate so fast because of altered cerebral functions.
Check the temperature, pulse respirations and B.P every 15minutes until condition stabilizes.
Observe the patency of the airway as the tongue could fall back or secretions easily build up.
Observe for any leakage of fluid {blood or CSF} from the ears, thorax or nose.
Observe the level of consciousness’ use the Glasgow coma scale to assess the levels of consciousness.
INTRAVENOUS INFUSION
Insert an intravenous line for infusion of fluids and medication. Patient is give plasma expanders that
alternate with 5% dextrose for energy.. Keep the veins open for easy access incase of resuscitation.
Monitor the IV insertion site for any swelling, infection or blockage
NUTRITION.
The patient obtains his food through the intravenous infusion, ensure that this is supplement ed by NG
feeds if the patient does not have fracture of the base of the head
Where food has to be given by NG, encourage a high nutritious diet that could easily be digested to
prevent stomach upsets
ELIMINATION
Maintain a intake and output regime, all fluids given to the patient should be documented and al the
output should equally be noted.
A urinary catheter should be left in situ for easy monitoring of output and documentation
Ensure that catheter hygiene is done to prevent URTI
Come up with routine bed pan round for easy evacuation of the bowels and prevention of constipation.
This will increase the comfort of the patient
HYGIENE
Activities of daily living such as mouth wash body wash hair should not be abandoned. Do routine mouth
wash, bed bath, elimination, change of linen and clothes nail care etc. This helps to prevent infections
which could acquire on the ward. A bath also helps to improve circulation of blood to vital centers of the
body. While bathing you can also observe for pressure sore development and be able to take appropriate
intervention. Bathing will also help you to do passive limb exercises and thus be able to prevent use
syndrome
MEDICATION
Administer the prescribed drugs to the patient following the 5 ‘Rs”. The patient will particularly benefit
from manitol which reduces ICP. Test doses for antibiotic should be done as patient is unconscious. This
helps to prevent incidental reactions. Continue monitoring the patient for any other incidental /adverse
reaction.
REHABILITATION
Develop a rehabilitation plan for the patient because of the likelihood of long term disability.
Involve the relatives or significant others throughout your care plan as these patient will stay much longer
with them in a deficit situation.
Help them to copy up with realities of the condition so that they could give maximum support,
Patient should also be fully involved if he’s is in a capable position to participate in the rehabilitation
plan. This will help him come to terms with situation.
The Psychotherapist, speech therapist dietitians, physiotherapists should be involved in the care of the
patient.
NURSING CARE OF A PATIENT WITH A HEAD INJURY

OBJECTIVES
 Maintain a clear and patent airway
 To ensure that the patient remains safe and free from further damage/injury to the head.
A patient with a scalp/skull may have a minor injury. A thorough assessment needs to be to ascertain this.
The patient will therefore be admitted for observations close to 24hrs. During this time the nurse needs to

monitor the vital signs, signs of impending shock, worsening of pain and other neurological signs. A
patient with brain injury is definitively in danger and the condition should be treated as an emergency.
ENVIRONMENT.
observations. It should be clean enough and well dumped dusted to prevent infections. There should be
adequate light that will facilitate easy observations in case of change of condition. The environment
should be quiet to allow the patient to have enough rest. Visitors should be allowed to visit patent but
only for short periods of time and in fewer numbers to promote rest. The patient is better nursed in a rail
bed that will prevent accidental falls as the patient attempt to turn.
POSITION
All patients with a head injury should be treated with assumption that they also have cervical spinal injury
until proved otherwise. The patient is therefore nursed on a flat hard board with head and neck kept in
body alignment.
Where cervical spinal injury has being ruled out, a 30 degree pillow may be put to prevent increased intra
cranial pressure. Generally main a clear and patent air way for adequate ventilation. As patient may be
unconscious ensure two hourly turnings to prevent pressure sore development.
REST VS ACTIVITY
Initially the patient should given enough time to rest. This helps to reduce tension and ICP.
bed bath.
OBSERVATIONS

Observe for any leakage of fluid {blood or CSF} from the ears, thorax or nose.
Observe the level of consciousness’ use the Glasgow coma scale to assess the levels of consciousness.
alternate with 5% dextrose for energy.. Keep the veins open for easy access incase of resuscitation.
NUTRITION.
The patient obtains his food through the intravenous infusion; ensure that this is supplement by NG feeds
if the patient does not have fracture of the base of the head
ELIMINATION
A urinary catheter should be left in situ for easy monitoring of out put and documentation
HYGIENE
Activities of daily living such as mouth wash body wash hair should not be abandoned.
Do routine mouth wash, bed bath, elimination, change of linen and clothes nail care etc. This helps to
prevent infections which could acquire on the ward.
A bath also helps to improve circulation of blood to vital centers of the body.
While bathing you can also observe for pressure sore development and be able to take appropriate
intervention.
Bathing will also help you to do passive limb exercises and thus be able to prevent use syndrome
MEDIACTION
Administer the prescribed drugs to the patient following the 5 ‘Rs”.
The patient will particularly benefit from manittol which reduces ICP.
Test doses for antibiotic should be done as patient is unconscious. This helps to prevent incidental
reactions.
Continue monitoring the patient for any other incidental /adverse reaction.
REHABILITATION
Develop a rehabilitation plan for the patient because of the likelihood of long term disability.
Involve the relatives or significant others through out your care plan as these patient will stay much
longer with them in a deficit situation.
Help them to copy up with realities of the condition so that they could give maximum support,
Patient should also be fully involved if he’s is in a capable position to participate in the rehabilitation
plan. This will help him come to terms with situation.
The Psychotherapist, speech therapist dietitians, physiotherapists should be involved in the care of the
patient.
IEC
Relatives should be taught to observe any usual behavior after discharge and encouraged to bring the
patient quickly to the health facility for further assessment
HERNIA
Definition
A hernia occurs when the contents of a body cavity bulge out of the area where they are
normally contained.
These contents, usually portions of intestine or abdominal fatty tissue, are enclosed in
the thin membrane that naturally lines the inside of the cavity. Although the term hernia
can be used for bulges in other areas, it most often is used to describe hernias of the
lower torso (abdominal wall hernias).
Hernias by themselves may be asymptomatic, but nearly all have a potential risk of
having their blood supply cut off (becoming strangulated). If the hernia sac contents
have their blood supply cut off at the hernia opening in the abdominal wall, it becomes a
medical and surgical emergency.
Types of abdominal hernias
Different types of abdominal wall hernias include the following:
1. Inguinal (groin) hernia: Making up 75% of all abdominal wall hernias and
occurring up to 25 times more often in men than women, these hernias are
divided into two different types, direct and indirect. Both occur in the groin
area above where the skin crease at the top of the thigh joins the torso (the
inguinal crease), but they have slightly different origins. Both of these types of
hernias can similarly appear as a bulge in the inguinal area. Distinguishing
between the direct and indirect hernia, however, is important as a clinical
diagnosis.
 Indirect inguinal hernia: An indirect hernia follows the pathway that

the testicles made during prebirth development. It descends from the
abdomen into the scrotum. This pathway normally closes before birth
but may remain a possible place for a hernia. Sometimes the hernia
sac may protrude into the scrotum. An indirect inguinal hernia may
occur at any age.
 Direct inguinal hernia: The direct inguinal hernia occurs slightly to the
inside of the site of the indirect hernia, in a place where the abdominal
wall is naturally slightly thinner. It rarely will protrude into the scrotum.
Unlike the indirect hernia, which can occur at any age, the direct hernia
tends to occur in the middle-aged and elderly because their abdominal
walls weaken as they age.
2. Femoral hernia: The femoral canal is the path through which the femoral
artery, vein, and nerve leave the abdominal cavity to enter the thigh. Although
normally a tight space, sometimes it becomes large enough to allow
abdominal contents (usually intestine) into the canal. A femoral hernia causes
a bulge just below the inguinal crease in roughly the mid-thigh area. Usually
occurring in women, femoral hernias are particularly at risk of becoming
irreducible (not able to be pushed back into place) and strangulated.
3. Umbilical hernia: These common hernias (10-30%) are often noted at birth
as a protrusion at the bellybutton (the umbilicus). This is caused when an
opening in the abdominal wall, which normally closes before birth, doesn't
close completely. If small (less than half an inch) this type of hernia usually
closes gradually by age 2. Larger hernias and those that do not close by
themselves usually require surgery at age 2-4 years. Even if the area is
closed at birth, umbilical hernias can appear later in life because this spot
may remain a weaker place in the abdominal wall. Umbilical hernias can
appear later in life or in women who are having or have had children.
Other types of hernia
1. Incisional hernia: Abdominal surgery causes a flaw in the abdominal wall.

This flaw can create an area of weakness where a hernia may develop. This
occurs after 2-10% of all abdominal surgeries, although some people are
more at risk. Even after surgical repair, incisional hernias may return.

2. Spigelian hernia: This rare hernia occurs along the edge of the rectus
abdominus muscle, which is several inches to the side of the middle of the
abdomen.
3. Obturator hernia: This extremely rare abdominal hernia develops mostly in
women. This hernia protrudes from the pelvic cavity through an opening in the
pelvic bone (obturator foramen). This will not show any bulge but can act like
a bowel obstruction and cause nausea and vomiting.
4. Epigastric hernia: Occurring between the navel and the lower part of the rib
cage in the midline of the abdomen, epigastric hernias are composed usually
of fatty tissue and rarely contain intestine. Formed in an area of relative
weakness of the abdominal wall, these hernias are often painless and unable
to be pushed back into the abdomen when first discovered.
Causes of hernia
Although abdominal hernias can be present at birth, others develop later in life. Some
involve pathways formed during fetal development, existing openings in the abdominal
cavity, or areas of abdominal wall weakness.
← Any condition that increases the pressure of the abdominal cavity may contribute
to the formation or worsening of a hernia. Examples include:
 Obesity
 Heavy lifting
 Coughing
 Straining during a bowel movement or urination
 Chronic lung disease
 Fluid in the abdominal cavity
 A family history of hernias can make you more likely to develop a
hernia.
Diagnosis of Hernia
If you have an obvious hernia, the doctor may not require any other tests (if you are
healthy otherwise). If you have symptoms of a hernia (dull ache in groin or other body
area with lifting or straining but without an obvious lump), the doctor may feel the area
while increasing abdominal pressure (having you stand or cough). This action may
make the hernia able to be felt. If you have an inguinal hernia, the doctor will feel for the
potential pathway and look for a hernia by inverting the skin of the scrotum with his or
her finger.
Hernia Treatment
Medical Treatment
Treatment of a hernia depends on whether it is reducible or irreducible and possibly
strangulated.

← Reducible hernia
← In general, all hernias should be repaired to avoid the possibility of future

intestinal strangulation.
← If you have pre-existing medical conditions that would make surgery
unsafe, your doctor may not repair your hernia but will watch it closely.
← Rarely, your doctor may advise against surgery because of the special
condition of your hernia.
← Some hernias have or develop very large openings in the
abdominal wall, and closing the opening is complicated because of
its large size.
← These kinds of hernias may be treated without surgery, perhaps
using abdominal binders.
← Some doctors feel that the hernias with large openings have a very
low risk of strangulation.
← The treatment of every hernia is individualized, and a discussion of the
risks and benefits of surgical versus nonsurgical management needs to
take place.
←
← Irreducible hernia
← All acutely irreducible hernias need emergency treatment because of the
risk of strangulation.
← An attempt to reduce (push back) the hernia will generally be made, often
with medicine for pain and muscle relaxation.
← If unsuccessful, emergency surgery is needed.
← If successful, however, treatment depends on the length of the time that
the hernia was irreducible.
← If the intestinal contents of the hernia had the blood supply cut off,
the development of dead (gangrenous) bowel is possible in as little
as 6 hours.
← In cases where the hernia has been strangulated for an extended
time, surgery is performed to check whether the intestine has died
and to repair the hernia.
← In cases where the length of time that the hernia was irreducible
was short and gangrenous bowel is not suspected, you may be
discharged.
Because a hernia that was irreducible and is reduced has a dramatically increased
risk of doing so again, , you should therefore have surgical correction sooner rather
than later.
Occasionally, the long-term irreducible hernia is not a surgical emergency. These

hernias, having passed the test of time without signs of strangulation, may be
repaired electively.
Self-Care at Home
In general, all hernias should be repaired unless severe pre-existing medical conditions
make surgery unsafe. The possible exception to this is a hernia with a large opening.
Trusses and surgical belts or bindings may be helpful in holding back the protrusion of
selected hernias when surgery is not possible or must be delayed. However, they
should never be used in the case of femoral hernias.
Avoid activities that increase intra-abdominal pressure (lifting, coughing, or straining)

that may cause the hernia to increase in size.
Prevention
You can do little to prevent areas of the abdominal wall from being or becoming weak,
which can potentially become a site for a hernia.
COLOSTOMY:
DEF:
This is an artificial surgical opening in the colon brought to the surface of the abdomen for the
purpose of evacuating the bowel which could be due to cancer colon, paralysis of the large bowel
and can be partial or permanent.
INDICATIONS FOR COLOSTOMY:

1. Cancer of the colon
2. Obstruction in the colon.
3. Patient with anal fistula
4. Paralysis of the large colon.
CLASSIFICATION OF COLOSTOMY:
1. Temporal colostomy.
2. Permanent colostomy.
TYPES OF COLOSTOMY:
 Transverse colostomy.
 Ascending colostomy.
 Descending colostomy
POST-OPERATIVE MANAGEMENT.
AIMS:
1. To prevent infections.
2. To maintain nutritional status.
3. To maintain hydration status.
4. To promote self esteem
RECEIVING PATIENT FROM THEATRE:

Post-operative care will start from the time am going to receive patient from theatre ,where I will
check the condition of the patient, for any bleeding from the incision site and if patient is awake
or not.I will also check the IV line whether in situ or not. I will also get the post operative orders
and if there is any spacimen that has been collected.
ENVIRONMENT
I will nurse the patient in the surgical ward on the post-operative bed.
I will ensure that I provide a drip stand for IV infusion.
I will also ensure that all emergency equipments such as oxygen cylinders and the suction
machine is available to use when ever need arises.
I will ensure that the environment is well dump dusted to prevent infections and promote
comfort.
I will also ensure that the environment is well ventilated to promote free circulation of air.
POSITION:
I will nurse the patient in the lateral position during the effects of anesthesia to prevent
aspiration.
Then the patient will assume position of comfort after the effects of anesthesia.
If the patient is unconscious I will turn him every two hours to prevent skin breakage.
PSYCHOLOGICAL CARE:
I will continue reinforcing the psychological as in the preoperative care to make patient accept
his condition.
I also explain what has been done in thaetre and the findings for the patient to appreciate surgery.
I will explain all the nursing procedures being done to the patient promote satisfaction and
cooperation.
I will involve the patient and relatives in the care for continuity of care after discharge.
I will also allow patient and relatives to ventilate the fears and worries and I will answer to them
correctly and truthfully.
If there is any patient who has had the same surgery, I will allow them to meet and share ideas to
make him have feeling that they can still maintain normal life.
OBSERVATIONS:
I will observe for any bleeding from the site of surgery and reinforce the dressing or inform the
surgeon if bleeding not stopping.
I will also observe for pain and do nursing interventions that relieves pain such as positioning the
patient in the comfortable position and ensuring that the bed is well made, and give prescribed
analgesia.
I will also observe the skin color from the stoma site as brown color indicates ischemia or
gangrenous formation and red color indicates normal blood supply to the area.
Normally the stoma start functioning after 3-6 days therefore I will observe for the contents,
amount color and consistency of the stoma.
I will also observe the vital signs such as temperature, pulse respirations and blood pressure to
monitor the progress of patient and I will do this ¼,1/2, hourly and then 4houry as patient
progress.
I will also observe patient acceptance of his condition and continue reinforcing the psychological
care.

COLOSTOMY CARE:
Observe color of stoma red normal but brown or dark indicates ischemia or gangrenous
formation.
Observe the skin excoriation.
Observe for patency of tubes.
Observe for function of the colostomy which normally start to function after 3-6 days.
Inform the patient about the tubes and the colostomy bug.
Care for the colostomy with aseptic technique to avoid infections.
Use nistatin powder at the stoma site to prevent fungal infections.
Observe for any oozing from the stoma site.
Change the colostomy every time it’s half full to prevent spillage of contents as it can excoriate
the skin.
Teach the patient on how to care for the colostomy for the continuity of care after discharge.
Use deodorant powder to prevent skin irritation.
Provide the patient with micro tape to help patient cover the stoma as he baths.
Educate patient to eat soft diet that is not gas forming such as beans cabbage and eggs.
However teach patient to eat diet which is rich in proteins for tissue build up, carbohydrates for
energy and vitamins to boost the immunity.
Report any excessive drainage from the stoma.
STOMA IRRIGATION:
I will also irrigate the stoma at least every day to empty the stoma from gases, mucus and faecal
matter as well as moistening the colon.
Then I will also pat dry the stoma site to prevent skin excoriation and also promote the
colostomy bag to adhere.
NURTRITION:
Encourage patient to eat diet which is not gas forming to prevent discomforts.
Encourage patient to be taking enough fluids to promote bowel movements
Encourage patient to be taking light diet that do not cause bowel irritations.
Encourage patient to be taking balanced diet such as:
Proteins: such as meat, soya porridge to promote quick wound healing.
Carbohydrates: such as rice, nshima for energy.
Vitamins: such as fruits, green vegetables to boost the immunity and promote quick wound
healing.
Teach patient to avoid eating irritating foods as they may cause bowel discomforts and odors.
ELIMINATION
Observe the intake and output to assess the patency of the stoma.
Observe the colour, consistency, and amount of stool to assess if there is any complication.
Give patient enough fluids to promote bowel movements and prevent constipation.
Give patient light diet to promote bowel movements.
Empty the colostomy bug every time it is half full to prevent spillage.
HYGIENE:
Ensure that patient is sleeping in a clean and well dump dusted room to prevent nosocomial
infections.
Ensure aseptic techniques every time you are caring out nursing procedures to prevent infections.

Always ensure that the dressings are clean to prevent secondary infections.
Teach patient to avoid touching the wound as he may introduce infections
Always change bed linen whenever it is wet or dirty to minimize infections and promote
comfort.
Perform bed bath or assisted bath if patient able to remove died epithelial tissue and promote
comfort.
Perform oral care and hair care to promote self esteem.
DRUGS:
Teach the patient about drugs they have been prescribed to promote adherence.
Give the patient drugs according to the dose, route, and time.
COMPLICATIONS:
INFECTIONS: Due to non aseptic techniques used during patient care.
HAEMORRHAGE: Due to non sutured blood vessels and infections
DIARRHOEA: Due to incomplete digestion.
ADHESIONS: Due to fibrotic formation.
PERITONITIS: Due to hemorrhage or infections.
SHOCH;Due to excessive loss of fluids and bleeding.
IEC
1. CARE OF COLOSTOMY.
2. HYGIENE.
3. NUTRITION.
4. DRUGS.
5. REVIEW DATES.
6.
NURSING CARE PLAN FOR SPINAL INJURIES
PROBLEM NURSING GOAL/ NURSING OUTCOM

DIAGNOSI OBJECTIVE INTERVENTION E
S S
1. Altered Altered To relieve  Administer humidified Dispnoea
respiration respirations dispnoea oxygen as per relieved as
s than than normal within 30 prescription to support evidenced
normal related to minutes tissue perfusion by normal
respiratory  Suction any secretions respirations
distress obstructing the airway to within 30
evidenced by encourage free passage of mins
labored air, thus aid respirations
breathing 
2. Risk of Risk of To prevent  Administer IV fluids, Shock
shock shock related shock within normal saline and prevented as
to trauma 30 mins dextrose 5% 4 to 6 L/24 evidenced
hrsto prevent by normal
hypovolaemic shock pulse rate 60
 Maintain an intake and -88 bpm, BP
output chart to monitor 120/80
hydration status of mmHg,
patient heart rate,
 Administer analgesics as
prescribed to prevent
neurogenic shock
 Offer psychological
support to client to
prevent psychogenic
shock
 Monitor vital signs;
pulse, respirations, heart
rate, blood pressure and
temperature to check any
deviations from normal
3. Pain Pain related To relieve pain  Administer analgesics Pain is
to injury to throughout such as paracetamol 1g relieved as
spinal hospitalization TDS to relieve pain evidenced
column  Avoid moving client by patient
evidenced by unnecessarily in case of verbalizing
patient fractured spinal column
verbalizing to prevent further damage
and pain
 Avoid narcotics as they
may depress respirations
in case of cervical spinal
injuries
4. immobilit Immobility To aid  Do passive exercises to Muscle tone

y related to restoration of maintain muscle tone maintained
paralysis of muscle tone  Apply warm compresses
limbs when client is to promote blood
evidenced by out of danger circulation
inability to
move
5. Altered Altered To aid client  Catheterize the client to Bowel and
nutrition nutrition less regain bowel promote hygiene and aid bladder
less than than body and bladder bladder control control
body requirement control  Schedule bladder reflex achieved as
requireme related to throughout exercises to prevent urine evidenced
nt paralysis of hospitalisation incontinence by client
bowel s and  Offer a high protein, calling for
bladder calorie and high roughage bed pan
evidenced by diet( involve the
stool and nutritionist) to promote
urine tissue healing and prevent
incontinence constipation
 Make a bowel control
program through
chemical and digital
rectal stimulation to aid
patient regain bowel
control in cases of stool
incontinence
6. Risk of Risk of To prevent  Maintain personal Pressure
pressure pressure pressure sores hygiene by frequent sores
sores sores related throughout change of soiled linen to prevented as
to hospitalization prevent evidenced
immobility  Cleanse client on by intact
related to pressure areas with mild health skin
paralysis soups and warm water to in pressure
prevent pressure sores points
 Care should be taken
when changing client’s
position to prevent
further damage
SPLEENECTOMY
1. a) Four other indications for spleenectomy.
i) Hereditary Spherocytosis:
The RBC are fragile and are easily haemolysed by the spleen. The person has a
large number of spherocytes instead of the normal erytomocytes. Spherocytes are
erythrocytes which are spherical rather than biconcave.
ii) Thrombocytopenic Purpura: a bleeding disorder that is caused by reduction of
circulating platelets. In this case the spleen is removed as it is the site of platelet
consumption to try and improve the number of circulating platelets.
iii) Leukaemia and Myelofibrosis: In these conditions the spleen breaks down the
RBCs faster than the rate of manufacture leading to anaemia. Spleenectomy helps
to control the situation.
iv) Portal Hypertension: In which case the spleen is severely enlarged, warranting its
removal.
21% for each = 8%
b) Signs and symptoms of a ruptured spleen.
i) Severe pain and tenderness in the left abdominal region due to the injury on the
spleen and exposure of nerve endings. Due to raising pressure within the
abdomen, from the internal bleeding, pain seems to be arising from the diaphragm
and radiating to the left shoulder. Abdominal tenderness will be present upon
palpation.
ii) Hypotension

and tarchycardia due to loss of blood from the system by internal bleeding, there
will be less amount for the heart to pump to all parts of the body. The heart will
therefore try to compensate by pumping faster causing a fast pulse rate, pressure
within the vessels decreases due to reduced volume of blood in circulation.
iii) Restlessness, sweating, short of breath will be present as shock pursues due to
internal blood loss. As blood supply continues to reduce to all body cells
especially to the brain tissues, patient presents with these signs and symptoms of
shock.
iv) Pallor is usually severe in the conjunctive and the palms due to rapid loss of
blood. The spleen Stores blood and once it raptures, a lot of blood which it
contains and that including from the general circulation is lost causing sudden and
severe anaemia.
v) Loss of consciousness will eventually pursue due to hypovolaemic shock.
Patient becomes comatose due to diminished supply of blood, oxygen and glucose
to the brain. This can occur very rapidly as patient looses large amounts of blood
within a short period of time.
5% for each = 25%.
c) PRE-OPERATIVE MANAGEMENT.
This is an emergency; life saving surgery so all procedures must be done quickly
and accurately with skill.
i) INVESTIGATIONS:
OBJECTIVE:
To confirm the diagnosis and to prepare for blood transfusion as quickly as

possible by:-
 Quickly obtain history from both patient if possible and from

relatives/spouse. This helps to establish part of the body the trauma was
applied. In this case they will explain that the patient was hit in the
abdomen.
 At the same time quickly collect blood for Hb, grouping and cross match
at least 2 pints of blood. This must be ready quickly before patient goes to
theatre.
 If possible an abdominal X-Ray and ultra sound is quickly done to
establish the internal bleeding or to rule out other causes of acute
abdomen.
 Physical examination to be done quickly but gently to try and palpate the
spleen. This may be difficult as the patient will be tense with muscle
guarding due to pain and tenderness in the abdomen. The conjunctive and
palms to be inspected for degree of pallor to try and assess anaemia due to
severe internal bleeding.
 Spleenic angiography-may be done if time and facilities allow to
visualize spleenic blood vessels.
2% for each = 10%.

ii) NURSING MANAGEMENT
OBJECTIVES

To rescuccitate Mr Nyoni quickly so that he is fit for operation.

To alley anxiety

To obtain consent

To provide physical preparation before the operation.
2%
RESCUCCITATION
Quickly provide a bed at the acute bay or intensive care unit. Upon patients
arrival on the ward, put up an I.V line of normal saline to help maintain arterial
pressure while waiting to transfuse. Blood transfusion is usually prescribed by the
doctor immediately even before patient goes into theatre. This must be
commenced as soon as blood is ready to prevent further shock as patient is having
internal bleeding. Blood transfusion and /or I.V fluids must be maintained to ease
breathing as prescribed. If very dyspnoec oxygen may be administered. 4%
PSYCHOLOGICAL CARE
Explain the condition of the patient to both him and the relative/spouse. That the
spleen has ruptured, internal bleeding is taking place due to the trauma. That
there is no option but to surgically remove the spleen to save Mr Nyoni’s life.
The abdomen will be opened up and the spleen removed. Reassure them that
there will be no effect /change to his normal life even after removal of the spleen.
Explain what patient expects to see and experience in theatre and after the
operation the anaesthesia and its possible side effects the doctor and anaesthetist
must take time to explain to the patient. 4%
OBTAIN CONSENT
After explaining and convincing the patient or relatives if possible, obtain written
consent. Patient must sign if he is able or spouse/relatives. 2%
OBSERVATIONS
To be done admission, then quarter hourly and as baseline data before taking
patient to theatre vital signs are observed as well as patients general condition.
This is important to detect if internal bleeding is getting worse in order to decide
on what resuscitative measures to take. State of shock and level of consciousness
must be observed to rule out comatose.
As patient is on blood transfusion do blood transfusion observations of vital signs
¼ hourly and carefully- If available, patient is observed continuously using
cardiac and respiratory monitors. Monitor and balance fluid intake and out put.
Record all observation findings and report to charge nurse/doctor every time they
are done until patient is taken to theatre 5%

PRE-MEDICATION
The surgeon may prescribe pre-medications like a shot of cover antibiotics which
must be given. It is mandatory that the anaesthetist must immediately see the
patient upon arrival on the ward. Inform the above two immediately patient
comes to the ward. The anaesthetist may order urgent pre-meds like atropine to
reduce secretions or valium or any sedative to relax the patient. 3%
PHYSICAL PREPARATION
 SKIN PREPARATION: Quickly clean the patient if necessary wipe

out all dirt or blood.
 Shave the abdomen from below the umbilicus up to the mid thigh and
clear skin thoroughly with soap and water then with a disinfectant to
minimize risk of infections during and after surgery. 4%
 CATHETERIZE: The patient with an in dwelling catheter to
continuously drain the bladder during surgery to avoid injuries from its
pressure if it fills up. 3%
 NG tube to be passed to aspirate and empty the stomach as this is an
emergency surgery. The tube can be removed after emptying the stomach.
This is done to avoid aspiration when the patient is unconscious and under
anaesthesia during and after the operation. Patient must be kept nil orally
from admission. 4%
 SAFETY of patient and property must be maintained at all times. ID
bands to be labelled correctly put into the wrist of the patient. remove all
jewellery and dentures and store in a locked cupboard or give to
relatives/spouse. 4%
PREPARATION IMMEDIATELY BEFORE TAKING PATIENT TO THEATRE.
 Change patient’s clothing into theatre gown. Check vital signs for
baseline data.
 Collect all the case notes, X-ray films, ultra sound results and carry to
theatre.
 Carry the already cross-matched blood for use in theatre as well as all
other laboratory results if ready.
 Using a stretcher escort patient to theatre while talking to him and his
relatives to reassure them. Wish him well and tell him that everything
possible is being done to ensure that all goes well.
 Hand over everything to theatre staff
 Back on the ward make Mr Nyoni’s post operative bed. Prepare and keep
post operative tray and all the necessary accessories next to the bed. The
oxygen and suction machines. If available make sure the respiratory and
cardiac monitor are working well.
5%
Total 40%

d) COMPLICATIONS OF SPLEENECTOMY
i) Haemorrhage:- If Some blood vessels were not well closed during the
operation, they will cause continued internal bleeding. This if not
managed early enough can proceed to anaemia or shock. 4%
ii) over whelming life- threatening post Spleenectomy infection caused by
streptococcus, pneumococus, Nesselia meningitides or Haemophilus
influenza. These bacteria take advantage of the large raw area from which
the spleen was removed and if poor aseptic techniques are used eighteen
on the ward during dressings or in theatre during the operation. Hence the
critical need for:
-Early ambulation
-Cover antibiotics
-Aseptic techniques of dressing 5%
iii) Pancreatitis and fistula formation: due to its proximity to the spleen, the
pancreas may end up with an infection or fistula from the spleen site. This
may later end into diminished insulin production causing diabetes
mellitus. 4%
iv Atelectasis and pneumonia may also develop due to the proximity of the
lower lobe of the left lung to the spleen. These may occur as a result of
surgical maneuver and infection respectively. 4%
Total = 17% Grand total = 100%
BURNS
Definition.
This is tissue damage caused by such agents as heat, chemicals, electricity, sunlight or nuclear
irradiation as a result of the transfer of heat energy from a heat source to any body part. Heat
can be transferred through conduction or electromagnetic radiation. Thus, burns may be
categorized as thermal, radiation or chemical burns.
Causes.
Burns are caused by;

 Heat {dry heat, moist heat}
 Chemicals
 Electricity
 Irradiation
Pathophysiology of burns
The destruction of tissue results from coagulation, denaturation, or ionization of cellular

contents. The skin and mucosa are particularly sites for skin destruction while deeper tissues
and visceral are usually damaged by electrical burns or prolonged contact to a heat source.
Disruption of skin leads to increased loses of fluids, infection, hypothermia, scarring,
compromised immunity, and changes in function, appearances and body image. Exposure to
the nerve endings is the cause of severe pain in superficial burns while little or no pain occurs in

deeper layers. Fluid loses account for the exudates and blister formation. Once pathogenic
microorganism gain access to the wound, necrosis occurs and pus formation results. The body
temperature is elevated because of infection.
1. Description of Burns by extent of body area injured
Various methods are used to estimate the total body surface area {TBSA} affected by burns.
Among them are;
 Rule of nines[Wallace}
 The Lund and Browder method
 The palm method
Estimating Percentage of Total Body Surface Area
The Lund-Browder chart is the most accurate method for estimating burn extent, and must be
used in the evaluation of all pediatric patients.
LUND-BROWDER CHART
Relative Percentage of Body Surface Area

Affected by Growth
Age in years 0 1 5 10 15 Adult

A-head (back or front) 9½ 8½ 6½ 5½ 4½ 3½
B-1 thigh (back or front) 2¾ 3¼ 4 4¼ 4½ 4¾
C-1 leg (back or front) 2½ 2½ 2¾ 3 3¼ 3½
If you chose to use the “Rule of Nines” for adults:

{Wallace rule of nines}
An estimation of the TBSA is done by assigning percentages in multiples of nine to major body
surfaces. It is a simplified and quick way of calculating the extent of burns.
{See Draw a diagram of rule of nines below}
Palm trick- {Palm method}

This is used in patient with scattered burns; the palm size is used and stands for it is
approximately 1% of the TBSA i.e. Use the patient’s palm size to represent approximately 1%
TBSA. Imagine a rectangle the width and length of your entire hand (from wrist to fingertips)
and that is the size of “one palm.”
HAIR Classification of Burns {revise diagram on the structure of the skin}

SHFT
SWEAT EPIDEMIS
SPORE

BLOOD
VERSEL
DERMIS
HAIR
SHRFT
SUBCUTE
NEOUS
Burns can be classified according to the depth of injury and the extent of body surface area
SWEAT
SEBACIOUSinjured. NERVE ERECTAPILLI
GLAND
GLAND MUSCLE
2. Burn depth
Classification of burns according to depth of tissue destruction is as follows;
 Superficial partial- thickness or { 1st degree burns}

 Deep partial –thickness or {2nd degree burns}
 Full thickness or {3rd degree burns}
{i} Superficial partial thickness or 1st degree burns.
This is where the epidermis is destroyed or injured. A portion of the dermis may be injured as
well.
{ii} Deep partial thickness or 2nd degree burns
These involve destruction epidermis and upper layers of dermis and injury to deeper portions of
the dermis. The wound is characterizes by pain, appears red and exudates fluids. Capillary refill
follows tissue blanching. Hair follicles remain intact. Deep partial thickness burns take longer to
heal and are more likely to result in hypertrophic scars
{iii} Full thickness burns
Involves total destruction of epidermis and dermis, and in some cases underlying tissues as
well. The wound colour ranges widely from white to red, brown or black. The burnt area is
painless because the nerves are destroyed. The wound appears leathery; hair follicles and
sweat glands are destroyed
Estimation of Burn Depth cont or may be discussed as follows; first, second or third degree.
Superficial Burns
 Superficial First Degree-

Injury involving only the outer epidermis layer. Erythema and mild discomfort. Resolves in 48-
72 hours with comfort measures. Healing is uneventful.
 Superficial Second Degree-

The entire epidermis and upper third of the dermis are destroyed. Vessels leak plasma which
lifts off the epidermis, causing blister formation. Wounds are pink, wet, and very painful. Heals
within two weeks via repopulation of epithelial cells present in skin appendages and the deep
dermis.
Deep Burns
 Deep Second Degree-
The injury extends into the dermis, leaving few viable epidermal cells. Re-epithelialization is
very slow. Wounds require months to heal. Blisters do not form because the dead tissue layer
is thick and does not easily lift off the surface. Wounds are red with scattered deeper white
areas throughout. The marked decrease in blood flow makes the wound very prone to
conversion to a third degree wound. Dermal necrosis with coagulated proteins turns the wound
a white to yellow colour (called coagulum). Should the coagulum get infected an ischium or
covering develops over the skin to prevent further destruction of underlying tissue and enhance
re-epithelisation.
The skin get a Topical antibiotics can add to this colour change and make the wound difficult to
differentiate from a third degree burn. Wound breakdown is common since the rete pegs have
been destroyed; thus, what little epidermis is left is thin and not well adherent. Dense scarring
is seen if the wound heals primarily.
Third Degree - A full thickness burn.
The entire epidermis and dermis are destroyed. No epidermal cells present for re-
epithelialisation. Initially, wound appears waxy and white, unless burn extends into the fat, in
which case a leathery brown or black appearance is seen along with coagulated subcutaneous
veins. The wound is painless and will not heal unless very small (smaller than 2 X 2cm).
Other Burn Injuries
Chemical Burns
These burns cause progressive tissue damage until inactivated or flushed with water. Acids
cause protein coagulation, limiting further penetration. Whereas alkali burns combine with
cutaneous lipids causing tissue saponification, which continues to injure the skin. Until proven
otherwise, chemical burns should be considered deep.
Electrical burns
Electrical injuries are of three major types which may occur in combination:
1) True electrical injury exists when electricity passes through the body. An entrance and exit
wound is produced, along with significant deep-tissue destruction. The quantity of heat
produced is expressed in Joule’s Law: J=I2RT, where (J) is the heat produced, I is the current,

R is resistance, and T the duration of contact. Therefore when performing the history and
physical examination, record the voltage and duration of contact with the source.
2) ARC burns occur when electrical current jumps from one part of the body to another,
producing scattered spots of injury which may be deep
3) Flame burns are caused by sparks sufficient to ignite clothing

High-voltage, high-current source electrical injuries (>1000 volts and >5000mA) cause
significant soft tissue damage. Low voltage, low current (<1000volts and 5-60mA) cause less
soft tissue damage but are noted to more commonly cause cardiac fibrillation.
Complications of electrical injuries include tetanic muscle contractions with resulting muscle
fractures and dislocations, or falls with crush injuries. Intraperitoneal damage occurs, perhaps
due to the low-resistance mesenteric vascular system. Cardiac dysfunction may be seen initially
in as many as one third of electrically injured patients, and ECG changes may be present,
[i] including RBBB, SVT, and other focal ectopic dysrhythmias.
[ii] Electrical injuries may also cause delayed neurologic changes and cataract formation.
Radiation burns
Accidents involving ionizing radiation are not common. Most frequently they are the result of a
local accident (laboratory), from an industrial accident (Chernobyl, Russia in 1986), or from the
detonation of a nuclear device.
Whole-body exposure of more than 100 rads causes acute radiation syndrome, marked by
nausea, vomiting, diarrhoea, fever, fatigue, and headache within hours of exposure. This is
followed by a latent period, and then by hemopoietic, GI, and vascular complications.
NURSING CARE/MANAGEMENT:
Objectives:
 To prevent shock
 To improve tissue perfusion
 To relieve pain
 To prevent infection
 To allay anxiety
 To prevent complication e.g. contractures
 To promote wound healing
(i) PSYCHOLOGICAL CARE:
 Relieve anxiety to promote mental health

 Explain procedures and educate the patient to understand the on going treatment and future
plans.
 Allow the patient to express his feelings to maintain sense of hope and positive body image
 Help patient to focus on positive aspect of self
 Any other related
(ii) PREVENTION OF INFECTION:
 Prevention of infection starts at the time of admission hence put patient in a clean bed.
 Injury to the skin destroys the body’s first line of defence thus infection sets in easily. Important
to clean wound on regular basis.

 Use aseptic technique and sterile gloves during wound care.
 Care for the patient in a special burns unit
 Give high protein foods to boost immunity
 Identify and monitor signs of infection: fever, Tachycardia, change in mental state.
 Prevent exogenous infection by not allowing any one with infectious disease near the patient (Mr.
Mayeso) (give 1% each for any 5 points-Max-5%
(iii) PROMOTING SKIN INTERGRITY:
 Daily inspection and cleaning of the wound

 Remove the Escher (slough) to support healthy tissue regeneration because slough contains dead
tissue, moisture and warmth that are conducive media for microbe’s growth.
 Saline bath is more comfortable method of removal of dressing.
WOUND CARE
(iv) Methods of Treatment: Depending on the location of burn, its size and depth.
a) OPEN OR EXPOSED METHOD
 Isolation technique is essential

 When nursing the patient, wear sterile gown, mask and apron, sterile linen may also be
put on the bed.
 Patient may experience a lot of pain give controlled administration of morphine sulphate.
 Minimise discomfort-patients loose more heat from burned surfaces than normal skin.
 Humidity of the room should be controlled.

(b) SEMI OPEN METHOD:
 Covering the wound with topical antimicrobial agents.
 A thin layer of gauze is used to cover the wound
 Clean the wound once or twice daily
(c) CLOSED OR OCCLUSIVE METHOD
 Wounds are cleaned and dressings changed at least once or twice daily.
 Promote mobility by 2nd day of injury-Any delay may result in contractures.
 Topical agents applied to the wound, help decrease infection and fasten wound healing.
The agents include: Silverdene, Silver, Nitrate, Providone, Furacin, Geramycin, and
Neomycin.
(v) THERAPEUTIC POSITIONING:
 Place the body parts correctly in anatomical position to present deformities.

 Apply splint currently if indicated
 Assess always the splinted limbs for adequate circulation, or cyanosis.
 Complaints of pain and pressure must not be ignored
(vi) EXERCISES AND AMBULATION
 Exercises of the arm when condition allows, to prevent and correct contracture
 Involve physical and occupational therapist
(vii) NUTRITION
 Give high protein diet, vitamins and vegetables for tissue repair.
 Ensure adequate nutritious fluids.
(viii) HYGIENE
 Daily bath-to prevent infection and promote self-esteem

 Oral care-to promote appetite and prevent oral infection
 Hair care-for self-esteem
 Nail care-to prevent injury
 Hygiene care necessary for maintaining body integrity.
(ix) OBSERVATIONS
 Temperature
 Pulse
 B/P
 Respiration
 Observe for any complaint (s) about pain or pressure on the limbs,
 Observe for cyanosis.
 Assess the wound healing process
 Observe whether patient is having good sleep and rest
 Assess for appetite and nutritional status.
(x) ELIMINATION PATTERN
 Monitor the intake and output and record the findings on the appropriate chart.
 Any deviation (e.g. constipation), in the normal bowel motion should be reported.
(xi) REST AND SLEEP
 Time your procedures in other to minimise disturbance

 Give prescribed pain reliever.
(c) COMPLICATIONS OF BURNS
 Hypovolaemic shock
 Neurological shock
 Infection
 Contractures
 Loss of body image
 Damage to organs
 Anaemia
 Anuria
 Renal failure
 Paralytic ileus
 Dehydration
(d) OUTLINE SEVEN (7) POINTS TO BE INCLUDED IN THE LESSON TO BE GIVEN TO THE
COOKS AT LUANGWA LODGE ON BURNS
(i) CAUSES OF BURNS
 Electrical burns-Heat generated from an electric current.

 Thermal burns-Contact with hot objects, flame, scald, hot cooking oil.
 Chemical burns-contact with chemicals that are noxious.
 Smoke/inhalation burns-as a result of inhalation of hot air, smoke (from burnt food) or
noxious chemical thus burning the respiratory tract.
(ii) CLASIFICATIONS OF BURNS
 Superficial
 Deep
(iii) FIRST AID TREATMENT
 For flames- stop the flame by covering with a blanket

 For hot liquid-pour cold water on the spot
 For fumes-place outside for oxygenation
(ix) PREVENTION OF BURNS

 Do not leave cooking oil burning on the stove or frying meat with a lot of fat in thatched
house
 Do not hold hot pans with bare hands
 Switch off electrical appliances when not used and when closing the hotel kitchen
 Use first Aid measures to put off fire e.g. use of sand, blanket.
 Ensure that extinguishers are always functioning
 The hotel kitchen must have a fire point.
1. PREVENTIVE MEASURE OF BURNS (TO THE COMMUNITY)
1. Avoid sleeping with fire on – candle, brazier

2. Switch off electrical appliances when not used
3. When bathing a baby put cold water first before hot water and test the water.
4. Do not leave boiling pots and a small child alone
5. Do not sleep in the same room with tins of petrol or diesel
6. Do not smoke in bed
7. Use first aid measures to put off fire-use of sand, blanket switch off.
8. Do not leave children playing with fire near a thatched house.
9. Do not leave cooking oil burning on the stove-or drying meat with a lot of fat in a
thatched house.
10. do not hold hot pans with bare hands.
2. COMPLICATIONS OF BURNS
1. Hypovolaemic shock
2. Infection
3. Contractures
4. Loss of body image
5. Damage to the organs
6. Dehydration
7. Anaemia
8. Anuria
9. Neurological shock
MANAGEMENT OF WOUNDS.
Objectives of wound management.

 To remove necrotic tissue
 To promote wound healing
 To protect new skin growth from disruption

There are basically two methods of wound management.
 The closed method
 The open method
The closed method is where by the entire wound is cleaned and covered by dressing, whereas in an open
method the wound is cleaned and left open.
The advantages of using the closed method are as follows;

1. It promotes healing by absorbing drainage and debriding the dead tissue
2. It protects the wound from contamination from microorganism
3. It aid in heamostasis through the application of pressure against the tissue
4. It aids in approximation of the wound edges
5. It reduces immobility by splinting and supporting the wound
6. It covers disfigurement
The disadvantages of the closed method are
It creates a reservoir for microbial growth
The enclosed tissue may become compressed and cause nerve or vascular damage if edema occurs
The dressing may cause irritation and disruption if the dressing pulls or rubs against the skin
Open method
The advantages of the open method are
 It reduces or eliminates a reservoir for microbial growth
 It reduces the irritation and friction against the wound and the skin surrounding the wound
 It aids in drying the wound
The disadvantages of the open method are as follows

 It does not immobilize a body part when that is necessary for wound healing
 I does not aid in wound approximation of wound edges
 It permits ready access for potentially harmful micro-organisms the open wound
Dressing techniques.
Wet –to- dry dressing: Wet to dry dressing consist of a moistened dressing that is packed into the wound
area. The wet layer is then covered with a dry layer. The wet layer is allowed to dry between the dressing
changes there by allowing the wet gauze to trap the necrotic tissue and drainage as it dries, such that when
the dressing is removed, debris is also removed. There fore these can applied to debride the wound,
promote healing and to enhance absorption of wound drainage. This type of dressing is used on wounds
that are extensive and will heal by secondary intention. This is a treatment of choice in wounds with large
amounts of drainage or those that require dedridement .are must be taken not to over wet the dressing s it
can cause skin maceration or increase the risk of bacterial growth. The disadvantage of this is that it
promotes medium for bacterial growth.
Dry –dry sterile dressing: These are applied to prevent wound from contaminating and from injury. Dry
dressing absorbs nonviscous exudates and provide for mechanical debridement of the wound .They are
usually applied to wounds that are healing by primary intension such as abrasions and post surgical
incisions. The dressing are usually applied in three layers, the firs layer, which is next to the skin or
wound, is a contact dressing of gauze or non adherent gauze, the second is a layer of gauze that absorbs
exudates and the third is a thick heavy dressing such as a composite pad or abdominal pad that protects
the wound from contaminants externally.
Transparent dressing

These are applied over an uncontaminated, debrided wound. It is applied wrinkled free but not stretched
too tightly over the skin If signs of infection occur the dressing is removed and a dressing applied
Pressure dressing
These are applied to prevent bleeding after injury, to temporally treat uncontrolled bleeding, to provide
support for skin graft and to support underlying structures following surgery.
Technique Advantages Disadvantages

Dry –to –dry Debrides mechanically Painful upon removal
Absorbs nonviscous exudates May detach viable epidermal
Is cost effective tissue
May cause
desiccation{drying}
Wet – to dry Debrides mechanically Painful upon removal

May detach viable epidermal
Dilutes and absorbs viscous tissue
solution
Less likely to cause
desiccation
Is cost effective
Wet – to damp May be used with medicated Less effective for mechanical
solutions debridement
Unlikely to cause desiccation Less absorptive
Unlikely to cause pain May macerate tissue
Upon removal Increases risk of bacterial
Dilutes viscous exudates growth
Requires accurate timing for
dressing changes
Wet – to wet Least painful Les effective for mechanical
May be use with medicated debridement
solutions May macerate viable tissue
Provides continuous cleaning Greater risk for bacterial
of wound, dilutes exudates growth
Does not cause wound Little absorption properties
desiccation
Transparent or synthetic Rapidly liquefies necrotic Requires close monitoring for
dressing tissue signs of infections
Cause s little pain upon Very costly
removal
Complications of wounds
Wound complication results when an unexpected physiologic or mechanic even t delays the healing
Two of the most common complications of wounds are
 Excessive bleeding
 Infection

Some bleeding occurs through the wound but it is checked by heamostasis, blood clotting that is
accomplished through a physiological coagulation or mechanical pressure applied over the wound.
Excessive bleeding is prolonged, unstoppable bleeding ranging from oozing to profuse bleeding.
Wound infection occurs with contamination of the tissues although treatable with antibiotic, infection
delays the healing process and prolongs the client’s recovery from injury.
Mechanical complications are dehiscence and evisceration
Wound dehiscence is the separation of the wound edges while evisceration is the protrusion of abdominal
contents through an open wound or incision
The Wound healing process
Surgical wound healing occurs in three phases.

 The inflammatory phase
 Proliferative phase
 Maturation phase
The inflammatory phase
This is also called the lag or exudate phase. It lasts for a period of about 1 to 4 days
During this phase, there is blood clot formation, the wound becomes edematous and
the debris of damaged tissue and blood clot is phagocytosed.
The Proliferative phase

This is also called the fibrotic or connective phase. It lasts for about 5 to 20 days.
During this phase there is collagen formation; granulation of tissue occurs an wound
tensile strength increases.
The Maturation phase also called differtiation or remodeling, resorption or plateau

phases.
It lasts for about 21 days to a month or even years.
During this phase fibroblasts leave the wound tensile strength increases the collagen
fibers reorganize and tighten to reduce scar size
Wounds also heal by different mechanism; depending on the condition of the wound.
These conditions include healing by first intension, second intension or third intension.
First intention
Wound made aseptically, with a minimal of tissue destruction and properly closed heal
with little tissue reaction by first intension. This is also called primary union.
When wounds heal by first intension granulation is not visible and scar formation is
minimal
Second intension healing {Granulation} occurs in the infected wound {abscess} or in

wounds in which edges have not been approximated. When an abscess is incised it
collapses partly but the dead and drying edges cells forming its walls are still being
released into the cavity. Gradually the necrotic material disintergrates and escapes and
the abscess fills with red soft sensitive tissue that bleeds easily. These tissues comprise
minute thin walled capillaries and bud that later form connective tissue. These buds
called granulation enlarge until they fill the area left by the destroyed tissue. The cells
surrounding the area change shape to become scar. The healing is complete when skin
grows over these granulations.
This kind of repair is called healing by granulation and takes place whenever pus is
formed or when ever loss of tissue has occurred for any reason.
Third intention healing
{Secondary suture is used for deep wounds that have either not been sutured early or
that break down and are resutured later thus bringing together two apposing
granulation surfaces. This results in a deeper a wider scar
Factors necessary for wound healing
As wound heals many factors such as adequate nutrition cleanliness rest and post
determine how quickly healing occurs.
Factors that affect wound healing
 Age of patient
 Hemorrhage
 Hypovolaemia
 Nutritional deficits
 Foreign bodies
 Oxygen deficit
 Medication such as corticosteroids which mast the presence of infection thus
impairing a normal inflammatory response
 Anticoagulants may cause hemorrhage
 Broad spectrum antibiotics only effective if administered before surgery
 Patient over re- activity
 Wound stressors
 Heavy coughing
 Vomiting
 Straining
 Sepsis
 Hepatic failure
 Hypoxia
 acidosis
This is an abnormal growth of the breast tissues which could be benign or malignant
characterized by painless lump and blood discharge.
CAUSES OF BREAST CANCER:

 The real cause of breast cancer is not known however there are predisposing
factors such as:
 Family history of breast cancer.
 Excessive intake fats diet.
 Exposure to radiations.
 Early menarche before the age of 12years.
 Late menopause after 55years.
 Smoking.
 Alcohol ingestion.
 Nulli palous.
 Having the first child after the age of 30years.
SIGNS AND SYMPTOMS:

 Retraction of the nipple.
 Painless lump.
 Blood discharge from the nipple.
 Swelling of the anxilliary lymphnodes.
 Skin changes (peau ‘d’ orange.
 Palpable nodes on the breast.
STAGING OF BREAST CANCER:

STAGE=0
This is the non invasive stage of cancer and not palpable (carcinoma in situ).
STAGE=1
The growth is localized to the breast and mobile and it is less than 2cms.
STAGE=2
The lump become fixed to the breast and is more than 2-5cms.
STAGE=3
The cancer cells spreads to the surrounding tissues and anxillaly lymphnodes.
STAGE =4
The cancer cells spreads to other distant organs such as the liver lungs through
blood and lymphnodes.
INVESTIGATIONS THAT CAN BE DONE TO DETECT BREAST CACER;

 History taking - that would review that there is cancer in the family.
 Physical examination that would review lump and dimpling of the breast.
 Mammography which can detect cancer which is too small to be palpated.
 Fine needle aspiration and biopsy for histology to detect cancerous cells.
 Ultrasonography which can distinguish between fluids filled cyst and a
solid mass.
 Chest x-ray which can pin point if there is spread to the lungs.

 Scan of the bone,brain,liver,and other organs to detect if there is
metastases.
MASTECTOMY:
DEFINATION;
This is the surgical removal of the whole breast tissue, which may be
lumphectomy, partial mastectomy, total mastectomy, modified radical
mastectomy or radical mastectomy.
APPROACHES USED FOR MASTECTOMY:
LUMPHECTOMY:
This type of surgery is used to patient with small well defined lesions. The lesion
is removed through a small incision made near the nipple. The surgeon removes
the tumour, surrounding tissue and possibly near by tissues, typically the patient
will under go radiotherapy after lumpectomy.
PARTIAL MASTECTOMY:
The surgeon removes the tumour along with wedge of normal tissue, skin, fascia,
and possibly anxillaly lymphnodes, radiotherapy or chemotherapy usually follows
after surgery to destroy undetected disease in other breast areas.
TOTAL MASTECTOMY : ( SIMPLE MASTECTOMY)

This is the removal of the entire breast, the surgeon uses this procedure if the the
cancer appears confined to breast tissue and no lymphnodes involvement is
detected, the surgery may be followed by chemotherapy or radiotherapy.
MODIFIED RADICLE MASTECTOMY:

The surgeon removes the entire breast, anxillary lymphnodes and the lining that
covers the chest muscles. If the lymphnodes contains cancer cells, radiotherapy
and chemotherapy follows the surgery.
RADICLE MASTECTIMY:
This is when the surgeon removes the entire breast, the surrounding tissues,
anxilary lymphnodes, pectoris major and the pectoris minor muscles.
POST-OPERATIVE CARE:
 ENVIRONMENT.
 POSITION.
 PAIN MANAGEMENT.
 OBSERVATIONS.
 PSYCHOLOGICAL CARE.
 CARE OF WOUND.
 EXERCISES.
 NUTRITION.

 HYGIENE.
 ELIMINATION.
INFORMATION, EDUCATION AND COMMUNICATION:

 Teach patient about sexual life.
 Inform patient about the need for physiotherapy.
 Inform patient about the prosthesis.
 Advise patient to stop taking alcohol.
 Advise patient on drug adherence.
 Inform the patient on follow up care.
 Advise patient on diet.
 Advise patient to stop smoking.
 Advise patient on hygiene.
 Teach the patient on how to do self breast examination.

CARCINOMA OF THE STOMACH

A) (I) DEFINE CARCINOMA
A malignant tumour whose origin is from anaplastic epithelial Cells or safuamous

epithelium. (5%)
A (ii) List 5 clinical features of caranona of the stomach (10%).
1. Feeling of malaise
2. Increasing fatique
3. Slight loss of appetite
4. Epigastric pain
5. Vomiting
6. Pallor
7. Marked weight loss.
8. Small haematemisis GIVE 10% FOR FINE POINTS
B. INVESTIGATIONS
1. Barium meal will reveal the tumour

2. Gastroscopy and Biopsy to identify concer cells
3. Gastric aspirate will reveal cancer cells
4. Gastric Secretion will reveal abnormal HCl secretion
5. Stool examination for occult blood. 3% for each point to make 15%.

C. POST OPERATIVE NURSING CARE:
OBJECTIVES: 1. Return to normal physiological functions (1%)
Ventilation: (5%)
Ensure that the patient is breathing through a patent airway. Place the patient in a
postoperative position to ensure patent airway and continued breathing. Suction PRN for
patent airway 1%.
The patient lies flat without a pillow and the head is tilted to one side. 3%.
VITAL SIGNS AND OTHER OBSERVATIONS: (5%)
1. BP, Pulse rate, Respiration rate and general condition are monitored and assessed 1/4
hourly for 1 hour if stable, 1/2 hourly for 1 hour, if stable 1 hourly for 2 hours, if stable 2
hourly and finally 4 hourly.
- Check the wound dressing for any bleeding and tightness of the bandage.
- Check the state of I.V line to ensure that it is running well. 1%.
MANAGEMENT OF PAIN: (4%)
Narcotics such as pethidine is given according to doctor's order to alleviate pain from the wound.
Encourage good comfortable
Position in bed and change of position to reduce discomfort 3%.
-Advise Mr. Miti to support the wound with his hand when coughing and sneezing to reduce the
strain on the incision. 1%.
PSYCHOLOGICAL CARE: (3%)

Explain the surgery done, all procedures being done and the reason for doing them. 1%.
Explain the reason for withholding food and for small frequent meals when food is commenced
as part of stomach which is a food reservoir has been removed. Explain other dietary changes
such as thorough chewing of food. Give him moral support, as he is lonely, and involve friends
and close relatives. (1%).
CARE OF NASOGASTRIC TUBE (7%).

Aspiration of gastric contents is done hourly. 1%
The early aspirates consist of bright red blood which in a few hours changes to dark blood.
1%.
This is modified to prevent suture line trauma 1%

In 24 hours, the aspirate should be bile stained looking darker
- The nurse should note the :-
 Colour changes
 Consistency of drainage
 Amount and record and report 1%
- Maintain patient's comfort while he has the tube.
- The tube should be gently cleaned to remove crystals, which can cause sores on
the external nares, which should be lubricated. 1%.
- After cleaning 30mls of clear water is instilled into the tube and the stomach is
aspirated an hour later and is recorded as intake. 1%
- The nasogastric tube is left in sit until normal emptying of the stomach occurs.
1%
EXERCISES AND AMBULATION (2%)

Early ambulation by the 1st day post OP, then Chair, around the bed and in the ward, to prevent
deep vein thrombosis and chest infection.
THE DRAINAGE TUBE: (4%)

Ensure that it is secure and left in still even after 48 hours. 1%
- It helps in the removal or expulsion of any discharges which if retained can cause distension or
infection. 1%
Observe for any discharging of bile and should be reported to the doctor immediately.
Shortening of the tube is done as discharge reduces. 1%
- Removed on the 5th day. 1%
CARE OF URINARY CATHETER: (1%)

Catheter toilet to be done aseptically to prevent ascending infection. 1%
NUTRITION FLUIDS AND ELECTROLYTES: 5%

The intravenous fluids are administered as ordered for the purpose of replacing electrolytes and
fluid loss through bleeding and for provision of nutrition. 1%

The patient is not given anything orally until the bowel sounds are heard, possibly the whole first
48 hours. 1%
Firstly normal saline would be ordered, thereafter 5% dextrose. 1%
Feeding may start after 3 days with sips of water, fluids and her diet to allow the stomach to heal.
2%
WOUND CARE: 3%
The wound is left intact until the doctor removes the 1st dressing on the 2nd day post operatively
1%
However, observations are made for bleeding and if observed apply pressure by more dressings
and inform the doctor. This is either primary or reactionary bleeding. 1%
Thereafter dressings are done aseptically to prevent wound infection using disinfectant.
HYGIENE:
- Bed bath will be done on the 1st day post operatively to promote skin integrity, circulation and
self-esteem. 1%
ORAL TOILET: 3%
Frequently oral care must be done because the patient is breathing through the mouth and the
mouth is dry. The frequent mouthwashes stimulate salivation. 1%
The teeth and the tongue to be brushed to prevent stomatitis and gingivitis. 1%
Ask the patient to gargle water to combat the feeling of dryness on the throat. 1%
PRESSURE AREA CARE: 3%

 Pressure areas are massaged with lubricant to promote circulation and to prevent decubitus
formation.
 Keep the bedding and dry straight
 Turn the patient frequently to prevent pressure. 3%
HEALTH EDUCATION: 2%
 Teach about disease process and surgery done.
 Teach on diet modification. 2%

ELIMINATION 4%
- The aspirate from the NG tube be recorded as out put. 1%
- The patient will have a catheter, whose contents be measured and observed according to
sediments, colour and volume. 1%
This is to be recorded as output on the fluid balance chart and balancing must be done to ensure
no over hydration or under hydration occurs. 1%
- Patient may not pass any stool in the 1st 48 hours because he went to theatre starving and is still
starving. When bowels sounds starts, patient should start to pass stool. If not laxatives be given
to prevent constipation. 1% TOTAL MARKS: 40%
STAGE 4:
E: AN OUTLINE OF 5 POINTS TO INCLUDE IN HEALTH EDUCATION.
1. Disease process
2. Surgery done
3. Psychological care
4. Physical rest
5. Dietary changes
6. Post gastrectomy complications
7. Prevention of complications
8. Life long treatment. 1% for each.
1. DISEASE PROCESS:
To explain the pathophysiological changes that occur as a result of the disease e.g. weight
loss, loss of appetite, etc. 5%
2. SURGERY DONE:
To explain the partial removal of the stomach for the purpose of removing the tumour. 5%
3. PSYCHOLOGICAL CARE (OR IMPORTANCE OF)
To explain the need to have emotional rest to reduce hyperacidity which could further
damage the already diseased stomach. To develop a calm attitude. 5%
4. PHYSICAL REST: (IMPORTANCE OF)
To advise the patient to have enough physical rest as the diet will not of the same amount of
food to promote recovery from the operation. 5%
5. DIETARY CHANGES (NEED FOR)

Explain the need to avoid irritating food but to take plenty of non-irritating food at frequent
intervals because of the change in size of the stomach. 5%
6. POST GASTRECTOMY COMPLICATIONS:
To explain the post gastrectomy complications such as the dumping syndrome, bilious
vomiting and malnutrition. 5%
7. PREVENTION OF COMPLICATIONS
Advise of how to prevent complications to be given e.g. avoidance of large meals and
monitoring the kind of diet. In addition, balanced diet at frequent intervals served
attractively to be emphasised. 5%
8. LIFE LONG TREATMENT:
Explain the possible complication of anaemia whose treatment and prevention is vitamin B
for life. Therefore emphasise on the need for this treatment. 5%
TOTAL = 20%
GYNAECOLOGY AND OBSTETRICS QUESTIONS

ANTENATAL CARE
Mrs. Mary Kauseni age 24 years a prime gravid is attending antenatal clinic for the first time .Her
last menstrual period LMP) was 26th June 2009.During history taking, Mrs. Kauseni tells you that
she was recently tested positive and she is not on ARVs, Her CD4 count is 600/mm3.
a. Define Antenatal care 6%

(ii)Show by calculation hr expected date of delivery 10%
b. List five (5) factors that would increase mother to child transmission of HIV 10%
c. Explain the activities that will be carried out on Mrs. Kauseni on her first visit. 50%
d. Outline four (4) points you would include in your information, education communication (IEC) to
Mrs. Kauseni in relation to mother tom child transmission of HIV. 24%
ANSWER KEY.
 Antenatal care is the attention, supervision and care given to a pregnant woman from conception
to delivery.
OR
 Antenatal care refers in the care that is given to a pregnant woman from the time that conception
is conformed until; the beginning of labour.
 is a screening system which aims to assess and obviate risk of harm to mother and baby
ACTIVITIES DONE AT ANTENATAL CLINIC

Booking clinic
 Assessment of risk begins when woman is seen by her midwife/CO/MD early- best within first 8
weeks
 First hospital booking visit should take place around 12 and not later 16 weeks gestation
Routine booking assessment
 Administrative details, including age, marital status and gravidity are recorded
 An accurate menstrual history is important to assess GA
 History
 examination
Investigations
 FBC and check for haemoglobinopathy when indicated; ABO and Rh group and check for
antibodies; rubella immunity; VDRL
 Hepatitis B status; HIV status( opt out)
 Mid-stream urine (MSU) for culture and sensitivity
 Appropriate pattern of antenatal care and place of delivery is determined based on maternal
choice and presence of risk markers
 Policy must be continually re-appraised during pregnancy .Women at low risk of pregnancy
problems can be delivered by their own midwife
 Among criteria for delivery at center with midwife
 Second, third or fourth pregnancy under 35 years of age
 No medical, psychological or obstetric contraindications
 No recognised fetal risk( e.g growth retardation; rhesus or other antibodies)
 Traditional pattern of care involved the woman being seen in clinic every 4 weeks up to 28
weeks; every 2 weeks from 28 t0 36 weeks weeks, and weekly thereafter
 This has not been proven to be necessary in women at low risk, for whom the following is
suggested:
 8-12 weeks- arrange booking and confirm dates, review her HIV status +/- needs treatment
 12-15 weeks- hospital booking , serology and screening tests, initiate malaria prophylaxis at
16/40
 26-28 weeks check for fetal growth, consider PMTCT at 32/40
 36 weeks to check for presentation
 40 weeks pre-delivery assessment
 41 weeks to hospital if not delivered
Routine assessments
 Every subsequent visit:
 Urinalysis
 Blood pressure
 Exclude peripheral oedema
 Measure and record fundal height( in centimetres above symphysis pubis)
 Every visit in third trimester
 Fetal lie and presentation
 Presence of fetal heart
 Record patient awareness of fetal movement
 At 26 and 36 weeks ( as a minimum)
 Full blood count
 Rh-D antibodies in Rh-negative women and other antibodies if necessary
 Presence of adverse features demands closer attention.Among risk factors that can arise during
pregnancy are:
 Vaginal bleeding, htn, proteinuria
 Persistent glycosuria, UTI and other infxns
 Oligohydramnios,polyhydramnios,reduced fetal movements, IUGR, malpresentations
Ultrasound in antenatal care

 Clinical situations in which it is useful
 Assessment of PVB and/or abdominal pain in early pregnancy
 Accurate assessment of GA- menstrual history can be unreliable in up to 45% of women
 Exclusion of multiple pregnancy
 Exam of fetus for severe congenital anomaly
 Check fetal size and liquor volume when the uterus is small or large for dates
 Monitoring fetal growth in high-risk pregnancies
 Ascertaining placental site and identifying the source of some APH
 Determination of fetal presentation if unclear by palpation
 Discovering fetal altitude ,wt , type of breech
 Although a policy of routine scanning has not been shown significantly to affect pregnancy
outcome, it is generally considered to be of clinical value
 Each centre must have a clear policy
 If ultrasound is offered the suggested optimal programme is
 First scan around 12 weeks’ gestation can confirm continuing pregnancy and GA
 A second scan at 20 weeks has the best predictive value in the detection of serious
malformations ( earlier scanning is more likely to miss serious cardiac anomalies)
Other aspects of care

 This is important time to provide health education and advice e.g
 Diet
 Dental care
 Habbits- ( avoid alcohol, smoking, substance abuse)
 Parentcraft
 Preparation for labour and breastfeeding should be given in advance
CALCULATION OF EDD
a. 26 06 09
+7 09
33 11 09
30 12
03 11 09
EDD 03 11 09
B. FACTORS INCREASING MOTHER TO CHILD TRANSMISSION OF HIV.

During Pregnancy
 High vital load
 New infection (vital spike)
 Clinical AIDs
 Poor immune status (low CD4 count)
 Placental infection
 Chorioamnionitis
 STIs
 Viral strain
 Immune response
 Nutritional status
 Other diseases
During labour and Delivery

 Prematurity
 Vaginal Delivery

 Prolonged rupture of membranes
 Prolonged labour
 Instrumental deliveries
 Invasive obstetric procedures.
 Episiotomy.
During Postnatal.
 Breast feeding beyond six months
 Mastitis
 Mixed feeding A
ACTIVITIES DONE DURING ANTENATAL CLINIC
1 History Taking
Comprehensive history from Mrs. Kauseni is elicited. Open ended questions that she understands are
asked and she is encouraged to talk. This information acts as baseline data for subsequent visits for
detection of deviation from normal. The history taken is as follows.
 Social history: is obtained for identification of the client as it is necessary for follow up and
health education. The client is asked on
 Name
 Age
 Educational level
 Occupation
 Marital status
 Name of Husband
 His occupation
 Religion
 Residential Address
 Type of house
 Water supply
 Sanitation
 Source of power, Environmental hygiene
 Family History : is obtained in order to find out if Mrs. Kauseni is suffering any of the
conditions that tend to run into if there are any family members suffering from any of the
following conditions :
 Diabetes mellitus
 Asthma
 Hypertension
 Mental illness
 Sickle cell diseases
 History of multiple pregnancies
 Also ask for history of contact of Tuberculosis.
 Personal Medical History: is taken to identify conditions Mrs. Kauseni may be suffering from
that may complicate pregnancy. Examples of such conditions are :
 Hypertension
 Asthma
 Cardiac disease
 Diabetes Mellitus
 Mental illness
 Sickle cell disease
 Epilepsy
 Tuberculosis
 Surgical History: is obtained to find out if Mrs. Kauseni had injuries or operations involving the
pelvic bone, spine or lower limbs that could result in alteration of the pelvic diameter and angle
of inclination leading to CPD .She I s also asked for any operations involving the lower abdomen
especially the uterus to exclude risk of uterine rupture. History of blood transfusion is asked to
exclude Iso-immunization if she is Rhesus negative.
 Menstrual History – Mrs. Kauseni is asked when she reached menarche, type of menstrual
cycle, duration of menses, flow and menstrual problems
 Methods of contraception used – When, for how long and reasons for stopping.
 Present obstetric history – Mrs. Kauseni is asked about.
 The first day of her last normal menstrual period (LMP) and calculate the expected date of
delivery.
 Her health during his pregnancy.
 Drugs been taken
 Minor disorders
 Sleeping pattern
 Nutrition – the type of foods she eats, any pie for non- nutritious foods, her appetite
 Any fetal movements
 Tetanus Toxoid immunization
 Availability of a social support person
 Any concern during this pregnancy.
2 Physical Examination
Physical examination serves to screen the woman for any existing abnormalities or high risk factors
in order to intervene early to prevent complications.
 Preparation
 Explain procedure to Mrs. Kauseni and get consent
 Ensure privacy
 Ask her to empty the bladder.
 Prepare necessary equipment
 Encourage her to talk during the examination.
Procedure.
 Wash hands and fellow the principles of infection prevention throughout.
 Observe the general appearance to assess her psychological and emotional state.
 Collect urine and test for
 Protein to rule out protenuria
 Sugar to rule
 Acetone to rule keto acidosis.
 Take her weight – Short stature is associated with some complications of pregnancy and birth
such as CPD.
 Not her gait :If sliming may be indication of altered angle of inclination
 Take her vital signs
 Temperature to rule out infection
 Blood pressure to rule out pre-eclampsia.
 Examine her from head to toe.

 Skin for the general appearance for signs of malnutrition, check for any rash
 Check for personal hygiene
 Hair whether well kept and combed
 Face for any puffiness
 Eyes for pallor and signs for jaundice
 Noise for any obstruction ,polyps
 Ears for any discharge
 Mouth for any signs of anemia on the lips, mucous membranes, guns and tongue, check for dental
caries.
 Check for lympadenopathy by palpating the enlargement of the peri auricular submandibular and
cervical lymph nodes, Lympadenopathy is an indication of chronic illness.
 Examine for enlargement of the thyroid gland in the neck
 Hands for any signs of anemia on the palms and venous return on the nail beds, Ask the woman
to make a fist and if there is tightness it’s an indication oedema.
 Inspect the breast for presumptive signs of pregnancy such as Montgomery’s tubercles, darking
of the primary areola. Inspect for suitability for breast feed by looking at the prominence of the
nipples. Also check for the skin changes such as appearance like an orange skin, rash,
discoloration and dimpling which could be an indication of a lump.
 Palpate the breast for any abnormal lumps in both breast and teach the woman on how to examine
her breasts.
 Check the valve and perineum for hygiene, rash, warts, or lesions, any abnormal discharge, any
offensive odors, varicose veins or oedema.
 Check the scar and anal region for oedema, and region for hemorrhoids and fissures, rash and
abscess.

 Investigation are done such as
 Blood for hemoglobin
 Blood for grouping and cross matching
 Blood for rhesus factor
 Blood for rapid plasma reagent (RPR)
 Blood for HIV test after counseling.
3 Health education.
 Importance of antennal clinic
 Good hygiene i.e. taking baths, breast care, maintaining hair, clean environment, clean
cloths etc.
 Dressing of loose clothing and avoid wearing high heeled shoes.
 Labour and baby layette, to start preparing early.
 Feeding option exclusive breast feeding or formula feed.
 Good nutrition, Eating balanced meals such as carbohydrates (maize, rice, millet,
sorghum, wheat, potatoes etc) Proteins such as beans, groundnuts, all forms of meat,
vitamins and minerals.
 Safer sex practice by use of condoms and having one sexual partner
 Dinger signs of pregnancy
 Rest and minimal exercises.
Mrs. Kauseni is advised on when to return (IEC)
Discuss with her the following:

 How HIV infection is transmitted from mother to child during pregnancy, in labour and
delivery and after delivery.
 Need for short course of ARVs to prevent mother to child transmission of HIV i.e. AZT
300mg bd after 28 weeks of pregnancy.AZT is given till labour for a woman who has
never had AZT,is given single dose nevirapine;AZT + 3TC.
 Safer feeding options
o Exclusive breast feeding for 6 moths followed by introducing of other foods
o Formula
 Safer sex practices by use of condom each time with one (1) sexual partner to avoid
reinfection.
 Good nutrition to boast the immunity
 Mode of deliveries with minimal risk i.e. caesarian section as there is no direct contact
with the mother’s blood or other body fluids.

Kashibi Masaka a 30 year old lady Shuungu modeling centre was brought to gynae clinic with history of
feeling a growth in the left breast. A provisional disgnosis of breast cancer is made.
a) Give four clinical staging of cancer 8%

b) Draw a well labeled diagram of breast 22%
c) Describe the management of Masaka operatively 50%
d) Explain four (4) points that you would include in your information, education and communication
to Masaka regarding the care of the affected breast 20%
LABOUR
Mrs. Dinga Erickson aged 37years, gravid 12 is admitted to your labour ward complaining of show and
backache, on examination cervical dilation is 5cm; her last LMP was June 2010
e) Calculate
iii. EED 5%
iv. Gestation as of today 10%
f) Explain how you would admit her to labour ward. 15%
(i)Using a partograph record her observations and explain the findings. 15%
g) Discuss the nursing care you would give her during the first of labour. 50%
h) State (5) five complications. 5%
MARKING KEY
THIRD STAGE OF LABOUR
DEFINITION:
The third (3) stage of labour is that of separation and expulsion of the placenta and membranes
which lasts from birth of the baby until the placenta is expelled. The usual length is 5-15
minutes, but any period up to one hour may be considered normal if the there are no
complications 5%
SIGNS OF PLACENTA SEPARATION 15%

I. Contractions of the uterus to push the placenta in the lower segment of the uterus as the
capacity of upper segment reduce. The fund is globular.
II. Lengthening of the cord at the vulva as the placenta lies in the lower segment of the
uterus or vagina. The cord outside the vulva will not recede.
III. There is a gush of blood as the area of placenta separation blood is torn across causing
30-60mls of blood to collect between the maternal surface and deciduas. (Give 5% for
each point)
C. THE MANAGEMENT
OBJECTIVES (6%)
1. To deliver the placenta and membranes after observing signs of separation.
2. To control excessive bleeding
3. To prevent infection during the 3rd stage of labour.
INTRODUCTION (3%)
- Good Management of third stage starts during the prenatal period as the woman is
brought into labour in excellent physical condition so that the uterus will have power to
contract and retract.
- The above measures should continue during the first and second stages of labour-The
woman should not be exhausted and baby delivered slowly.
- Administration of oxytocic drug syntometrine 1ml with the birth of the anterior shoulder
shortens the 3rd stage, reduces blood loss
PREVENTION OF INFECTION (8%)
- There is greater need now of asepsis and antisepsis for the mother’s resistance, both
general and local is diminished.
- Lacerations and bruising are found in the tissues of the vulva and vagina and render them
prone to invasion by organisms.
- In the raw placental site and the alkaline lochia, organisms find an ideal place to flourish.
- An aseptic technique must be vigorously observed to prevent HIV infection to be
transmitted from the mother to baby during birth.
POSITION OF THE PATIENT 2%

- The dorsal position has numerous advantages
- The uterus can be observed better, and the cord traction can be applied more effectively.
- It is more comfortable for the woman.
DELIVERY OF THE PLACENTA BY CONTROLLED CORD TRACTION AFTER

GIVING SYNTOMETRINE 20%
- Apply Mayo’s artery forceps to the cord near the vulva. This provides a better hold for
traction and reinforces the sensation of placental descent to a greater degree than when
cord is wound around the fingers.
- Wait for a strong uterine contraction usually about 2-4 minutes after delivery.

- Place the left hand on the lower abdomen, the palmar surface bracing back the upper
uterine segment the fingers stretching the lower uterine segment upward towards the
umbilicus to prevent inversion of the uterus.
- Traction on the umbilical cord begins gently and continued steadily without jerking to
avoid breaking the cord.
- Should the uterus relax traction is stopped temporarily. The hand on the abdomen can
with practice detect that the uterus is not being pulled downwards as would occur if the
placenta were still adherent to it.
- If after 20 to 30 seconds of traction the placenta does not descend, the attempt should be
abandoned for one or two minutes then it can resume again.
- The direction of the pull is first down wards then outwards as the placenta descends and
up-wards when it appears at the vulva following the axis of the birth canal and the
placenta is delivered.
- The safety of the procedure is avoiding the inversion of the uterus.
- Fundal pressure and cord traction must never be combined as this would be very liable to
cause inversion of the uterus.
- Perinea laceration are looked for and sutured when necessary. (Give 2% for each point)
OBSERVATIONS 8%
- The pulse is the best guide to the loss of blood. Keep the finders on the pulse through
-out the 3rd stage.
- During this time the pulse is slightly slower than normal due to additional blood that has
entered the circulation from the contracted uterus.
- If the pulse is raising reaches 90, the possibility of haemorrhage must be considered.
- The skin should feel warm and dry.
- The systolic blood pressure over 110mHg
- Action should be taken by a Midwife to control excessive bleeding even though the
amount is not sufficient to be classified as post partum haemorrhage.
- The consistency of the uterus should be firm like tennis balls. The upper border being
about 2.5cm below the level of the umbilicus.
- Observe the general condition of the patient should be good though may feel tired but not
ill.
CONTROL OF EXCESSIVE BLEEDING 2%

- Blood loss is measured
- The contraction and retraction of the uterine muscle fibres that bring about separation of
the placenta also act as living ligatures by compressing the blood vessels and controlling
the bleeding. Suture the lacerations.
CONCLUSION 1%
- The woman is kept warm and any soiled wet linen removed from under the patient and
she is given a pad.
EXAMINATION OF THE PALCENTA (30%)
-This is done to ensure that nothing has been retained in utero.

-The placenta has two surfaces – foetal and maternal surface.

THE FETAL SURFACE
- It is shiny because of the amnion membrane is usually complete because it is tough and
easily torn like the chorionic.
-If portions of chorion appear to have been retained, it should be stripped off the amnion
as far as the cord insertion.
-Next the hole in the membranes through which the child was born is examined.
-If opposite the placenta, the latter’s attachment must have been fundal, but if the
hole is close to its edge then the placenta must have been praevia.
-If there is an extra small hole with two arteries and a vein running to it, a lobe
has been retained. The vessels may also run to an obvious succenturiate lobe or
a velamentous insertion of the Cord.
-The cord is inserted at the foetal surface.
THE MATERNAL SURFACE
-The blood clot is cleaned away and cupping of the placenta in both hands.
-It is ascertained whether all of the cotyledous are present or not
-They should be about 20 in number
-The placenta is also examined for facts, Oedema as in hydrops fetalis or syphilis.
-The cord insertion is noted, whether centre, lateral or bottle dose.
-The placenta is then weighed- normal is 1/6 weight of the baby.
-In syphilis it may weigh as much as a third of the baby’s weight. 30%
Give 2% for each point.
HYSTERECTOMY
DEF:
It is the surgical removal of the uterus resulting in the inability to be come pregnant.
NOTE: Hysterectomy is a common operation, the uterus may be completely or partially removed
and the fallopian tubes and ovaries may be removed at the same time.
TYPES OF HYSTERECTOMY:
1. A PARTIAL OR SUPRACERVICAL HYSTERECTOMY:
Is the removal of the upper portion of the uterus leaving the cervix intact.
2. TOTAL HYSTERECTOMY:
This is the removal of the entire uterus, the cervix and the ovaries.
3. RADICLE HYSTERECTOMY:
This is the removal of the uterus tissue of both sides of the uterus (parametrium) and thee
upper part of the vagina bilateral lymph nodes is removed.
SURGICAL APPROACHES THAT CAN BE USED TO REMOVE THE UTERUS:

I. ABDOMINAL HYSTERECTOMY
The removal of the uterus through the abdomen.

II. VAGINAL HYSTERECTOMY:
The removal of the uterus through the vagina.
INDICATIONS OF HYSTERECTOMY:
Hysterectomy may be recommended for;
1.tumous in the uterus which may be uterine fibroids,cancer cervix or,cancer ovaries.
2.Severe long term bleeding not responding to medications.
3.prolapse of the uterus or severe post partum haemorrhage.
4.raptured uterus.
MANAGEMENT
INVESTIGATIONS
 History taking that will review the onset and signs of the disease.
 Physical examination that will review some tenderness of the pelvic area.
 Lower abdominal x-ray that will review some abnormalities of the uterus.
 Biopsy that may review cancerous cencerous cell.
PRE-OPERATIVE CARE:
PSYCHOLOGICAL CARE:
 Explain to the patient the reason for hysterectomy and the procedure involved and what
to expect after surgery and the extent of hysterectomy.
 Ensure that the patient has signed the consent form before surgery as it is the legal
document that protects both the patient and the surgeon.
HYGIENE:
 Valva swabbing or irrigation may be done before surgery, especially by the surgeon.
PHYSICAL PREPARATION;
 Ensure that the woman is clean, shaved, catheterized and nasal gastric tube inserted
before surgery.
 Also ensure that the patient is labeled, gowned in the theatre gown, and has dentures
removed, and all the jewellies removed and kept safely by the sister in charge.
 Collect all the patient documents such as the doctors notes, nurses notes, x-rays, lab
results, and if any blood products, and escort the patient to theatre.
IN THEATRE (RECEIVING BAY).

 Hand over the patient to the theatre nurse indicating the name of the patient, ward,
indication of operation, premedication given, and if any blood products available.
CARE OF RELATIVES:
 Inform the relatives that the patient is now in theatre and will be taken care of by the
theatre staffs.
 Show them the lounge where they can seat waiting for there relative to come out of the
theatre.
BACK ON THE WARD;

 Prepare the post-operative bed closer to the nurses’ station for easy observations when
patient comes back from theatre.
POST-OPERATIVE CARE:
ENVIRONMENT:
 Nurse patient close to the nurse’s station for easy observations.
 Ensure all emergency equipments are within rich such as the oxygen cylinder, suction
machine, and drip stand for resuscitative measures.
POSITION:
OBSERVATIONS:
PAIN MANAGEMENT:
PSYCHOLOGICAL CARE:
NUTRITION:
HYGIENE:/WOUND CARE:
ELIMINATION:
COMPLICATIONS;
 Urinary tract infections.
 Haemorrhage.
 Shock.
 Infections.
 Wound dehiscence.
 Paralytic ileus
 Thrombophlebitis.
IEC:
Discuss with the patient the following
 Wound care.
 Refere patient to sexual therapist.
 Rest and activity.
 Nutrition.
 Follow up care.
VESICLE –VAGINAL FISTULA V.V.F

DEFINITION OF 5 %
This happens when there is severe pressure upon the urethra and the base of the bladder leading
to necrosis of the internal tissues causing opening of the bladder into the vagina.
B. FIVE (5) SPECIFIC INVESTIGATIONS ON V.V F 20-%
i) High vaginal swabs: - this is done to detect any infection that may be
Present and treat before the repair of the fistula is done.
ii) Midstream urine examination. This is done to exclude any urinary
infection that may interfere with healing.
iii) Full blood count-so as to know the condition of the patient, whether
they can stand the operation.
vi) Cross-matching and grouping so as to prepare for blood when needed
during the operation.
v. Examination under anaesthesia-Blue dye is introduced into the
bladder, if it comes to the vagina, a fistula is detected.
vi. Chest X-Ray is done to exclude any chest infections that may
complicate the operations.
(Give 4% for any 5 points)
THE POST OPERATIVE CARE AFTER THE REPAIR OF THE V.V.F 50%
THE OBJECTIVES: (10%)
1. To avoid tension on the incision and ensure sympontanous healing

2. To prevent infection which may delay or even prevent healing.
3. To normalize the elimination process.
4. To help the patient follow specific instructions after discharge to maintain
the healing process
5. To provided psychological care.
1. AVOIDANCE OF TENSION ON THE INCISION TO ASSIST THE PATIENT

ACHIEVE SYMPOTENCEOUS HEALING ESPECIALLY OF THE FISTULA.
(9%)
-When the patient comes back from theatre she will have Forley’s catheter in situ
for continuous drainage of urine to rest the bladder and protect the suture line.
- The catheter is usually left for 14-21 days following repair of V.V.F.
- The catheter should be cared for to prevent infection
- Ensure that there is free drainage of urine
- Ensure that you avoid drinking or break in drainage of urine
- Position of the patient-She should be in bed as long as the catheter is in position.
- Exercises are done regularly and position changed.
- Reflex of urine returning to the bladder should be avoided-this can be done by
clamping the tube.
- Chest infections are avoided. If there is one it must be treated promptly.
- Check for the vaginal pack. If it is there it must not be forgotten.
- It has to be removed.
- Vulva swabbing is carried out regularly.
- Inspect closely for vaginal blood loss for the 1st 12hrs.
2. PREVENTION OF INFECTION -6%

-The patient should wear sterile sanitary pads to prevent infection
-Frequent aseptic vulva swabbing for example three times a day.
-Vulva toilet is done as long as stitches are in place

-The sutures should stay as long as 6-10 days.
-The patient continues to be on broad spectrum, prophylactic antibiotics. As long
as the catheter is in side the antibiotics should continue to prevent infection.
-Hygiene is practiced.
3. a ELIMINATION -5%
-Prevention of strenuous defaecation is important.
-By 2nd day post operation liquid paraffin 30mls once a day is given to
loosen the stool.
-On the 4th day the patient has glycerine suppository inserted
-The patient is to have plenty of fluids orally after the drip.
-Diet must have roughage
3. b FLUID BALANCE 3%
-The patient is on IV fluids for the 1st 24hrs.
-Ensure adequate out put. Urine is measured hourly to ensure that there is no
blockage.
-The patient should have at least 2-3 lts in 24hrs.
-Normal saline is used.
4. OBSERVATIONS. 8%
-Vital signs are observed QID as long as the catheter is in .

-Temperature
-Pulse
-Blood pressure
-Respirations
-Watch closely for leakage of urine.
-If any leakage seen report to the doctor promptly.
-Observe the suture line
5. PSYCHOLOGICAL CARE – 3%
-Reassure the patient that every thing possible is being done to alleviate the suffering.
-Explain all procedures and report progress to the patient.
-Give clear instructions on specific information to enhance healing.
6. OTHER GENERAL CARE OF THE PATIENT 6%
-The patient should have nutritious diet rich in protein to aid healing.
-Must have bed bathes to promote comfort and hygiene purposes.
-Perineal exercise are encouraged for better healing of pelvic floor muscles.
-The patient should be in a clean bed and linen changed
-The environment must always smell fresh.
-Windows opened for fresh air
IEC FOLLOWING THE OPERATION TO ENHANCE HEALING OF THE V.V.F. -25%

1. The patient is encouraged to rest and avoid long standing as it may cause strain.

2. Good diet with roughage is encouraged to prevent infection.
3. High protein diet assist in the healing process
4. The patient is told to refrain from sexual inter course during the healing process.
5. She is also told that successive pregnancy will now be delivered by caesarean
section.
6. Three months post operatively the patient will be normal
7. She is also told that the chance of reoccurance of the fistular is high.
8. Must avoid pregnancy within 6 months after operation-use Family Planning.
9. She should avoid sexually transmitted diseases.
10. If there should be any problem she should seek medical advice quickly.
(Give 4% for any 6 points.)
VESICO VAGINAL FISTULA 2

 Mrs. Martha Mutasmba aged 17years is admitted to a Gynecological ward with the
diagnosis of Vesico vaginal fistula.
 Define Fistula 5%
 Explain five (5) predisposing factor of vesico vaginal fistula 15%
 Discuss in detail the preoperative management of Mrs. Mutasmba 50%
 Outline five (5) preventive measures of vesico vaginal fistula 30%
ANSWERS
Definition of fistula 5%
 It is an abnormal duct or passage resulting from injury, disease, or a congenital disorder that
connect on abscess, cavity, or hallow organ to the body surface or to another hallow organ.
 Five (5) predisposing factors of VVF. 15%
o Trauma. Direct trauma or injury on the tissue between the urinary blander and the vagina
may lead to formation of a fistula. For example penetrating injury due to sharp objects.
o Child birth. Prolonged application of pressure on the tissue between the vagina and
urinary bladder may lead to necrosis of this tissue. This is common in prolonged
obstructed labour.
o Surgery. Surgery on the perineum. Accidental surgical injury can lead to VVF.
o Infection: Infection which affects the lining or tissue of the vagina and urinary bladder
predisposes to VVF, especially where there is abscess for formation and ulceration of
tissue.
o Radiation therapy
 Internal radiotherapy, due to its destructive effect on the cell, contributes to
weakening and development of VVF.
 Carcinoma of the vesico vaginal tissue as it progress and during its treatment predisposes to
fistula formation.
 Traditional practices. Traditional practices such as female circumcision predispose to
development of vesico vaginal fistula.
PRE-OPERATIVE MANAGEMENT: 50%

 The following points should be considered in the pre-operative management of Mrs. Mutumba.
Objectives 2%
 To prepare the patient for surgery
 To prevent postoperative complications
Investigations: 5%
 Screen the patient of any infection, especially urinary tract infection to avo9id post operative
infection.
 Samples of urine can be collected for urinalysis.
 Ensure that the patient is not anemic by checking the hemoglobin level.
 Fistulogram may be done. Injection of dye is given into the vagina to assess the exact location
and seventy of the fistula.
 History on how the problem stated should be obtain to determine health education to be given ton
the patient.
Psychological care: 5%
 The condition should be explained to the patient and caretaker. That is leakage of urine into the
vagina as a result of the perforation between the two cavities.
 Treatment option should be explain such as healing on its own if it is small or surgical
intervention.
 If there is any patient whose operation was successful can be introduced to encourage her.
 Allow the patient and relatives to air out their views to relieve anxiety.
 Provide adequate information to the client and patient.
 Procedure should be explained before carrying them out.
 All these measures will enable the patient to accept her condition cooperate in the management
and promote self care.
Obtaining written consent: 4%
 The patient or a relative should sign the consent form to show that an agreement was reached and
the patient consented that she should be operated.
Observation:
 General observations should be done such as TPR and BP
 Routine urinalysis if the procedure is delayed should be done to detect infection.
 Nutrition status
 Psychological status.
Urinary Output: 4%
 Catheterize the patient to ensure that the perinea area is dry.
 Nephrostomy catheter may be used to keep the area well drained.
 Treatment of other illness or inflammation at the local site,
 Ensure that the patient is treated of any infraction which can complicate surgery,
o e .g urinary tract infections.
 If there is inflammation around the fistula, treat the patient before surgery.
Hygiene: 5%
 Perineal hygiene in this case is very important.
 Advise the patient to clean the perineum with soap and water every 4 hours to
prevent excoriation and of the vagina and vulva tissue.
 Warm sitz bath should be done 3 times every day.
 Change perineal pads as often as possible.
Nutrition: 5%
o Give the patient nutritious food, low in residue. Enema may be

given to reduce the constant flow of faeces.
o Maintain adequate hydration by encouraging oral fluid intake.
o If the patient is dehydrated IV fluids can be given.
Immediate Pre- Operative care: 10%
 Nil orally
 Premedication
 Identify band
 Perineal care
 Assembly all investigation results
 Gown the patient to theatre
 Give a thorough hand over to the theatre Nurse.
D. Five (5) preventive measure of VVF 30%
 Avoid traditional practices such as female circumcision and others which predisposes to VVF.
 Discourage early marriage. These put young woman at risk of prolonged and obstructed labor to
their underdevelopment physiologically
 Malnutrition. Some feeding practice favors boys. This must be avoided. Girls and woman need to
be eating well for growth and health. Malnourished woman usually have obstetric complications.
 Education. Lack of health education hinders VVF prevention. Most rural woman see obstetric
complications as a result of the pregnant woman’s sin, a curse, Heredity. Health education must
be intensified.
 Decision making. Woman should be encouraged to make decisions concerning their health, e.g. if
there is obstructed labor, they should not wait for the husband or any other person, they need to
be taken to the hospital.
 Family planning, This is important for the woman‘s health.
 Traditional Birth Attendants. Woman sound be encouraged contact trained TBAs and avoid home
delivery.
ABORTION
Mirinda aged 19years of highlands compound is brought to the Gynae ward with complaints of
sudden bleeding and severe abdominal pains her last normal menstrual period being 10 th
November, 2009.
f) Define post abortal care (PAC) (5%)

g) Using a diagram illustrate the types of abortion (22%)
h) Mention elements of PAC (8%)
i) Describe the nursing care you will give Mirinda before the MVA is done (40%)
j) Explain five (5) possible complaints of abortion (25%)
Definition
POSTABORTAL CARE: This is care given to a girl or a woman after an abortion or a

miscarriage in order to reduce the risk of long term illness, disability and health due to
Complications
ABORTION: This is termination of pregnancy before the fetus becomes viable [26-28 weeks
gestation] In united kingdom it is from 24-26 weeks, this was legalized in 1967 but was
reinforced in 1991. In Zambia the law was enacted on 13th October 1972.
TYPES
1. SPONTANEOUS –Usually referred as a miscarriage because of external causes such as
trauma or diseases .This is not voluntarily induced.
2. INDUCED-There is deliberate interference with the pregnancy by oneself or someone
.This is usually said to be criminal as un sterile things are used such as knitting needles,
cassava sticks, hanging wire, traditional herbs or taking overdose of drugs.
3. THERAPEUTIC- This is done legally if there is a risk to maternal health or signs of
fetal abnormalities especially risks of a physically and a mentally handicapped child.
39% are on clients requests

24% restricted,
24% Illegally
13% Are done on social grounds especially if due to rape or incest sex between
closely related people].
TYPES OF ABORTION
ABORTION
Spontaneous abortion Induced abortion
Threatened abortion
Missed abortion Inevitable abortion Termination of preg. Criminal

abortion
Complete abort. Incomplete abort.
Blood mole
delivery of viable infant Septic abortion
Cernuous mole

Method in the first trimester using MVA under General Anaesthesia . Give mifepristone a low
dose anti progesterone orally and a low dose prostaglandin is inserted vaginally to stimulate
cervical dilatation and uterine contractions.
2ND trimester induce with large doses of oxytocin for the mother to experience labour pains ,this
should not result in a live birth .Give antibiotics and if she is rhesus negative give her anti D
immunoglobulin. From 1991-1994 in Europe this law was amended to allow TOP to reduce on
multiple pregnancies once a diagnosis of downs syndrome was confirmed by an amniocentesis
test
CAUSES OF SPONTANEOUS ABORTIONS
 Acute infection-malaria, influenza, toxoplasmosis, rubella, pneumonia syphilis and
appendicitis
 Cervical incompetence, trauma infection or erosion
 Hormonal-fright, grief, accidents or severe pain
 Uterine disorders eg infantile, biconuate, myomas or fibroids
 ABO/ Rhesus incompatibility
 Anaethetic drugs,oxytocics,herbs,antimetabolic drugs
 Defective implantation of the trophoblast
 Defective ovum or fetus-60%
 Chromosomal defects-20-40%
 Medical problems –anaemia,diabetes,hypertension,thyroid or renal diseases
 Systemic chronic infections-pyelonephritis ,diarrhoea, dysentery
 Extreme emotional stress on the pituitary hormones,increased intrauterine pressure due to
polyhydromnious which may result in cervical dilatation.
SIGNS AND SYMPTOMS

 History of a missed period for more than a month
 Per vaginal bleeding
 Cramping or lower abdominal pains similar to labour pains
 Passage of placental fragments.
 Always consider infection with failed attempts of unsafe abortion by use of unsterile
instruments.
SCREENING- Identify life threatening complications [shock, severe per vaginal bleeding,
infection, intra abdominal injury or uterine perforation.
Assessing shock –fast weak pulse-110/minute,rapid respirations-30/minute,low diastolic BP
below60mm/hg
PALLOR. In the inner eyelids palms and around the mouth. Patient may look anxious, confused
or unconsciou
TREATMENT Turn the head to one side so that she does not inhale the vomitus .keep on nil by
mouth
Maintain a clear airway,give oxygen 6-8 litres/minute ,keep the patient warm and raise the foot
of the bed to increase blood supply to the heart
Give I.V fluids ringers lactate or isotonic saline 1 litre in 15-20 minutes then1-3 litres in 24 hours
if she has lost a lot of blood. An Hb of 5gms/100mls or a haematocrit of less than 15 the client
will need a blood transfusion
Check for products of conception in the vagina and remove by MVA
Investigations do blood cultures if she has fever chills or pus
Do FBC, Platelet, grouping, crossmatch and blood urea nitrogen.

Give broad spectrum antibiotics intramuscularly or intravenously. The most commonly used
are;1cefotaxone,ciprofloxacinor spectinomycin in combination with gentamycin or
metronidazole
2 doxycycline with metronidazole
3penicillin with chlora mphenicol.
ADMISSION-Registration ,social history specific reproductive information eg LMP ,current
contraceptive methods used .abdominal or shoulder pain –sign of intra abdominal injury.tetanus
vaccination status possible exposure through insertion of unclean instruments.
Enquire about drug allergies[ anaethetics,antibiotics or chronic intake of
corticosteroids,bleeding disorders –sickle cell,thallassemia,haemophilia or platelet s
Herbal medication or H/Omalaria during this pregnancy
Reassure client throughout the procedure,obtain aconsert for MVA /OT
Do vital signs ,allow patient to empty the bladder,do aphysical examination head to toe
CHEST –Examine lungs and heart
ABDOMEN –Check for masses or gross abnormalities,distension with decreased
bowelsounds,rebound tenderness with guarding supra pubic or pelvic tenderness
PELVIC EXAMINATION-Done to determine thesize,consistency and position of the
uterus,cervical tenderness tearsand dilatation
Speculum Examination
Check vulva for profuse bleeding,odour of vaginal discharge .Insert speculum to look at the
cervix and remove any visible products of conception [keep it for examination]
Take samples for bacteriological culture. Remove speculum and do bimanual examination in
incomplete abortion the uterus is smaller than the LMP might suggest, assess the shape and
position of the uterus. This helps in the safety and success of the procedure.
If the uterus is larger this may indicate multiple pregnancy, post abortal syndrome ,molar
pregnancy or the presence of uterine fibroids Treat client with an advanced pregnancy .This
could be due retroverion of the uterus, overweight or guarding abdomen
IN threatened abortion the woman should rest for 24-48 hours
MVA this is manual vacuum aspiration of the products of conception through a cannula with
minimal scrapping of the uterus.In the industrial world suction is done by an electric or foot
pump
EQUIPMENT
MVA Syringe 60mls, single valve, locking valve, plunger handle, collar stop
Vaginal speculum, sponge holding forceps, tissue tenecullum forceps, silicone for lubricating the
syringe Oring,adapters,cannulas sizes 16-22mm and uterine sound
Include hypodermic needles,syringes lignocaine,oxytocin sterile gloves cotton wool gauze pads
and anti septic solution –savlon 1 in 200mls
Patient should empty the bladder and wash the lower abdomen and external genitalia with soap
and water
Health care provider washes hands with soap and water before putting on surgical gloves
Prepare mva syringe by creating avacuum.insert the speculum, using sponge holding forceps
clean the cervical os with an antiseptic solution
Grasp the cervix with a forcep and insert a sizable cannula depending the cervical dilatation.
Push the cannula slowly into the uterine cavity up to 10cms, withdraw the cannula slightly
Attach the prepared MVA syringe to the cannula by holding the forceps and cannula.

Release the pinch valves to allow bloody tissue and bubbles to flow through the cannula into the
syringe
Evacuate all contents by rotating the syringe from side to side at 10 or 12 o’clock. If using 4-6
mm canula move canula gently,slowly,back and forth within the uterine cavity.
Check for signs of completion; There is no red or pink foam or tissue in the canula
A gritty sensation as the cannula passes over the surface of the evacuated uterus and the
contracted uterus grips the cannula
Withdraw the cannula,detatch syiringe,put cannula in decontaminating solution,whilst valves
are open empty contents into a strainer by pushing on the plunger
Remove the forceps and do a bimanual examination to check the size and firmness of the uterus
,inspect the products of conception and tissue.
Reinsert speculum to check for bleeding if present repeat the procedure
Place contaminated surgical waste in a plastic bag
Decontaminate all instruments in 0.5% chlorine for 20 minutes.
Immerse gloved hands in decontaminating solution , remove the gloves.
Wash hands with soap and water
Give client oxytocin 10 units im stat and if rhesus negative anti D immunoglobulin injection
before she goes home
Continue with appropriate antibiotics
Second TRIMESTER INCOMPLETE ABORTION
Give 10 units oxytocin in 500 mls of 5%dextrose infusion for 4 hrs-this safely completes
expulsion of retained products of conception.If bleeding continues do an MVA using a larger
cannula or prepare client for Dilatation and Currettage in theatre under general anaesthesia
POST operative care do vital signs whilst she is in the treatment room and allow full recovery
before discharge after 6hrs.
Give mild analgesics
ADVICE;The spotting should not exceed a normal menstrual period in the next 5-7 days though
bleeding for more than 2weeks she should report to the clinic.
Should not have any sexual intercourse as fertility returns within 10-14 days. This client
contraceptive counseling so that she makes an informed choice on family planning
Normal period should occur within 4-8weeks
COMPLICATIONS
Prolonged bleeding,severe increased pain,fever,chills,malaise and fainting
Set a date for the follow up visit
POST ABORTAL FAMILY PLANNING
Following an abortion of less than 12 weeks fertility returns within 11 days.
Inform about available methods-long and short term
Relate to clients emotional and physical state
Apply NFP until return of a regular menstrual pattern
Counsel in the context of the clients reproductive goals
Assuarance of contraceptive supply, access to follow-up care.
Need for protection against STDs
Individual assessment –characteristics, needs, clinical condition and her reproductive goals
Service delivery capabilities at local clinic
Attitude of healthworkers egunderstanding the factors that led to the unwanted pregnancy as this
will influence her choice of an appropriate family planning method.
COMPLICATIONS-Uterine or cervical perforation,severe per vaginal bleeding, air embolism
and possibly death if complications are not recognized promptly.

POST ABORTAL SYNDROME [Acute Hemato metra ] This is of the blockage of blood flow
from the uterus causing intrauterine bleeding,uterine distension,severe abdominal and fainting
within a few hours after a MVA. If it occurs after 3 days the client’s uterus is larger and feels
tender on examination. This is treated by re evacuating the uterus, giving oxytocics and
massaging the uterus to keep it well contracted.
Fainting is due to forceful cervical dilatation or vigorous scraping of the uterus causing severe
pain and stimulates the vagus nerve –this slows the heart and respiration rates which leads to
syncope ACTION-Stop the procedure,. use smelling salts[spirits of ammonia]
Maintain a clear airway,raise the legs ,ventilate with ambubag using oxygen
Give iv isotonic saline or ringers lactate and do vital signs
POSTABORTAL CARE
This is care given to a girl or a woman after an abortion or a miscarriage in order to reduce the
risk of long term illness, disability and health due to
Complications
ELEMENTS OF PAC
1. Providing emergency treatment of incomplete abortion of potentially life threatening

complications by; treating the client for shock, relieving pain and reducing per vaginal
bleeding by performing a Manual Vacuum Aspiration
2. Providing post abortal links to family planning counselling services. Client should be
availed this service and be able to choose any family planning method on discharge
3. It links the client to postabortal emergency services and the reproductive healthcare
system-ie Patient is referred to a gynaecologist or obstetrician for further management of
infertility ,cervical erosion, cervical incompetence hormonal imbalance and
mucopurulent discharges
WHO estimates 15% of all pregnancies end in spontaneous abortions .These women need
immediate care as abortions cause 50% of pregnancy related deaths
WHO World wide estimates -20% million unsafe abortions occur yearly, 70,000 women die
yearly and 1:3 deaths due to unsafe abortions
PARACERVICAL BLOCK
The giving of lido caine without epinephrine to dilate the cervix,minimises physiologicl
disturbance,helps the uterus to contract and patient’s speedy recovery.
This a sterile procedure, show the client the instruments as you continue using them
Fill 1% lidocaine in a 10-20mls syringe and attach to a 21g hypordermicneedle
Grasp the cervics with a tena culum forcep,inject 1ml lidocaine at 10 and12 o clock sites, the
needle should not be deeper than 2mm,aspirate to ensure the needle is not penetrating a blood
vessel finish by injecting 2mls lidocaine at 3,5,7 and 9 o’ clock sites,ask patient to cough to help
pop the needle under the surface of the tissue.
Perform the procedure after 2-4minutes.Standard dose of lidocaine is 4.5mg/kg

VERBACAINE-Talking to the patient throughout the procedure as the MVA can be completed
in 2-3 minutes
Give supportive treatment before and after the procedure eg ibuprofen or acetaminophen
Continue with verbacaine unless the cervix is not dilated which is attained by establishing
appositive relationship with the client.
Explain each step,wait a few seconds after performing each step and avoid jerky motions of
forceps when opening or closing.use instruments with confidence.
Avoid saying- this wont hurt or iam almost done
The use of supplemental analgesics,sedatives or paracervical block will depend on clients
emotional state, dilatation of cervical os, anticipated length of the procedure and skill of the
provider
MILD EFFECTS.-Numbness of the lips or tongue, metallic taste in the mouth, dizziness, light
headedness, ringing in the ears and difficulty in focusing.
SEVERE EFFECTS-Sleepiness, disorientation, muscle twitching, shivering, slurred speech
,tonic clonic convulsions, respiratory depression and respiratory arrest.
MANAGEMENT –For mild effects wait afew minutes,talk to the patient and co ntinue the
procedure when symptoms subside.
 SEVERE- Maintain aclear airway,give oxygen by mask or ventilation. If convulsing give
diazepam 1.5mg iv though it may cause respiratory depression.The increased blood flow
to the uterus and surrounding tissues causes rapid absorption of local anaesthesia giving
areaction of itching,rashes or hives.Treat with 25-50mg Benadryl[diphenhydramine] In
intense signs of respiratory distress give 0.4mg Epinephrine subcutaneously and support
breathing with aventilator
ECTOPIC PREGNANCY
Definition
An ectopic pregnancy is an abnormal pregnancy that occurs outside the womb (uterus). The baby
cannot survive.
Causes
An ectopic pregnancy occurs when the baby starts to develop outside the womb (uterus). The
most common site for an ectopic pregnancy is within one of the tubes through which the egg
passes from the ovary to the uterus (fallopian tube). However, in rare cases, ectopic pregnancies
can occur in the ovary, stomach area, or cervix.
An ectopic pregnancy is usually caused by a condition that blocks or slows the movement of a
fertilized egg through the fallopian tube to the uterus. This may be caused by a physical blockage
in the tube.
Most cases are a result of scarring caused by:
 Past ectopic pregnancy

 Past infection in the fallopian tubes
 Surgery of the fallopian tubes
Up to 50% of women who have ectopic pregnancies have had swelling (inflammation) of the
fallopian tubes (salpingitis) or pelvic inflammatory disease (PID).
Some ectopic pregnancies can be due to:
 Birth defects of the fallopian tubes

 Complications of a ruptured appendix
 Endometriosis
 Scarring caused by previous pelvic surgery
In a few cases, the cause is unknown.
Sometimes, a woman will become pregnant after having her tubes tied (tubal sterilization).
Ectopic pregnancies are more likely to occur 2 or more years after the procedure, rather than
right after it. In the first year after sterilization, only about 6% of pregnancies will be ectopic, but
most pregnancies that occur 2-3 years after tubal sterilization will be ectopic.
Women who have had surgery to reverse tubal sterilization in order to become pregnant also
have an increased risk of ectopic pregnancy.
Taking hormones, especially estrogen and progesterone (such as those in birth control pills), can
slow the normal movement of the fertilized egg through the tubes and lead to ectopic pregnancy.
Women who have in vitro fertilization or who have an intrauterine device (IUD) using
progesterone also have an increased risk of ectopic pregnancy.
The "morning after pill" (emergency contraception) has been linked to some cases of ectopic
pregnancy.
Ectopic pregnancies occur in 1 in every 40 to 1 in every 100 pregnancies.
Symptoms
 Abnormal vaginal bleeding

 Amenorrhea
 Breast tenderness
 Low back pain
 Mild cramping on one side of the pelvis
 Nausea
 Pain in the lower abdomen or pelvic area
If the area of the abnormal pregnancy ruptures and bleeds, symptoms may get worse. They may
include:
 Feeling faint or actually fainting

 Pain that is felt in the shoulder area
 Severe, sharp, and sudden pain in the lower abdomen
Internal bleeding due to a rupture may lead to shock. Shock is the first symptom of almost 20%
of ectopic pregnancies.
Diagnosis
A pelvic exam, which may show tenderness in the pelvic area.
Other Tests that may be done include:
 Culdocentesis
 Hematocrit
 Pregnancy test
 Quantitative HCG blood test
 Transvaginal ultrasound or pregnancy ultrasound
 White blood count
A rise in quantitative HCG levels may help tell a normal (intrauterine) pregnancy from an
ectopic pregnancy. Women with high levels should have a vaginal ultrasound to identify a
normal pregnancy.
Other tests may be used to confirm the diagnosis, such as:
 D and C
 Laparoscopy
 Laparotomy
An ectopic pregnancy may affect the results of a serum progesterone test.
Medical /Surgical Treatment
Ectopic pregnancies cannot continue to birth (term). The developing cells must be removed to
save the mother's life.
You will need emergency medical help if the area of the ectopic pregnancy breaks open
(ruptures). Rupture can lead to shock, an emergency condition. Treatment for shock may include:
 Blood transfusion
 Fluids given through a vein
 Keeping warm
 Oxygen
 Raising the legs
If there is a rupture, surgery (laparotomy) is done to stop blood loss. This surgery is also done to:
 Confirm an ectopic pregnancy

 Remove the abnormal pregnancy
 Repair any tissue damage
In some cases, the doctor may have to remove the fallopian tube. {Salpingectomy}
A mini-laparotomy and laparoscopy are the most common surgical treatments for an ectopic
pregnancy that has not ruptured. If the doctor does not think a rupture will occur, you may be
given a medicine called methotrexate and monitored. You may have blood tests and liver
function tests.
Possible Complications
The most common complication is rupture with internal bleeding that leads to shock. Death from
rupture is rare. Infertility occurs in 10 - 15% of women who have had an ectopic pregnancy.
.Prevention
Most forms of ectopic pregnancy that occur outside the fallopian tubes are probably not
preventable. However, a tubal pregnancy (the most common type of ectopic pregnancy) may be
prevented in some cases by avoiding conditions that might scar the fallopian tubes.
The following may reduce your risk:
 Avoiding risk factors for pelvic inflammatory disease (PID) such as having many sexual
partners, having sex without a condom, and getting sexually transmitted diseases (STDs)
 Early diagnosis and treatment of STDs
Early diagnosis and treatment of salpingitis and PID
OTHORPAEDICS QUESTIONS
OSTEOMYLITIS
Mrs. Joyce Wenu aged 35 years; Married with five (5) children is admitted to your ward
complaining of tenderness in the left leg and general body malaise. After thorough examination, a
diagnosis of Osteomyelitis is made.
a. Draw a well labeled diagram of the femur 15%

b. List five (5) signs and symptoms Mrs. Wenu is likely to present with other than the ones
mentioned in the stem 10%
c. Identify five (5) problems Mrs. Wenu is likely to present with and using the nursing care plan,
describe the management of Mrs. Wenu 50%
d. Explain five(5) complications of Osteomyelitis 25%
MARKING KEY FOR OSTEOMYELITIS
b. SIGNS AND SYMPTOMS OF OSTEOMYELITIS

 Pain in the left leg fever
 Redness on affected leg
 Warmth on the affected leg
 Drain sinus (when the inflammation has become chronic)
 Selling on the left leg
NURSING CARE PLAN

Problem Objective/Goal Intervention Rationale Outcome/Evaluation
Pain on the To relieve pain  Give prescribed To relieve pain (aspirin Patient verbalizes less
affected site through out the analgesics/ant- relieves inflammatory or no pain at all through
patients stay in inflammatory drug processes including out hid stay in hospital
hospital e.g. Aspirin pain
 Provide a To shift the attention
diversional therapy from pain and relieve
like playing the pain.
radio
Risk for To prevent extension  Clean the wound Hydrogen peroxide is a Infection has not
extension of of infection to other daily with strong disinfectant extended to another part
infection of parts of the bone and hydrogen peroxide cleaning solution (kills of the bone and
infections to surrounding tissues using aseptic some of the infection surrounding soft tissue
other parts of technique producing micro- evidenced by swelling,
the bone and  Give prescribed organism) not increasing and
surrounding antibiotics such as absence of draining
soft tissue crystalline Antibiotics are bacterial sinus
penicillin, (kill bacterial) and
Gentamycin etc. bacteriostatic(Arrest the
 Observe the growth of bacteria)
affected site for
increase in swelling To see if the infection
and draining is extending to another
 parts of the bone .
Impaired Physical mobility  Immobilize Assistive device Physical mobility is
physical will be increased affected leg with increase physical increased during the
mobility during the patients splint, but use mobility. patients stay in hospital
stay in hospital assistive device to To increase physical
increase to increase mobility
mobility.
 Ensure full function
of unimpaired
extremities
 Ensure patient
participate in self –
care activities.
Patient will be  Listen carefully to Listening helps in Patient is
Knowledge knowledgeable about what the patient detection of knowledgeable about
deficit the disease and its says about the misunderstanding and the disease and its
treatment within 48 illness misinformation and treatment within 48
hours of admission  Prepare a teaching provides opportunity hours of admission
plan and provide an for education.
explanation about
the disease, cause, Knowledge about
signs and disease and treatment
symptoms and usually increase
treatment, etc compliance
Allow patient to ask  The patient ‘s
questions question indicate
issues that need
clarification
5 Prevent development  Immobilize  Avoids
Risk of of pathological affected leg with a pressure/stress
developing fracture splint to the
pathological  Use assistive weakened (or
fracture device affected ) bone
 Ensure full unction  Assistive
of unaffected device will
extremities. bear the
pressure/stress/
 The will help
bear pressure,
No pathological
fracture develops.
6 Patient will not have  Give prescribed  These There is absence of
Risk of bacteria and their antibiotics, e.g x- antibiotics are bacteria and their toxins
septicemia toxins in her blood pen bactericidal(kill in the patient’s blood
stream gentamycine,etc. bacteria) and stream evidenced by
 Clean the wound bacteriostic temperature which is
daily with arrest the within the normal
hydrogen peroxide growth of range.
using aseptic (Hydrogen
technique. peroxide is a
 Take temperature strong
2-4 hourly daily disinfectant
depending on the which kills
condition some micro-
organisms
 Monitoring
temperature
helps to detect
fever which is a
sign of
7. Swelling To reduce on the  Elevate the affected  This promotes Swelling is reduced
swelling of the limb with pillows venous within 72 hours of
affected part within  Give proscribed drainage admission
72 hours of anti inflammatory thereby
admission drug e.g. Aspirin reducing the
swelling
 Aspirin
counteracts the
inflammatory
processes
including
swelling
EXAMPLE 2 IF USING LOPER ROGAN MODEL OSTEOMYELITIS
Problem Objective/Goal Intervention Rationale Outcome/Evaluation

1.Pain as a To  Immobilization left To reduce movement Pain is relieved within
result of relieved pain within leg with a splint and stress on the 48hours of admission
immobilization 48 hours of  Elevation of affected leg thereby evidenced by facial
of affected intervention after affected leg on reducing pain. expression.
limb admission pillows
 Putting bed cradle To reduce on the
over the affected swelling and pressure
leg to the affected site,
thereby reducing pain.
To Lift weight of the

linen (or pressure)
from affected leg
thereby reducing pain
D. COMLICATIONS OF OSTEOMYELITIS
 Pathological fracture- the bone on the affected part becomes weak and may end up breaking
 Septic arthritis – Infection may spread from the nearby joint causing inflammation of the joint.
 Septicemia- Bacteria’s and their toxin may invade the blood stream causing widespread infection
 Draining sinus – this discharge from the infected bone (bone abscess) through the surrounding
soft tissue
 Sequestrum- this is the dead bone tissue where the abscess has formed. There is deprivation.
ANSWER KEY TWO OSTEOMYELITIS

DEFINATION
 Osteomyelitis is the infection of bone tissue from pathogenic, organism particularly
staphylococcus aurues, which irresponsible to 80% of infections.
CAUSES:
 This mainly a staphylococcal aurues, infection (80%), occasionally, species of proteins
pseudomonas and E.Coli are responsible.
PRE – DISPOSING FACTORS

The people that are at high risk of getting this infection are
 The poorly nourished
 The Elderly
 The obese
 People with impaired immune system
 Those with chronic illness such as diabetes, rheumatoid arthritis.
 Patients receiving corticosteroids

 Invasive bone surgery.
MODES OF INFECTION
Bone tissues can become infected by one of the three modes
 Extension of infection to soft tissue as in infected ulcer, vascular ulcer or incision infection.
 Direct bone contamination from bone surgery, open fracture gunshot or traumatic ulcer.
 Haematogenic spread from other side from the body i.e. infected tonsils, boils, URTI.
PATHOPHYSIOLOGY OF OSTEOMYELITIS
 Osteomyelitis is mainly caused by staphylococcal aurues. The initial response to the infection is
inflammation, followed by increased vascular and oedema.
 If the infection is blood bone, the onset is usually sudden, causing (acute Osteomyelitis) It is
accompanied by chills fever rapid pulse and general malaise. These systematic symptoms may at
first overshadow the local symptoms.
 As the infection progress it involves the periosteumm, extends to the cortex of bone and the
eventually the soft tissue .Because of the swelling and pressure from oedema, the infection area
becomes painful and very tender. Increased vascular makes the area to feel warm and swollen.
 2 to 3 days after infection, a thrombus of blood vessels occurs. This may occlude blood
supply thereby causing ischemia and bone necrotic forming pus. The patient feels a
pulsating pain as pus accumulates.
 The resulting necrotic tissue forms sequestrum which does easily liquefy and drain, therefore the
cavity does not collapse and heal.
 The increased in pressure results in whole being formed known as a sinus through which the pus
attempts to escape. New bone growth (involuculum) begins to form around the sequestrum
through the sequestrum remains infected even when healing has occurred.
 This produces recurrent abscess throughout the patient’s life.
 This condition is referred to as chronic Osteomyelitis.
 A patient with Osteomyelitis present with a continuous draining sinus or experiences recurrent
periods of pain, inflammation, low grade fever, swelling and drainage.
CLINICAL FEATURES OF OSTEOMYLITIS (SIGNS AND SYMPTOMS)

 Onset is usually sudden, especially if it is blood bone
 Increased actuality and oedema
 High fever
 Rapid pulse
 Chills
 General malaise
 Infected area is painful, swollen and tender
 Area may feel warm
 Sinus formation in chronic Osteomyelitis
DIAGNOSIS / INVESTIGATIONS
 History of underlying predisposing factors is collected
 X- ray of affected part may demonstrate soft tissue swelling in the early stages.
 Blood studies review elevated WBC counts.
 Wound culture swabs are collected to isolate causative organism
 Blood culture is done to determine infective organism and for appropriate antibiotics therapy.
 Sinuses are observed in chronic Osteomyelitis
 Increased ESR is evident.
MEDICAL MANAGEMENT
OBJECTIVES
 The main objective is to control or halt the infection process
 Immobilize the effected part
 Relieve and discomfort
 Prevent Complication.
 The medical management aims at controlling the process of infection so that blood supply for the
area is not diminished
 Antibiotic therapy is immediately. This should be based on the blood and culture results. The I.V
anti biotic therapy should continue for 3 to 6 weeks. After the infection appears to have been
controlled, oral administration continues for up to 3 months.
To enhance absorption oral antibiotics should not be administered with food
Other supportive measures in include:
 Hydration
 Good nutrition with high vitamins and proteins
 Correction of anemia
 Analgesia may be prescribed to relieve comfort and pain.
SURGICAL MANAGEMENT.
The main objective is to halt the infective process

Relieve pain
Prevent pathological fractures and deformity.
If patient does not respond to antibiotics therapy, the infected bone is surgically exposed, and the
pus and necrotic tissue is removed. The area 1 irrigates with sterile saline solution. This is s called
Surgical Debridement, followed by sequestectomy.
 Sequestectomy is the removal of sequerum or the involuclum, In most cases sufficient bone tissue
is removed such that the deep cavity appears shallow like a saucer the term (Saucerization)
 Because surgical Debridment weakens the bone, internal fixation or external supportive devices
may be used to stabilize support the bone to prevent pathological fracture.
NURSING CARE /MANAGEMENT.
The objectives of nursing care management are

 Provide a safe and conducive environment for rapid recovery from the disease process
 Help to relieve discomfort and pain.
 Prevent occurrence of complications such as pathological fractures.
ENVIRONMENT
 The patient with Osteomyelitis is nursed in a surgical ward preferable in a side ward aw ay from
routine ward traffic to ensure maximum rest and com fort.
 The ward should be cleaned everyday by through dump dusting, mopping all the surfaces. It
should be well ventilated with adequate light. These measures prevent cross infection. Provide a
comfortable and soothing environment
POSITION
 The patient is nursed in a position he find more comfort regimes, such as immobilization, he
should ensure frequent turnings (at least 2 hourly ) to promote circulation and prevent
development of pressure sores.
PSYCHOLOGICAL CARE
 The patient may be apprehensive about the outcome of the disease process at the possibility of
long term treatment or immobilization.
 Explain to the patient the disease process, its eventful outcomes without alarming the patient.
Focus on the positive outcomes but avoid giving false hopes, patient should understand the need
to restrict certain vigorous activities while remaining productive.
 Involve the significant others in the care of the patient as home care will be inevitable
REST AND ACTIVITY
 The patient should understand the rationale for the activity restrictions. The joint above and
below the affected part should be gently placed through a range of motions. The nurse encourages
full range of ADLs within the physical limitations to promote the general well being
PAIN RELIEF
 The effected part is usually immobilized in a split to decrease pain and muscle spasm.
 The nurse monitors the neuromuscular status of the affected extremity. The wounds are usually
very painful thus should be handled with care and gentleness.
 Elevation reduces swelling and the associated discomfort while the pain can be controlled
prescribed analgesia.
OBSERVATIONS
 Vital signs of temperature and pulse rate are taken to monitor the disease process.
 Monitoring of the neuromuscular function is cardinal to ensure that ischemia is not developing.
 The general well being of the patient is frequently assessed, his reaction to pain, his nutritional
status, compliance to the treatment regimes such a immobilization and generally his reaction to
hospitalization.
 Development of sinus or drainage of pus from the wound site is checked.
 Daily wound care with the prescribed antiseptic solution should be done. This helps to halt the
 Patient is also encouraged to assume personal hygiene measure such as general body hygiene oral
care and hair care.
 The clothes worn should be clean and linen where patient is lying should be frequently changed.
MEDICATIONS
 Patient may be put on long term antibiotic therapy, thus adherence to the therapeutic regime will
be critical to avoid resistance developing. The nurse monitors the patient for super infection as a
result of long term use of antibiotics. These could be vaginal candidacies oral candidacies or foul
smelling stools.
PATIENT TEACHING /IEC

 Patient relative must learn and recognize the importance of adhering to the therapeutic regimes,
preventing falls and other injuries.
 Patient may need to know how to manage IV at home
 Identification of additional painful sites should be reported
 Report any elevation in temperature
ARTHRITIS
Mr. Monze, a famous cyclist, underwent knee surgery after suffering from acute septic arthritis which
developed after falling off his bicycle.
a) Define acute septic arthritis 5%

(i) List five {5} causes of arthritis 10%
b) Explain five {5} signs and symptom of acute septic arthritis. 10%
c) Discuss in detail the Pre operative care of a patient due for bone surgery 50%
d) Mention {4} four rehabilitative measures that you would inoperative in your teaching plan to
your patient 5%
DEF: This is the inflammation of the tissues of the joints. Arthritis is frequently accompanied by
joint pain. Joint pain is referred to as arthralgia.
There are different types of arthritis depending on the infection: e.g. Rheumatoid arthritis.
SEPTIC ATHRITIS OR INFECTIOUS ARTHRITIS:

Is an infection in the synovial fluid and tissues of the joint? There are many forms of arthritis
(over 100 and growing). The forms range from those related to wear and tear of cartilage (such
as osteoarthritis) to those associated with inflammation resulting from an overactive immune
system or wear and tear of collagen fibres(such as rheumatoid arthritis).
Pathophysiology.
The joint can become infected through spread of infection from other parts of the body
{haematogenous spread or directly from trauma or surgical instrumentation.
Previous trauma to joints, joint replacement, coexisting arthritis and diminished host resistance
also contribute to development of infection. The main causative organism is staphylococcal
aureus. Streptococcal and other forms of gram-negative organisms have been sited.
The infection leads to development of joint pain, due to nerve irritation, there is redness,
warmth, swelling and tenderness due to increased vascularisation, patient has restricted
movements resulting in joint stiffness as a result of fear of pain.
Many of the forms of arthritis, because they are rheumatic diseases, can cause symptoms
affecting various organs of the body that do not directly involve the joints. Therefore,
symptoms in some patients with certain forms of arthritis can also include fever, gland swelling,
weight loss, fatigue, feeling unwell, and even symptoms from abnormalities of organs such as
the lungs, heart, or kidneys.
CAUSATIVE ORGANISMS
include
 injury (leading to osteoarthritis),

 abnormal metabolism (such as gout
 infections,
 Unclear reasons (such as rheumatoid arthritis and systemic lupus erythematosus).
BACTERIAL
 Staphylococcus aurous
 Heamophylus influenza
 Gonococcus
 Streptococcus pneumonia
 E.coli
 Salmonella
 Pseudomonas
 Mycobacterium
VIRUSES
 Hiv
 Parvo virus
 Rubella virus
 Hepatitis B virus
FUNGAL
 Candida albicans
MODE OF TRANSMISSION
1. Haematogeneous spread from other parts of the body.

2. Direct contamination of the joint during surgery or trauma.
PREDISPOSING FACTORS
1. Any current bacterial infection esp. of the genital urinary system or upper respiratory
system
2. Chronic debilitating illness such as cancer and Diabetes mellitus.
3. Patients with immunosuppression e.g. HIV.
4. Alcoholics and elderly.
5. Patients with recent joint surgery
CLINICAL MANIFESTATIONS
1. Warm painful swollen joint with decreased range of motion
2. Chills and fevers because of inflammatory process
3. Joint pain
4. Limited function of joints.
5. Inflammation of the joints, characterized by joint stiffness, swelling, redness, and

warmth.
6. Tenderness of the inflamed joint can be present.
7.
MANEGEMENT
Objectives
 Ensure early and accurate diagnosis for proper treatment

 Relieve of pain
 Prevention of deformity and complications
INVESTIGATION
1. History taking that will review previous long standing infection of upper respiratory or
urinary system infection. may also review previous bone surgery or trauma.
2. Physical examination that will review swelling, pain and at the site of infection and fever.
3. Full blood count that will review elevated white blood cells.
4. ESR that will be elevated.
5. X.RAY of the joint.
6. Joint aspirate for M/C/S to isolate the causative organism
7. Urine Examination
8.
TREATMENT
 Prompt treatment with IV Antibiotics until symptoms disappear. Such as cloxacillin,
gentamycin. Prompt treatment is essential. Broad spectrum IV antibiotics are started
immediately and changed to organism specific antibiotics once culture results are
available. The IV antibiotics are continued until symptoms disappear.
 Doctors may aspirate the joint with a needle to remove the excessive fluid and exudates
this prompts comfort and decrease joint discomforts.
 Arthrotomy is done to drain the joint and remove dead epithelial tissue.
 Infection caused by fungi can be treated with antifungal drugs. And combined TB
infection is treated by combined antibiotics.
 Analgesia, such as codeine may be prescribed to control pain. After the infection
has responded to antibiotic therapy, NSAIDs may be prescribed to limit joint
damage.
 The inflamed joint is supported and immobilized in functional position by a splint
that increases the patient’s comfort.
 Progressive range of motion exercises are prescribe after the infection has subsided
NURSING CARE OF APATIENT AFTER ATHROTOMY
PAIN RELIEF
Splitting a joint and immobilizing it in a functional position can help ease the pain and promote
comfort.
Prescribed analgesia such as codeine is given to control pain.
FLUID AND NUTRITION.

IV fluids can be given initially to prevent dehydration due to fever, later encourage plenty oral
intake of fluids. Encourage high intake of calorie diet to promote healing.
WOUND CARE:
Practice aseptic technique to prevent infections
Monitor for signs of joint inflammation such as swelling, heat, excessive pain and excessive
drainage.
OBSERVATIONS:
Monitor vital signs esp. temperature for fever pattern
EXERCISES:
When the temperature is stable encourage patient to do progressive range of exercises.
Encourage patient to perform such much self care as his immobility and pain allows.
IEC:
 Explain the importance of supporting the affected joint.
 Adhering to prescribed antibiotic treatment and observing weight bearing and activity
restrictions
 Teach patient how to use assistive devices such as crutches safely.
 Encourage patient to perform normal range of exercises to prevent joint distraction.
 Teach patient on how to promote healing through balanced diet and proper wound care.
AMPUTATION
DEFINITION
1. Amputation is a surgical procedure or traumatic removal of a part of an individual’s body
through bone.
2. Amputation is the removal of a body extremity by trauma or surgery.
3. Disarticulation. Disarticulation is the removal of a part of the body through a joint space.
• Amputations range from removal of part of a digit to the removal of half of the patient’s
entire body.
(i) Draw and labelled the femur:

N.B Check diagram in Wilson and Ross page 390, Figure 15.38 (12%.)
(ii) 5 Indications of Amputation:

1. Infection such as gangrene. Diabetic foot infection or gangrene (the most
common reason for non-traumatic amputation)
2. Vascular disease (peripheral)
3. Trauma crushing injuries. Severe limb injuries in which the limb cannot be spared
or attempts to spare the limb have failed
4. Burns (electric)
5. Congenital deformities
6. Chronic osteomyelitis. Cancerous bone or soft tissue tumours (e.g. osteosarcoma,
osteochondroma, fibrosarcoma, epithelioid sarcoma, synovial sarcoma)
7. Circulation problems
TYPES OF AMPUTATION.
• Below the knee amputation. {BK or BKA} The below knee amputation preserve the
knee joint and make prosthetic fitting and ambulation easier.
• Knee disarticulation. {KD}. Knee disarticulation removes the lower leg through the knee
joint. The procedure is rarely used because of the difficult in fitting the prosthesis.
• Above knee {AK or AKA} These do not preserve the knee .They are usually performed
for trauma and PVD
• Hip disarticulation.{HD} This is the removal of the leg through the hip joint a occurs
more commonly in young patients due to trauma or neoplasm.
• Hemopelvectomy.{HP} This an amputation that removes half o f the patients pelvis ad
all the patients legs and is usually performed because of neoplasm
• Hemicorporectomy{HP} This is the removal of the lower half of the body ,which
includes loss of the lower extremities, a colostomy, a urinary diversion and loss of sex
organs .It is usually done in advanced pelvic cancer or pelvic sepsis
• finger and thumb. Finger or thumb amputations include all or only a portion of the digit.
It is usually done due to trauma or frost bite
• Wrist disarticulation. This is the removal of hand through the wrist joint
• Below the elbow. This is usually performed as a result of trauma or congenital
deformities
• Elbow disarticulation is done to remove arm through the elbow
• Above the elbow. This is also done as a result of trauma or congenital deformity
• Shoulder disarticulation is the removal of the shoulder joint through the shoulder
• Four quarter amputation. This remove a large portion of the patient shoulder and arm .It
is usually performed as a result o f trauma
(a) Identify and explain 4 investigations (12%)

1. X-ray of the bone - to confirm diagnosis
2. Serum alkaline phosphate - will be elevated
3. Bone scan - to detect extent of cancer
4. Chest x-ray - to eliminate metastasis
5. Renal and liver function test to check effect on these organs
6. Bone biopsy - to confirm the diagnosis after identifying cancer cells.
Preoperative care.
• Before surgery, the patient’s general condition must be evaluated. A prosthetics should
evaluate the patient and take measurements and a shoe for the patient to assist with the
prosthetic fitting.
• The preoperative psychological assessment will also greatly enhance postoperative
evaluations and nursing care. It is important that the patient understands the operation
before it occurs to foster a positive attitude towards rehabilitation. Let the patient ask
questions and make the patient comfortable enough to express fears anxieties. Observe
his interactions between the family, and significant others specifically to the topic of
amputation. A visit by a person who has had an amputation may be very helpful.
DISCUSS THE POST-OP CARE IN THE FIRST 72 HOUR; (50%)

Objectives (2%)
1. To prevent complications e.g. pain, haemorrhage
2. To maintain psychological stability
3. Have the patient free of physical and emotional complications
4. Maintain full and functional capabilities
5. Restore as much leg function as possible by use of prosthesis and rehabilitation
6. Decease level of pain through repositioning
7. Increase mobility
8. Maintain skin integrity
9. Ensure a positive self concept.
Environment.
• The patient will be admitted to a postoperative surgical ward after surgery and recovering
from anesthesia.
• In the acute stages, he may be put in the acute bay for easy observations.
• He is placed in a rail bed to avoid accidental falls as he gains full consciousness.
• The environment should be clean, well ventilated for comfort and reduction of cross
infection.
• It should have adequate light for easy observation and prevention of accidental falls.
• The floors should not be slippery or any spills of water should not be left for a long time
as these may lead to accidents.
• A quiet environment would be appropriate as it would reduce anxiety.
Breathing:
 Ensure patent airway by good positioning
 Patient lies flat on the bed with no pillows
 Recumbent position with head tilted on one side (Give 3%)
Position
• The position to be assumed should ensure a patent airway as the patient is recovering.
• A fracture bed should be used to prevent discomfort and contracture formation
• Immediately after surgery, the patients affected leg may be elevated to reduce swelling
and pain but only for the first 24 hours.
• The patient should be encouraged to use the trapeziums-initially with assistance to
change position in bed.
• The patient is allowed to turn either side but he will probably prefer to turn to the
unaffected side with pillows between the legs for comfort.
• The also pillows help to reduce the any feelings of stress the patient may have where a
cast has been applied to the leg.
• Good positioning helps the patient to regain physical mobility.
Observations:
Assess the patient level of consciousness, auscultator chest for clearness of lungs and any heart
problems
*1/4 hourly vital signs obs and general condition

 Then 1/2 hourly, Observations of vital signs of temperature, pulse, respiration and blood
pressure as ordered. A fall in the blood pressure and pulse soon after surgery may be
indicative of severe haemorrhage. note the amount of drainage from the wound drains
 Low blood pressure may denote passive bleeding or severe blood loss in theatre. Give
I.V fluids such as normal saline should the BP be low.
 High pulse rate denotes bleeding or severe blood loss
 Observe and watch for bleeding from the stump.
 Observe for rest of stump by putting a well folded towel in between two sand bags to rest
the stump.
 Observe for signs of pain and give appropriate measures. Give 7%.
 Assessment of the stump is done to exclude excessive bleeding. The dressing should only
be reinforced if the bleeding is heavy. If the bleeding appears not to stop, the Doctor is
informed immediately.
 Observe the patients reaction towards the stump {self –concept disturbance} Most patient
will not look at the stump.
 Observe that the cast or bandage is not too tight to interfere with normal circulation
{inform the Doctor immediately}
 Check the residual limb for any pressure sores
 Check the skin integrity and any possible injuries if amputation was due to trauma
 Check for presence of infection on the stump {foul smelling dressing}

Pain Relief: 5%
 Surgical be controlled by narcotics such as pethidine 100 mgs PRN
 Evacuation of accumulating fluid and blood by a drain and bag help to relieve pain.
 This is to prevent haematoma formation which causes severe pain
 Change of position relieves discomfort and pain arising from bony prominence pressure.
 Placing towel above the stump placed in position by two sand bags on each side reduces
movement of stump which causes discomfort arising from spasm
 With the use of a rigid dressing strong opiates are often unnecessary. The rigid dressing is
able to decreases the severity of pain after surgery. The extremity can also be elevated to
reduce edema and pain. but this should only be for 24hrs as it can lead to development of
flexion contractures
 The patient may complain of phantom pain] sensation of pain felt in the amputated limb ,
it is real and occurs in 80% of cases} t can not be relieved by medications.
 Phantom pain may begin immediately after surgery or may occur 2 to 3 months later. A
immediate post surgical prosthetic fitting helps to decrease phantom pain but having the
patient describe the pain in detail may be the most beneficial intervention. The patient
may also be told of the pain before surgery so that h does not get extremely alarmed and
think that he is out of his mind if he complains.
Phantom pain on the removed part is prevented by keeping patient occupied. Minor
tranquillisers may be given. Give 5%.
Care of stump - 7%
 Elevate the foot of the bed to prevent swelling of the stump as elevation promotes
drainage.

 Observe for bleeding from the stump which could be from a loosed suture by
collaborating with vital signs.
 Bed cradle be placed on the bed to lift the weight of bed linen as this may spike spasms.
 Observe the change of colour of bandage as this may indicate infection.
 Don't open the dressing or bandage any how to prevent infection from setting in.
 Prevent infection by administering prophylactic broad spectrum antibiotics as ordered.
 The bandage is left intact in all the 72 hours. Give 7%.
Psychological Care:
 Loss of limb causes severe grieving. Assess the emotional responses to the surgery and
attitude towards the residual limb. There is usually disturbance of self concept and loss of
self esteem.
 Be understanding if change of behaviour is seen e.g. crying, withdrawal. Depression, etc.
 As a nurse acknowledge the loss. You can play a vital role to uplift the self esteem.
 Create an accepting and supportive atmosphere
 Spiritual care by the clergy is very important
 Be a good listener.
 Allow the patient to ventilate. Encourage a positive outlook by inviting other patients
with a similar disability. Encourage independence of daily living activities
 Explain the change of bed by cradles, sand bags, drains, bed elevation for co-operation.
 Relief of pain will help greatly in reducing anxiety
 Explain on the use of crutches.
 Support patient in coping process.
 Begin rehabilitation and other support measures early
 Encourage significant others to support the patient
Infection
• Infection or potential for infection are a special concern for a with a BK amputation
especially if the reason for amputation was trauma or osteomyelitis. The operation is
usually performed high enough to gain good blood supply and to remove any necrotic
tissue. However they is always a chance that the procedure may not eradicate the
osteomyelitis or prevent infection.
• So the patient is place on antibiotic therapy.
• Observations foe signs of infection should therefore be done frequently.
• Wound dressing should be done using aseptic technique
• The patient is not allowed to put dirty clothes on the wound or touch the wound with bear
hands
• Soiled lined is changed whenever dirty t reduce contamination of the wound
Exercise and Ambulation: 4%
 Patient will be bed ridden for a long time even in the whole of 72 hours.
 In the initial stages rest will be encourage. However with full recovery from anesthesia,
early ambulation with limited weight bearing on the prosthetic fitting will be beneficial
psychologically a it helps to lessen emotional trauma from loss of the limb.
 Chest exercises to prevent pneumonia.
 Passive exercises of other limbs to prevent contractures.

 Turnings two hourly to prevent bed sores formation but also to prevent constipation.
Give 4%
Nutrition 3%
 Patient begins to eat once he has fully recovered from anaesthesia.
 Food rich in proteins and vitamins for healing of stump
 Encourage a lot of fluids to encourage defecation and urination since bed riddeness
causes stone formation.
Elimination: 2%
 Promote urination by giving plenty oral fluids
 Give a laxative to promote opening bowels
Hygiene - 3%
 Bed bath for self esteem and blood circulation
 Pressure area care to prevent bedsores and two hourly turnings
 Encourage patient to do what he can e.g. mouth care.
Health education: 3%
 Walking exercises with crutches
 Teach how to wrap the residual stump
 Advise patient to care for the other limb to prevent injury. Total 50%. For
 Before the patient can accept a change in the body image, he must first understand what
happened and the prognosis. It is clear that the patient with an amputation, his family and
significant others will need a lot of time to adjust to the disability. This may come so
easily with some patient but may be a night mare to others. As a nurse you need to take
time to understand the predicament and offer the best possible care to this patient.
 Be able to identify people and counselors ho would best assist with the situation
 Involve other team members directly dealing with such disability like the physiotherapist
in the care plan
 This whole process will influence the adjust process.
 For most patients with BK amputation the chance of returning to near normal activities
are very good.
 Many are able to ambulate to gait which I s indistinguishable from normal
 Sub headings 1% - Objectives - 2%.
Rehabilitation
Objectives
• The main goal of rehabilitation is to assist a patient function to his pre-illness or pre-
injury level as quickly as possible . If this not possible then the aim should be to assist the
patient gain maximum independence and to live a quality of life acceptable to him. so
realistic goals should be set based on the assessment of the patient and established with
the patient.
Definition.
• This is a dynamic, health-oriented process that assess an individual or a person with
disability {restriction in performance or function in every day activities} to achieve the
greatest possible level of physical, mental spiritual, social and economic functioning. The
rehabilitation process helps to achieve the acceptable quality of life with dignity, self
respect and independence and is designed for people with people with mental emotional
or physical disabilities. During rehabilitation or sometimes called habilitation-the patient
adjusts to the disability by learning how to use resources and to focus on existing
abilities. In habilitation abilities not disabilities are emphasized.
• Disability can occur at nay time and can be a result of an acute incident such as stroke or
trauma or progression from the chronic condition such as arthritis or multiple sclerosis. A
person with a disability experiences many loses including loss of function, independence,
social role, status and income. The patient and his relatives experience a range of
emotional reactions to these loses. the reaction may progress from disorganization and
confusion to denial of the disability .Theses reaction may subside over time and recur at a
later time. Patients who exhibit grief should not be blithely encouraged to cheer up. The
Nurse should show a willingness to listen to the patient talk about the disability and
should understand that grief, anger, regret and resentment are all part of the healing
process.
• Rehabilitation is an integral part of nursing because every illness or injury carries a threat
to disability or impairment, which involves a loss of function or an abnormality. The
principles of rehabilitation are basic o the care of all patients.
• Rehabilitation of patients should begin with the initial contact with the patient.
Focus of rehabilitation
• The patients preexisting coping abilities play an important role in the adaptation process
one patient may be particularly independent and determined while the other patient may
be dependent and seem to lack personal power.
• One aim of rehabilitation is to help the patient gain a positive self concept through
effective coping
Four complications and prevention:

1. Oedema 1%
2. Fat embolism 1%
3. Gas gangrene of stump 1%
4. Deformity of stump 1%
5. Reactionary/secondary haemorrhage. 1%
Prevention:
1. Haemorrhage: 3%
 Prevention is by good ligating in theatre, prevention of infection and resulting the stump.
2. Fat Embolism: 3%
 Good suturing in theatre will have to be ensured to prevent this.
3. Gas Gangreme: 3%
 This is prevented by ensuring sterility in theatre
 Do not open the wound or bandage in the whole of 72 hours.
4. Oedema of stump: 3%
 Prevent this by keeping the bandage on the stump tight
 If it comes out then re-tie it tight back
 Elevation of foot bed.
5. Deformity of stump: 3%
 Avoid hip flexion
 Good bandaging technique to ensure good alignment and narrowing of the distal stump
for possible fixation of prosthesis. Total = 16%, 1% for listing, 3% for prevention,
for 4 total is 16%.
FRACTURES
Definition:
A Fracture is a break in the continuity of bone tissue.
Causes of Fractures
 Direct blows
 Crushing injuries
 Sudden twisting motions
Pathophysiology of a Fracture
Fractures occur when bone is subjected to stress greater than it can absorb. Among the
causes, are direct trauma and crushing injuries, when a bone is broken, adjacent
structures may be involved also, resulting in soft tissue damage, oedema, and
haemorrhage into muscles and joints, there may be dislocations, rupture tendons,
severed nerves and damage to blood vessels. Internal body organs may be damaged
too, by the force that the fracture may cause or through fracture fragments
Clinical manifestations of a Fracture
 Pain. The pain is continuous and increases in intensity until the bone fragments
have been immobilised. The pain is due to muscle spasms. These spasms are a
natural splinting mechanism designed to minimise further movements of the
fractured fragments.
 Loss of Function. After a fracture, the extremity cannot function properly since
the normal function of the muscles depends on the integrity of the bones to
which they are attached. Pain equally contributes to the loss of function
 Deformity. This may be due to displacement, angulation or rotation. The
deformity can be visible or palpable. The deformity also results from soft swelling
 Shortening of bone. In fractures of long bones ,there is actual shortening o f
the extremity because of contraction of the muscles that are attached that are
attached above and below the site of the fracture
 Creptus. When an extremity is examined with hands a granting sensation is felt.
These are called creptations {Creptus}
 Swelling and Discolouration. Localised swelling and discolouration of the
skin {ecchymosis} occurs after a fracture due to trauma and bleeding into the
vascular tissue

Types of fractures;
Fractures can be described according to type and extent of damage. They can also be
named according to anatomical placement of fragments.
1. Open Fracture – This is any fracture with an associated open soft tissue injury.
Skin integrity over or near the fracture site is disrupted. It’s also called
compound fracture.
2. Closed Fracture – Any fracture without associated open soft tissue injury. Skin
integrity over or near a fracture site is intact.
3. Transverse Fracture – Results from angulation force or direct trauma. The
fracture line is straight across at a right angle to the long axis of the bone.
4. Oblique Fracture – Results from a twisting force. The fracture line crosses the
bone at an oblique angle.
5. Spiral Fracture – Results from twisting force with firmly planted foot. The
fracture line twists around and through the bone.
6. Comminuted Fracture – Results from severe direct trauma causing splintering
of bone into 2 or more fragments.
7. Compressed or Impacted Fracture – Results from severe force to top of
head or heel. It also may be caused by acceleration-deceleration forces. Distal
and proximal fracture sites are wedged into each other.
8. Greenstick Fracture – Results from compression force. The bone buckles or
bends. This is an incomplete fracture.
9. Avulsion Fracture – Results from muscle mass contracting forcefully, causing
bone fragment to tear off at insertion.
10.Depression Fracture – Results from blunt trauma to a flat bone; usually
involves much soft tissue damage.
General Care of Fractures:
Medical management at accident site;
Objective
 Arrest haemorrhage
 To prevent further injury

 Ensure prompt medical attention
 Prevent complications
Patient Assessment:
Determine area of suspected fracture. Extremity may be deformed, discoloured, and/or

painful to touch. Determine if evidence of skin disruption near or over the suspected
fracture which would indicate an open fracture.

1. Attempt to control bleeding. Apply direct pressure or pressure bandage. Elevate
2. Obtain history from patient and/or significant other, including mechanism of
injury, time and date of injury, any treatment or splinting prior to arrival.
3. Open fractures should be dressed with sterile saline dressing before splint
applied.
4. Assess the "Five P's": Pain, pallor, pulses, parathesia, and paralysis.
5. Check distal pulse.
All suspected fractures should be splinted. Immobilize joints above and below fracture
before moving the patient. Do not attempt to push back any bone ends.
Check circulation and pulse of extremity before and after immobilizing and record. If no
pulse or limb cyanotic, inform physician immediately
1. Use of splints:
A. Suspected forearm and hand fractures, apply plastic splint padded and wrapped
with Kling.
NOTE: Plastic splints x-ray better. All suspected fractures should be splinted
before x-ray.
B. Suspected shoulder and upper arm injury - apply sling or allow patient to
immobilize with other hand and arm. May be more comfortable for patient to sit
upright with forearm resting on pillow.
C. Suspected fractures of lower leg, foot, and ankle. Use long padded plastic leg
splint applied with sling.
D. Splint suspected femur fractures with Hare traction splint or bucks traction per
physician orders.
E. For suspected elbow fractures splint with plastic jointed splint or sling in position
of injury.
NOTE: No attempt should be made to change position of limb. Frequently check
circulation, movement, and sensation of involved extremity.
F. Pelvic fractures require no splinting.
NOTE: Observe patient for signs of shock. There is a potential for large amount
of blood loss.
Analgesia of choice may be ordered by orthopaedic surgeon. Consider other injuries. No

attempt should be made to change position of dislocation. All suspected extremity
fractures should have cold application and elevation with ice packs wrapped in light
cloth and applied to injury site. Extremities should be elevated above the level of the
heart. All orthopaedic patients should be placed on carts in the Emergency Department.
General Care of Fractures:
Objectives of management
 Reduction of fracture

 Immobilization
 Pain relief
 Regaining of normal function through rehabilitation

Obtain thorough history of mechanism of injury in order to identify potential

orthopaedic injuries that may otherwise be missed.
 Assess for the "Five P's": Pain, Pallor, Parathesia, Pulse and Paralysis.
 Assess for deformity, swelling, creptations, discoloration, open wounds and other
injuries. Open fractures are considered contaminated due to foreign material and
bacteria being introduced into the wound. Assess the presence of foreign
material.
 Elevate, immobilize and apply ice to the affected area.
 Determine degree of pain, swelling and deformity.
 Inform the patient of probable need for radiologic studies. (Note date of LMP for
female patients)
 Frequently re-assess Neurovascular status.
 If skin integrity is disrupted, obtain tetanus status, and immunize as appropriate.
Surgical management
 Reduction
Reduction of fracture also called “setting the bone” refers to the restoration of the
fracture fragments to anatomical alignment and rotation. Either a closed reduction or
open reduction can be used to achieve this with the specific method depending on the
type and nature of fracture. Reduction need to be done as quickly as possible to
prevent loss of elasticity through infiltration oedema or haemorrhage. Delayed reduction
becomes difficult as injury may begin to heal
Open reduction
Some fractures require open reduction through a surgical procedure. The fracture
fragments are reduced by internal fixation devices metallic pins wires screws plates
nails or rods} may be used to hold the bone fragments into position until solid bone
healing occurs. The devices may be attached to the side of bone or may be inserted
through the bony fragments or directly into the medullary cavity o f the bone .Internal
fixation devices ensures firm approximation and fixation of the bony fragments
Closed reduction
Is accomplished by bring the bone fragments into apposition { ie placing the end in
contact} Through manipulation and manual traction. The extremity is held in the
desired position while the Doctor applies a cast, splint or other device. Immobilization
devices maintains the reduction and stabilizes the extremity for bone healing .X-rays are
obtained to verify that the bone fragments are correctly applied Traction {skin or
skeletal} may be used to effect fracture reduction and immobilization. The traction may
be used until the patient is physiologically stable and able to withstand surgical fixation.
 Immobilization
After the fracture has been reduced, the bone fragments must be immobilized or held in
correct position and alignment until union occurs, immobilization may be accomplished
by external or internal fixation. Method of external fixation includes bandages, casts
splints continuous traction and external fixators. Methods of internal fixation include use
of implants as internal splints.
Maintaining and regaining normal function
• Reduction and immobilization are maintained as prescribed t promote bone and

soft tissue healing swelling is controlled by elevation of the injured extremity and
applying ice as prescribed.
• Neurovascular status {circulation movement sensation} is monitored and the
surgeon is notified immediately if sings of neurovascular compromise are
identified. Restless anxiety and discomfort are controlled with a variety of
approaches such as reassurance position changes pain relief strategies including
use of analgesia
• Isometric and muscle setting exercises are encouraged to minimize disuse
atrophy and to promote circulation.
• Participation in activities of daily living {ADLs} is encouraged to promote
independent function and self esteem. Gradual resumption of activities is
promoted within the therapeutic prescription. with internal fixation , the surgeon
determines the amount of movement and weight bearing stress , the extremity
can withstand and prescribed the level of activity
Specific management of certain types of fractures
Fractures involving the head {cranium and face}
1. Ensure adequate airway and breathing.

2. Control any bleeding with direct pressure.
3. Assess level of consciousness and history of loss of consciousness.
4. Assess c-spine
5. Assess malocclusion of teeth and chipped, loose or lost tooth.
6. Assess visual perception. Observe pupils, and their reaction to light and any foreign
material or bleeding from the eye.
Fractures Involving the Shoulder (Clavicle, Scapula, Ribs):
1. Ensure adequate airway and breathing.

2. Ensure adequate circulation

3. Protect cervical and thoracic spine. Assume spinal injury.
4. Assess for life threatening injury. Clavicular fractures often cause damage to
underlying structures such as lung, the subclavian vein, and/or the airway.
5. Scapular fractures may cause such injuries as a hemothorax, pneumothorax,
and/or pulmonary contusion.
6. Assess patient's respiratory status. Rib fractures can cause paradoxical chest wall
motion with respirations.
7. Assess for internal injuries. Rib fractures can possibly cause injury to spleen,
kidneys and liver.
8. Sternal injuries: Consider myocardial contusion.
Fractures Involving the Humerus, Elbow and Hand:
1. Assess Neurovascular status.

2. Remove all jewellery from affected arm and hand.
3. Obtain time, place, and mechanism of injury. Include position of hand/arm
during injury.
4. Note and record patient's dominant hand, patients occupation. Fractures to the
hand/dominant arm can have devastating effects on the usage of the hand or
arm after injury.
5. Check for haematomas beneath fingernails.
6. Immobilize area for comfort.
Fractures Involving the Pelvis:
1. Assess patient for hematuria, abdominal distention, cessation of bowel sounds,

genital trauma, and severe back pain. Consider possibility of internal injuries.
2. Patients require frequent vital signs and close observation for shock symptoms.
Average loss of blood is two units.
3. Immobilize on long board to avoid unnecessary movement, if necessary.
Fractures Involving the Femur:
1. Immobilize, using Hare traction if necessary.

2. Observe for shortening of leg and severe muscle spasms.
3. Monitor frequent vital signs, observing for signs of shock. (Note: *two units of blood
can be lost from a femur fracture)
4. Assess Neurovascular status frequently.
Fractures Involving Distal Lower Extremities:
 If angulation of heel exists, do not attempt to straighten.

 Control swelling with application of ice.
 Immobilize with splint if necessary.

Pre-op care and post op care for Reduction of Fracture or Repair of
Orthopaedic Injury:
The general preparations and post op care are the same. {Refer to pre op care} i.e.
1. Keep patient NPO

2. Provide pre-op teaching to patient and/or family.
3. Document pre-surgical checklist
4. Implement pre-op orders as appropriate
5. Foley catheter & IV placement as per MD orders
IEC on post care
 If cast or plaster splint is applied, perform:

 Sensation and circulation check of extremity, before and after.
 Provide information to patient to care for cast and injury at home. Provide
written instructions. Instruct in cold application and elevation. Teach patient to
watch for change in circulation.
 Apply sling if necessary. Instruct patient in use of sling.
 Crutches provided if necessary. Instruct patient in use of crutches and rental
system.
 Patient discharged per wheelchair.
 Patient may require to under go rehabilitation
Potential Complications of All Fractures:
1. Blood loss, resulting in hypovolemia and/or shock.

2. Injury to vital organs.
3. Neurological and/or vascular damage.
4. Infection in open fractures.
5. Fat embolism.
6. Compartment syndrome.
FRACTURE FEMUR 2
A) Give Six (6) other types of fractures 12%
Comminuted fracture- bone is splintered in to more than three fragments.

Avulsion fracture-occurs when a small piece of bone to which the tendon is attached is
pulled off from the bone. Often requires open reduction and fixation.
 Impacted fracture – the bone end are crushed together.
 Stress fracture-often occurs in metatarsals known as March fracture or shaft of tibia in
athletes.
 Complicated fracture-involves neighbouring structures such as organs, blood vessels,
nerves.
 Oblique or Spiral fracture-Unstable, may result in shortening.
 Transverse fracture-stable but may result in delay or non-union.

2% for each point
B) State three (3) Clinical features 12%
1. Severe pain at the site caused by swelling, muscle spasm, damage to periosteum.
Pressure at the site of injury and attempted motion aggravates the pain.
2. Loss of normal function. The injured part is incapable of voluntary movement.
3. Obvious deformity resulting from loss of bone continuity with evidence of fracture on x-
ray film.
4. Excessive motion at the site of fracture i.e. motion where motion does not usually occur.
5. Creptus or grating sound if limb is moved gently.
6. May be signs of shock related to severe tissue injury, blood loss or intense pain.
7. Soft tissue oedema in the area of injury resulting from extravasations of blood and tissue
fluid.
8. Warmth over injured area resulting from increased blood flow to the area.
9. Loss of sensation or paralysis distal to injury resulting from nerve entrapment.
10. Ecchymosis of skin surrounding injured area may be apparent after several days.
3% for any 3 to make 12%.
C) Describe the Nursing Management 51%
OBJECTIVES: 2%
- To prevent shock
- To promote body alignment
- To prevent complications e.g. infection, pain, deformity.
- To maintain psychological stability.
PREVENTION OF SHOCK 3%
- Administer prescribed fluids to maintain circulating volume.
- Watch for evidence of haemorrhage on dressings, close monitoring of vital signs
- Report any sudden or progressive changes in respiration.
- Watch for evidence of internal haemorrhage from fluid, from possible wound
drainage tube.
- Administer oxygen if prescribed.
CARE OF AFFECTED LIMB: 4%
- Kirschner wire or Steinmann pin could have been used as a tibia pin for treatment
of femoral fracture.
- Maintain elevation of affected limb.
- Maintain immobilization of affected limb.
- Patient’s movement in bed should not affect the line of pull of the traction.
- The areas under the popliteal space and heel are left open to prevent pressure.
PAIN RELIEF: 3%
- When traction is applied the patient should have immediate relief and should
require little or no sedation.
- Check that the immobilisation and traction are not faulty. Any splint ring should
fit perfectly to avoid constriction if too tight or friction if too loose.
- Analgesics e.g. panadol to relieve pain.
- Sedatives to promote rest and relaxation.
PREVENTION OF PRESSURE SORES: 5%
- Avoid friction over pressure areas by cramps, creases, loose rings.

- Keep pressure area points clean and dry. Prevent pressure and increase blood
circulation by gentle massage two or three times per day over ischial tuberocity.
In balanced traction encourage the patient to move the non immobilised parts of
the body. Encourage slight movement from side to side and to lift up on the
trapeze to relieve pressure on sacrum and scapulae.
OBSERVATIONS: 14%
- Vital signs, temperature to rule out infection 1/2hourly, hourly, 4hourly pulse and
blood pressure to monitor cardiovascular function. Respirations to monitor
breathing pattern. A rapid pulse, low blood pressure respiratory distress may
indicate fat embolism. Vital signs are checked 4 hourly when patient’s
condition is stable then B.D and charted.
- For balanced traction ensure that pulleys are smooth running, no knots in cords
and free movement of the limb. No obstruction from sandbags, bedclothes,
cradles etc.
- Weights should hang away from the bed and all staff should be warned not to pull
them up or knock against them.
- Monitor progression of swelling of thigh in the first 2-5 hours.
- Ensure that pin points are corked to protect bed linen and attendants.
- Monitoring for impaired circulation or sensation should be done every hour in the
first 24 – 48 hours. Any sign of neuro – circulatory compromise should be
reported.
- Ensure that traction is maintained 24hours and released only by order of the
Surgeon.
- Sudden cessation of traction causes displacement in a fracture and is very painful
for the patient.
- Inspect skin frequently to be sure it is not being rubbed, contused or macerated by
traction equipment. Readjustments are made where necessary.
2% each point

PREVENTION OF INFECTION: 4%
- Dress any wound as prescribed.

- Wounds around the pin should be cleaned aseptically and kept dry. The
physicians’ preference should be followed to prevent pin tract infection. Pin site
care may be done 2-3 times per day.
- Avoid padding rings since this creates dampness that increases risk of infection.
PSYCHOLOGICAL CARE: 4%
- Mrs Phiri must be nursed as a whole

- The Surgical procedure, limits of motion and weight bearing to the affected limb
should be explained.
- Cheerfulness and occupational therapy relieves patient’s boredom.
NUTRITION:3%
- Well balanced diet, high protein and vitamins and sufficient irons to enhance
healing.
- Vitamin supplements if necessary
- Adequate fluid intake to prevent constipations and bladder stone formation.
HYGIENE: 1%
- Bed bath for self esteem and blood circulation.
DIVERSIONAL THERAPY: 1%
- A radio, T.V or interesting game to deliver her mind from the condition and pain
according to Mrs Phiri’s interest.
ELIMINATION: 2%
- Support the back when patient is using bed pan with folded linen etc.
HEALTH EDUCATION: 5%
Explain traction in relation to fracture and physician’s plan of treatment.
- Explain amount of movement permitted and how to achieve it e.g. passive
exercise of muscle to prevent wasting with involvement of the Physiotherapist
- Explain correct body positioning
- Walking exercises with crutch or any ambulatory assistance devices.
3% for any other general care to make 52%.
D) STATE FIVE (5) MAJOR AREAS OF REHABILITATION: 25%

The major areas of concern are the diagnosis, medical and surgical treatment, psychological
adjustment self care activities housing, occupation, sexual activity, recreation.
1. Diagnosis/medical and surgical treatment- correct diagnosis arrived at early with

appropriate interventions i.e. skeletal traction will promote good alignment of fractured
femur and healing without complications such as shortening of the limb. The plan of
rehabilitation is executed by both the medical staff and the patient e.g. observation of
weight bearing restrictions.
2. PSYCHOLOGICAL ADJUSTMENT:-
- Be aware of factors influencing the patient’s behaviour
- Involve the patient in the plan of his rehabilitation from admission to discharge
i.e. exercises, maintaining good body alignment, physiotherapy e.g. ambulation
with walking aids e.g. crutches
- Support patient in coping process
- Any assistance and equipment needed for activities of daily living is explained
and how it can be obtained.
3. SELF - CARE ACTIVITIES:
- Involve patient in plan of his care and evaluation. Mrs Phiri should be
encouraged to do what she can early e.g. use of trapezius, gentle side to side
turnings, feeding herself, brushing her teeth. During ambulation, any walking
difficulties should be overcome or minimised. Where necessary use of crutch.
Involve Physiotherapist occupational therapist.
4. OCCUPATION:
- Might need to change departments or shifts. If necessary involve occupational
therapist where altered mobility or activity restrictions affect normal work.
Discourage heavy physical work e.g. carrying bags of maize until bone union and
healing is complete and Surgeon allows it.
5. SEXUAL ACTIVITY:
Any problem arising with his sexual activity should be addressed. Try to find out the
underlying cause. Involve experts e.g. Psychologists, Physicians
EAR, NOSE AND THROAT DISEASES (ENT) QUESTIONS

OTITIS MEDIA
Given Hachundu has been complaining of pain the right ear after the swimming festival. Its 4 weeks now
and the pain seems to be getting worse. You are the clinician at the health centre attending to this client.
e) Define Otitis Media. 2%

f) Mention six (6) signs and symptoms your patient is likely to present with 24%
g) Discuss the Medical management of your client 50%
h) State six (6) complications that could occur if there is further delay in the management of this
client 24%
Definition
It is the inflammation of the membranes lining the middle ear usually as a result of
infection, characterized by ear ache, fever and ear discharge. Otitis media is
inflammation of the middle ear, or middle ear infection.
Otitis media occurs in the area between the tympanic membrane (the end of the outer ear) and the inner
ear, including a duct known as the eustachian tube. It is one of the two categories of ear inflammation that
can underlie what is commonly called an earache, the other being otitis externa. Diseases other than ear
infections can also cause ear pain, including cancers of any structure that shares nerve supply with the ear
and shingles which can lead to herpes zoster oticus.
TYPES
Acute otitis media (AOM) and otitis media with effusion (OME). Both occur mainly in childhood and may
be caused by bacterial or viral infection.
Acute Otitis media (AOM)

AOM is a condition in which there is inflammation of the middle ear, frequently in association
with an upper respiratory tract infection (URTI). Acute Otitis media (AOM) is most often
purely viral and self-limited, usually accompanying viral URI (upper respiratory infection).
There is congestion of the ears and perhaps mild discomfort and popping, but the symptoms
resolve with the underlying URI.
If the middle ear, which is normally sterile, becomes contaminated with bacteria, pus and pressure in the middle ear
can result, and this is called acute bacterial Otitis media. Viral acute Otitis media can lead to bacterial Otitis media
in a very short time, especially in children. The individual with bacterial acute Otitis media has the classic "earache",
pain that is more severe and continuous and is often accompanied by fever of 102 °F (39 °C) or more.
OTITIS MEDIA WITH EFFUSION (OME) This is common in children between the ages of
Otitis media with effusion (OME), also called serous or
four and ten. it is a common cause of deafness.
secretory otitis media (SOM), is simply a collection of fluid that occurs within the middle ear
space as a result of the negative pressure produced by altered Eustachian tube function. This can
occur purely from a viral URI, with no pain or bacterial infection, or it can precede and/or follow
acute bacterial Otitis media. Fluid in the middle ear sometimes causes conductive hearing
impairment, but only when it interferes with the normal vibration of the eardrum by sound
waves. Over weeks and months, middle ear fluid can become very thick and glue-like (thus the
name glue ear), which increases the likelihood of its causing conductive hearing impairment.
Early-onset OME is associated with feeding while lying down and early entry into group child
care, while parental smoking, too short a period of breastfeeding and greater amounts of time spent in
group child care increased the duration of OME in the first two years of life.
Chronic suppurative otitis media

The World Health Organization defines chronic suppurative otitis media (CSOM) as "a stage of
ear disease in which there is chronic infection of the middle ear cleft, a non-intact tympanic
membrane (i.e. perforated eardrum) and discharge (otorrhoea), for at least the preceding two
weeks" (WHO 1998). (Notice WHO's use of the term serous to denote a bacterial process.
Chronic suppurative otitis media involves a perforation (hole) in the tympanic membrane and
active bacterial infection within the middle ear space for several weeks or more. There may be
enough pus that it drains to the outside of the ear (otorrhea), or the purulence may be minimal
enough to only be seen on examination using a binocular microscope. This disease is much more
common in persons with poor Eustachian tube function. Hearing impairment often accompanies
this disease.
PREDISPOSING FACTORS:
 Foreign body in the ear. Removal of foreign body due to bruises or trauma in the ear.
 Perforated tympanic membrane allowing penetration of dirty water.
 It nearly affects the young age.
 Recurrent respiratory tract infections.
 Nutritional status such as in malnutrition.
 Swimming in water.
 Immunosuppresed due to HIV.
 Measles through hematogenous spread.

 Common cold.
 Malformation of the nostrils in which mucus is being drained in to the ear, through the
Eustachian tube.
 Children below the age of seven years are much more prone to otitis media since the Eustachian tube is
shorter and at more of a horizontal angle than in the adult ear. They also have not developed the same
resistance to viruses and bacteria as adults. Numerous studies have correlated the incidence of acute otitis
media in children with various factors such as nursing in infancy, bottle feeding when supine, parental
smoking, diet, allergies, and automobile emissions; but the most obvious weakness of such studies is the
inability to control the variable of exposure to viral agents during the studies. Breastfeeding for the first
twelve months of life is associated with a reduction in the number, and duration of all OM infections
CAUSETIVE ORGANISMS:
Otitis media is most commonly caused by infection with viral, bacterial, or fungal pathogens. The most
common bacterial pathogens are Streptococcus pneumoniae, nontypable Haemophilus influenzae, and
Moraxella catarrhalis. Among older adolescents and young adults, the most common cause of ear
infections is Haemophilus influenzae. Viruses such as respiratory syncytial virus (RSV) and those that
cause the common cold may also result in otitis media by damaging the normal defenses of the epithelial
cells in the upper respiratory tract.

A major risk factor for developing otitis media is Eustachian tube dysfunction, which leads to the
ineffective clearing of bacteria from the middle ear.
 Streptococcus aureus.
 Staphylococcal pneumonia.
 Proteus mirabilis.
 E.colis.
 Streptococcus aureus.
 Haemophylus influenza
 Group A beta hemolytic streptococcus.
SIGNS AND SYMPTOMS:

1st phase - exudative inflammation lasting 1-2 days, fever, rigors, meningism, occasionally in children,
severe pain worse at night, muffled noise in ear, deafness, sensitive and mastoid process.
2nd phase - resistance and demarcation lasting 3-8 days. Pus and middle ear exudates discharge
spontaneously and afterwards pain and fever begin to decrease. This phase can be shortened with topical
therapy.
3rd phase - healing phase lasting 2-4 weeks. Aural discharge dries up and hearing becomes
normal.
 Headache due to pressure in the ears.

 Clear, bloody, purulent mucous or serous discharge due to infection.
 Hearing loss due to distraction of the ossicles.
 Pyrexia due to high metabolic rate in the body.
 Redness of the ear drums due to inflammatory process.
 Severe ear pain due to accumulation of fluids in drum. When the middle ear becomes
acutely infected, pressure builds up behind the eardrum (tympanic membrane), frequently
causing pain. It may result in bullous myringitis, in which the tympanic membrane is
inflamed and blistered
 In severe or untreated cases, the tympanic membrane may rupture, allowing the pus in the
middle ear space to drain into the ear canal.
 Echo sounds when speaking due to accumulation of fluids in the ear drum.
 Nausea and episodes of dizziness.
 Giddiness due to irritation of inner ear and fever.
 Loss of balance due to inflammation in the ear canal.
MANAGEMENT:

 INVESTIGATIONS:
 History taking that will review prolonged respiratory tract
Infections, earache, ear discharge.

 Physical examination that will review ear discharge.
 Ear swab for micro culture and sensitivity that will review the causative
organisms.
 Full blood count that will show increased number of white blood cells.
 X-ray of the temporal bone that will review alteration of meatus.
 Tympanometry to assess the hearing loss and evaluate the condition of the
middle ear.
 Autoscopy of the ear canal reviews the bulging of the tympanic membrane.
TREATMENT:
 Amoxicillin 250-500mgs three times daily for seven days.
Side effects:
GIT disturbance, drowsiness,
 Ear wicking.
 When organisms are isolated, the most common pathogens are S. pneumoniae (25%), H.
influenzae(25%)and Moraxella catarrhalis(15%) and therefore, when antibiotics are used,
a broad spectrum antibiotic such as amoxicillin, trimethoprim or erythromycin is most
commonly used for a period of 5 days. Amoxicillin is still the antibiotic of choice.
 The acute phase benzylpenicilline is given intravenously 6 hourly until there is an improvement
in symptoms and then changed to oral antibiotics.
 Chloraphenical ear drops.
 Gentamycin ear drops.
 Paracetamol 500-1000mgs tds by three days. To treat the pain caused by otitis media oral as well
as topical analgesics are effective. Oral agents may include ibuprofen, acetaminophen, or narcotics. Topical
agents shown to be effective include antipyrine and benzocaine ear drops
 Antihistamines such as piriton 2-4mgs bd by 3days.
 The role of the anti-H. influenzae vaccine that children are regularly given is to prevent invasive
disease such as meningitis and pneumonia. This vaccine is active only against strains of serotype
b, which has been found to cause meningitis and pneumonia in children less than five years, with
children between 4 and 18 months the most susceptible. Isolates of serotype b rarely cause otitis
media.
Supportive treatment;
 OraL toilet.
 Asytimizolecan be used in place of Piriton.
NURSING CARE.
AIMS
 To combat the infections.
 To relieve discomforts.
 To alley anxiety.
 To prevent complications.
ENVIRONMENT
The child is usually pyrexial and ill during the course of the disease.
The child should be confined to bed in a warm, well- ventilated environment.
HYGIENE
Ear care- wicking the ear three times in a day to keep it dry.
Keep the auditory meatus open after cleaning, packing the meatus with cotton wool
or gauze provides an ideal environment for growth of gram-negative bacteria or fungi.
Daily bathing of the child to promote hygiene and comfort.
OBSERVATIONS
Observe for pain, it should be reducing after administration of analgesics.
Observe ear discharge, for color, consistency, amount and odor. Observe whether
reducing or the same.
The perforation closes spontaneously leaving a fine scar.
Hearing should return to normal.
Observe vital signs 2hourly in the acute stage, then 4hourly as condition improves.
DIET
The child has loss of appetite, provide nutritious foods and fluids. Serve small attractive meals
frequently; serve foods mostly liked by the client
IEC:
 Advise patient with acute Otitis media to seek quick medical advise when
ever symptoms appear.
 Children with a discharging ear or a perforated ear drum should be seen again
in 2 or 3 weeks' time to check progress and be told to avoid getting water in
the affected ear until then.
 Advise the community to cover their ears when swimming.
 Advise the patient to avoid introducing foreign bodies in their ears.
 Advise the patient to quickly seek medical advise for upper respiratory
infections.
 Encourage the patient to do some manoeuvres several times.
COMPLICATIONS:
 Spontaneous rapture of tympanic membrane due to increased pressure in the middle ear.
 Mastoiditis due to involvement of the mastoid bone.
 Deafness due to ruptured tympanic membrane.
 Meningitis due to spread of infection to the brain meninges.
 Perforation of the eardrum in not uncommon and progression to chronic
suppurative otitis media may occur.
 Labyrinthitis, meningitis, intracranial sepsis or facial nerve palsy are very rare
and occur in less than 1 in 1,000.
 Recurrent episodes may lead to scarring of the drum with permanent hearing
impairment, chronic perforation and otorrhoea, cholesteatoma or mastoiditis.
In recurrent (either three or more acute infections of the middle ear cleft in a
six-month period, or at least four episodes in a year) strategies for managing
the condition include the assessment and modification of risk factors where
possible, repeated courses of antibiotics for each new infection, antibiotic
prophylaxis and the insertion of ventilation tubes (grommets). Grommets have
a significant role in maintaining a 'disease-free' state in the first six months
after insertion.
 In a small child with a high temperature there is a risk of febrile convulsions.
 Bacterial cases may result in perforation of the ear drum, infection of the mastoid space
(mastoiditis) and in very rare cases further spread to cause meningitis
TRACHEOSTOMY
Mr. Lubinda a regular cigarette smoker is admitted with a complication of cancer of the larynx.
He is to have a permanent colostomy.

a) Define tracheostomy 5%
b) Mention (5 )five predisposing factors to Ca of the larynx 15%
c) Discuss in detail the post op care of Mr. lubinda 50%
d) Mention five (5 )complication that Mr. lubinda is likely to present with 10%
MARKING KEY FOR TRACHEOSTOMY
Definition
1. A tracheostomy provides direct access to the trachea by surgically making an opening in the
neck. Once an opening is made it needs to be maintained usually via a tracheostomy tube.
2. This is a surgical procedures on the neck to open a direct airway through an incision in the trachea (the
windpipe} tracheostomy, from the root stoma- meaning "mouth," refers to the making of a semi
permanent or permanent opening, and to the opening itself
Indications for a tracheostomy

 Obstruction of the upper airway e.g. foreign body, trauma, infection, laryngeal tumour,
facial fractures
 Impaired respiratory function e.g. head trauma leading to unconsciousness, bulbar
poliomyelitis
 To assist weaning from ventilatory support in patients on intensive care
To help clear secretions in the upper airway

Predisposing factors of cancer of larynx
 Cigarette smoking
 Alcohol
 Vocal cord straining
 Chronic laryngitis
 Noxious fumes
 Family predisposition
 Asbestos wound and cement
Uses of tracheotomy
The conditions in which a tracheotomy may be used are:
 Acute setting - maxillofacial injuries, large tumours of the head and neck, congenital tumours,
e.g. branchial cyst, acute inflammation of head and neck, and
 Chronic / elective setting - when there is need for long term mechanical ventilation and tracheal
toilet, e.g. comatose patients, surgery to the head and neck.
 In emergency settings, in the context of failed endotracheal intubation or where intubation is
contraindicated, cricothyroidotomy or mini-tracheostomy may be performed in preference to a
tracheostomy.
POST-OPERATIVE CARE
 The aim of the post-operative care is to promote a patent airway, allay and prevent complications.
 ……………………………………………………………………………………………….
 …………………………………………………………………………………………………
ENVIRONMENT
 The patient will be nursed in an intensive care unity or near the nurse’s bay for close
observations. The environment should be well ventilated and clean to prevent the patient from
inhaling contaminated air.
 The room should be humidified to prevent irritation of the tracheobronchial mucosa as the
tracheotomy by passes the part that humidifies, warm and filters the air. The environment should
have the mechanical ventilator /oxygen cylinder, suctioning machine, sterile catheters and a
tracheotomy care set for immediate use when needed.
POSITION AND CLEARANCE OF AIR- WAY
 Initially when the patient comes from the theatre he will be positioned in a supine position but as
he awakes from anaesthesia, he will be nursed in a semi- fowler’s position to promote proper lung
expansion and coughing up of secretions.
 Suctioning of secretion is done frequently when need arises to promote expansion, reduce risk of
atelectasis, pulmonary infection and ineffective gas exchange.
OBSERVATIONS
 Vital signs are observed every 15 minutes initially until the patient stabilizes, that is temperature
which can be low due to the effect of anaesthesia or high because of some infection, pulse, blood
pressure and respirations if increased will indicate hypoxia. Assess for cyanosis especially around
the lips and palms of the patient that may be as a result of hypoxia and necessitating
administration of oxygen.
 Observe for dyspnoea and restlessness which will indicate secretion in the airway. Suctioning
should be to clear the air way and promote ventilation.
 Monitor the fluid intake and output of the patient to prevent dehydration which can make the
tracheobronchial secretions to be thick and hence block the air-way.
TRACHEOSTOMY CARE
 TUBE: Securing the tube in the place using either twill tape or velcrotracheostomy hold to
prevent dislodgement and decannulation. This intervention reduces movement and traction on the
tube from oxygen or ventilator tubing or accidental pulling by the patient.
Care of a patient with a short-term tracheostomy

 Meticulous care towards hygiene and asepsis
 Speaking - once the cuff can be deflated, the patient can begin to speak if the opening is
occluded. Usually this takes time and patients need lots of support.
 Removal - as the patient improves the tracheostomy can be plugged for longer durations
each day provided the patient can tolerate it.
 Swallowing - oral intake can occur but swallowing may be difficult. Patients must be
watched for aspiration risk.
Care of a patient with a long-term tracheostomy

 Educate patient and carers
 Meticulous care towards hygiene and asepsis

 Carers will need to be taught how to suction and replace outer tubes
 Providing humidification
 Management regarding speaking and eating as above
Once a tracheostomy is removed the stoma usually heals over with time although a scar often
remains6
COMPLICATIONS
 Air embolism Emphysema, Laryngeal nerve damage, posterior tracheal wall penetration
 Airway obstruction, Protrusion of the calf, Infection, Dysphasia
1. Immediate Complications
1. Haemorrhage e.g. from thyroid isthmus
2. Hypoxia
3. Trauma to recurrent laryngeal nerve
4. Damage to oesophagus
5. Pneumothorax
6. Infection
7. Subcutaneous emphysema
2. Early
1. Tube obstruction or displacement
2. Aspiration
3. Bleeding from tracheostomy site
4. Infection
3. Late
1. Airway obstruction with aspiration
2. Damage to larynx e.g. stenosis
3. Tracheal stenosis
4. Tracheomalacia
5. Aspiration and pneumonia
6. Fistula formation e.g. tracheo-cutaneous or tracheo-oesophageal
4. Early - secretions and mucus plugging, dislodged tube, respiratory arrest and post obstructive
pulmonary oedema (when tracheostomy is performed in a patient with longstanding upper airway
obstruction, and is dependent on hypoxic drive for respiration).
5. Late - bleeding from tracheoinnominate fistula (can be torrential), tracheal stenosis (from
ischemia induced by a cuffed tracheostomy tube), tracheoesophageal fistula, tracheocutaneous
fistula and cosmetic deformity must be considered upon decannulation.
Problems
1. Immune problems - air inhaled through a stoma is not filtered or moistened like it is when inhaled
through the nose or the mouth.
6
AKASHAMBATWA MWANANG’ONO FREEBORN, akashambatwaf@yahoo.com +260979306395 - LNSCH
2. Drowning - as little as two teaspoons of water in the stoma can drown the person; therefore, they
cannot swim and bathing must be done with extreme care. 7
3. Suffocation - if the stoma is covered, the person will suffocate, as in some
MASTODITIS
Definition.
This is a bacterial infection of the air cells of the mastoid antrum.
Causes.
The bacteria that causes Mastoiditis include

 Pneumococci
 Haemophilus influenza
 Moraxella catarrhalis
 Beta-hemolytic streptococci
 Staphylococci
 Most gram negative organism.
Pathophysiology
Mastoiditis is usually a complication of chronic otitis media, less often does it follow acute otitis media.
Accumulation of pus under pressure in the middle ear cavity results necrosis of adjacent tissue and
extension of infection to the mastoid cells.
Signs and symptoms.
The classical signs include

 A dull ache and tenderness on the area of mastoid process
 Low grade fever
 Headache
 Thick purulent ear discharge
 Post-auricular erythema and edema
 Conductive hearing loss due to pressure and swelling
Diagnosis
History Predisposing factors in the patient's history may help confirm the diagnosis
or indicate underlying conditions that require therapy. The two most common
predisposing factors are a recent upper respiratory tract viral infection (lasting
more that seven to 10 days) and allergic disease.
Physical examination
 Audiometric testing may reveal conductive hearing loss

 physical examination shows a dull thickened and oedematous tympanic membrane
 persistent oozing may indicate perforation of tympanic membrane
7
AKASHAMBATWA MWANANG’ONO FREEBORN, akashambatwaf@yahoo.com +260979306395 - LNSCH
Investigations radiological x-rays
 computer tomography of mastoid area will reveal hazy mastoid air spaces
Medical management
Objectives
 To halt the infective process
 To relieve pain
 To prevent complications
The treatment for Mastoiditis consists of intense parenteral antibiotic therapy.

Initial antibiotic choice is ceftriaxone with clindamycin.
If bone damage seems minimal then drainage by tympanocentesis or myringotomy can be done and a
specimen for culture and sensitivity collected
Surgical management
A chronically inflamed mastoid bone requires radical mastoidectomy - excision of the posterior wall of
the ear canal, remnants of the tympanic membrane, and the malleus and incus (although these bones are
usually destroyed by infection before surgery). The stapes and facial nerve remain intact.
Radical mastoidectomy, which is seldom necessary because of antibiotic therapy, does not drastically
affect the patient's hearing because significant hearing loss precedes surgery.
With either surgical procedure, the patient continues oral antibiotic therapy for several weeks after
surgery and hospital discharge
Objectives
 To halt the infective process
 To relieve pain
 To prevent complications
Definition.
Radical mastoidectomy.
This is the excision of the posterior wall of the ear canal, remnants of the tympanic membrane and the
malleus and incus destroyed by infection. The stapes and facial nerve remain intact.
Indications
 Chronic Mastoiditis
 Meningitis due to Mastoiditis
 Brain abscess
 Sinus thrombosis
 Acute suppurative labrinthitis
 Facial palsy.
Types
 Simple mastoidectomy
 Radical mastoidectomy

Complications of mastoiditis
 Currently, prospects of full recovery are very good. However, if not treated promptly, mastoiditis
may lead to further complications, including meningitis, facial paralysis, labyrinthitis, and brain
abscess, in addition to hearing loss and bone destruction
Nursing care
NURSING CARE OF A PATIENT WITH MASTOIDECTOMY
OBJECTIVES
ENVIRONMENT.
observations.
It should be clean enough and well dumped dusted to prevent infections. There should be adequate light
that will facilitate easy observations in case of change of condition
The environment should be quiet to allow the patient to have enough rest.
Visitors should be allowed to visit patent but only for short periods of time and in fewer numbers to
promote rest.
The patient is better nursed in a rail bed that will prevent accidental falls as the patient attempt to turn.
POSITION
All patients with a mastoidectomy should be treated with assumption that they also have disseminated and
systemic infection until proved other wise. The patient is therefore nursed on a flat hard board with head
and neck kept in body alignment.
Generally maintain a clear and patent air way for adequate ventilation.
.
REST VS ACTIVITY
Initially the patient should given enough time to rest. This helps to reduce tension and ICP.
bed bath.
OBSERVATIONS
alternate with 5% dextrose for energy.. Keep the veins open for easy access in case of resuscitation.
NUTRITION.

The patient obtains his food through the intravenous infusion, ensure that this is supplemented by NG
feeds if the patient does not have fracture of the base of the head
ELIMINATION
A urinary catheter should be left in situ for easy monitoring of out put and documentation
HYGIENE
Activities of daily living such as mouth wash body wash hair should not be abandoned.
Do routine mouth wash, bed bath, elimination, change of linen and clothes nail care etc. This helps to
prevent infections which could acquire on the ward.
A bath also helps to improve circulation of blood to vital centers of the body.
While bathing you can also observe for pressure sore development and be able to take appropriate
intervention.
Bathing will also help you to do passive limb exercises and thus be able to prevent use syndrome
MEDIACTION
Administer the prescribed drugs to the patient following the 5 ‘Rs”.
Continue monitoring the patient for any other incidental /adverse reaction.
SINUSITIS
Definition
Sinusitis is an inflammation of the nasal sinuses. It is usually caused by infection (bacterial or viral), but
can also be caused by allergic reactions or other responses to environmental agents.
Pathophysiology of Sinusitis
The sinuses are holes in the skull between the facial bones. There are four large sinuses: two inside the
cheekbones (the maxillary sinuses) and two above the eyes (the frontal sinuses).
There are also smaller sinuses (ethmoidal and sphenoidal sinuses) located between the larger ones. The
sinuses are lined with membranes that secrete antibody-containing mucus, which protects the respiratory
passages from the onslaught of irritants in the air we breathe.
Causes of Sinusitis
Most sinusitis is caused by infection (such as a cold or an upper respiratory tract infection) spreading to
the sinuses from the nose along the narrow passages that drain mucus from the sinuses into the nose.
Allergies to dust, pollen, pet dander; indoor air pollutants, such as cigarette smoke, rug shampoo and
formaldehyde (used in the manufacture of carpeting, particleboard and plywood); and outdoor air
pollutants all can induce inflammation.

Excessive dryness in homes and offices from dry-air heating and air-conditioning systems can also
inflame the sinuses.
Symptoms of Sinusitis
The classic symptoms of chronic (long lasting) sinusitis are:

 a dull ache or pressure across the midface, especially between or deep into the eyes
 a headache that occurs daily for weeks at a time, and is often notably worse in the morning and
with head movement facial pain or headache that is sometimes aggravated by bending over
(When pain is present, this may suggest which sinus is affected.) The classic symptoms of
acute sinusitis in adults usually follow a cold that does not improve, or one that worsens
after 5 - 7 days of symptoms. Symptoms include:
 nasal congestion
 postnasal drip
 raspy voice
 loss of sense of smell
 Bad breath or loss of smell

 Cough, often worse at night
 Fatigue and generally not feeling well
 Sore throat and postnasal drip
Symptoms of chronic sinusitis are the same as those of acute sinusitis, but tend to be milder and
last longer than 8 weeks.
Symptoms of sinusitis in children include:
 Cold or respiratory illness that has been improving and then begins to get worse
 High fever, along with a darkened nasal discharge, for at least 3 days
 Nasal discharge, with or without a cough, that has been present for more than 10 days and
is not improving
Types of sinusitis
 Maxillary sinusitis (the most common type) manifests as cheek or dental pain.
 Frontal sinusitis prevents with forehead pain .
 Ethmoid sinusitis. Pain at the bridge of the nose or behind the eye suggests
 Sphenoid sinusitis. Pain is often referred to the top of the head with
Investigations/Diagnosis Sinusitis.
History Taking
Predisposing factors in the patient's history may help confirm the diagnosis or indicate underlying
conditions that require therapy. The two most common predisposing factors are a recent upper respiratory
tract viral infection (lasting more that seven to 10 days) and allergic disease.

Physical examination
 The doctor will examine the mouth and throat and look up the nasal passages to determine
whether the sinus outlets are blocked.
 Additionally, the doctor may do a transillumintion or CAT scan a diagnostic technique in which
the combined use of a computer and x-rays are passed through the body at different angles,
producing clear, cross-sectional images of the nasal cavities
 Tapping over a sinus area to find infection
Transillumination is done in a dark room with a very bright flashlight that is pressed against the forehead
or cheek. If the light shines through the sinuses, the doctor can rule out sinusitis. If little or no light
penetrates, the cavity is clogged and sinusitis is evident.
 The doctor may also perform an endoscopic examination. This is a narrow, flexible fiber-optic
scope that is placed into the nasal cavity through the nostrils. It allows the doctor to view where
the sinuses and middle ear drain into the nose.
Regular x-rays of the sinuses are not very accurate for diagnosing sinusitis.
Viewing the sinuses through a fiberoptic scope (called nasal endoscopy or rhinoscopy) may help
diagnose sinusitis. This is usually done by doctor who specializes in ear, nose, and throat
problems (ENT).
However, these tests are not very sensitive at detecting sinusitis, and are often considered
unnecessary.
A CT scan of the sinuses may also be used to help diagnose sinusitis. If sinusitis is thought to
involve a tumor or fungal infection, an MRI of the sinuses may be necessary.
Other Investigations
 Allergy testing
 Blood tests for HIV or other tests for poor immune function
 Ciliary function tests
 Nasal cytology
 Sweat chloride tests for cystic fibrosis
Treatment of Sinusitis
 If a bacterial infection is present, antibiotics, such as amoxicillin, erythromycin or sulfa drugs, are
usually prescribed for about 10 days.
 Your doctor also may prescribe one or more of the following remedies (which can be useful in
reducing inflammation in the sinuses and nose and speeding recovery):
 Decongestants. These temporarily relieve symptoms and also help the healing process by
draining the nose and sinuses.
Decongestants like pseudoephedrine, phenylpherine and phenylpropanolamine constrict the blood

vessels and shrink the sinus and nasal membranes, thus, reducing stuffiness in the sinuses and
nasal passageways.
 Expectorants. Medicines, such as Guaifenesin, thin the mucus so it drains more easily.
 Antihistamines. These medications help relieve nasal itchiness and inflammation by blocking the
action of histamine, however, they do not help mucus drain. Antihistamines include
chlorpheniramine.
 Apply a warm, moist washcloth to your face several times a day.

 Drink plenty of fluids to thin the mucus.
 Inhale steam 2 - 4 times per day (for example, sitting in the bathroom with the shower
running).
 Spray with nasal saline several times per day.
 Use a humidifier.
Prevention of Sinusitis
 Reduce exposure to allergens.

 Improve household ventilation by opening windows whenever possible.
 Use a humidifier in the home or office when the person has a cold.
 Sleep with the head of the bed elevated. This promotes sinus drainage.
 Use decongestants with caution.
 Avoid air pollutants (such as smoke) that irritate the nose.
 Eat a balanced diet and exercise.
 Minimize exposure to persons with known infections.
Be careful with over-the-counter spray nasal decongestants. They may help at first, but using
them beyond 3 - 5 days can actually worsen nasal congestion.
Also, for sinus pain or pressure:
 Avoid flying when you are congested.

 Avoid temperature extremes, sudden changes in temperature, and bending forward with
your head down.
 Try acetaminophen or ibuprofen.
Antibiotics are usually not needed for acute sinusitis. Most of these infections go away on their
own. Even when antibiotics do help, they may only slightly reduce the time you or your child is
sick. Antibiotics may be prescribed sooner for:
 Children with nasal discharge, possibly with a cough, that is not getting better after 2 - 3
weeks
 Fever higher than 102.2° Fahrenheit (39° Celsius)
 Severe swelling around the eyes
 Headache or pain in the face
At some point, your doctor will consider prescription medications, antibiotics, further testing, or
referral to an ear, nose, and throat (ENT) or allergy specialist.
Other treatments for sinusitis include:
 Allergy shots (immunotherapy) to help prevent the disease from returning

 Avoiding allergy triggers
 Nasal corticosteroid sprays and antihistamines to decrease swelling, especially if there are
swollen structures (such as nasal polyps) or allergies
Acute sinusitis should be treated for 10 - 14 days. Chronic sinusitis should be treated for 3 - 4
weeks. Some people with chronic sinusitis may need special medicines to treat fungal infections.
Surgery to clean and drain the sinuses may also be necessary, especially in patients whose
inflammation returns, despite medical treatment. An ENT specialist (also known as an
otolaryngologist) can perform this surgery.
Most fungal sinus infections require surgery. Surgical repair of a deviated septum or nasal polyps
may prevent the condition from returning.
The best way to prevent sinusitis is to avoid or quickly treat flus and colds:
 Eat plenty of fruits and vegetables, which are rich in antioxidants and other chemicals
that could boost your immune system and help your body resist infection.
 Get an influenza vaccine each year.
 Reduce stress.
 Wash your hands often, particularly after shaking hands with others.
Other tips for preventing sinusitis:
 Avoid smoke and pollutants.

 Drink plenty of fluids to increase moisture in your body.
 Take decongestants during an upper respiratory infection.
 Treat allergies quickly and appropriately.
 Use a humidifier to increase moisture in your nose and sinuses.
Prognosis
Sinus infections are usually curable with self-care measures and medical treatment. If you are
having recurrent attacks, you should be checked for underlying causes such as nasal polyps or
other problems, such as allergies.
Complications
Although very rare, complications may include:
 Abscess
 Bone infection (osteomyelitis)
 Meningitis
 Skin infection around the eye (orbital cellulitis)
A green or yellow discharge does not necessarily indicate a sinus infection or the need for
antibiotics.

SINUSITIS:
DEF:
This is the inflammation of the paranasal sinuses which may be acute,subacute, chronic, allergic
or hyperplastic. Acute sinusitis usually results from the common cold where as chronic sinusitis
follows persistent bacterial infections,generally occur when a cold spreads to the sinuses.
Allergic sinusitis accompanies allergic rhinitis.Hyperplastic sinusitis is a combination of purulent
acute sinusitis and allergic sinusitis or rhinitis.
CAUSES OF SINUSITIS:
Sinusitis usually results from a bacterial infection(haemophilus influenza,anaerobes)or less
frequently from a viral infection.
ACUTE SINUSITIS IS MOSTLY CAUSED BY:

 Staphylococcus aureus.
 Treptococcus pnuemoniea
 Streptococcus pyogens.
PREDISPOSING FACTORS:
Includes any condition that interferes with sinus drainage and ventilation,such as chronic nasal
edema,diverted nasal septum or viscus mucus.bacterial invasion also may result from swimming
in contaminated water,generalied debilitation conditions,including chemotherapy, malnutrition,
diebetis, long term steroids and immunodeficiency may also predispose an individual to sinusitis.
FIVE TYPES OF SINUSES:

1. Paranasol sinuses.
2. Frontal sinuses.
3. Maxillary sinuses.
4. Ethymoid sinuses.
5. Sphynoid sinuses.
MANAGEMENT OF SINUSITIS:
AIMS:
1. To relieve nasal congetion.
2. To relieve headach.
3. To prevent complications.
INVESTIGATIONS:
1. History taking that will review chronic rhinitis or benig allergic to some things.
2. Physical examination that will review nasal congestion.
3. X-ray of the nasal sinuses that will review some inflammation of the nasal sinuses
4. Nasal swab that will bacteria if its bacterial infection.
TREATMENT:
ANTIBIOTICS SUCH AS:
1. Amoxycillin 250-500mgs qid for 14days orally.
2. Ampicillin 250-500mgs qid for 14days intramusculary or intravenously.

ANALGESIAS SUCH AS:
1. Panadol 500mgs-1000mgs tds for 3days.
2. Asprin 300-600mgs for 3days tds.
VASOCONSTRICTORS TO LESSEN NASAL SECRETIONS;

1. Epinephrine,1:1000
 In severe allergic reaction may require treatment with corticosteroids and epinephrine.
 Other supportive treatment may include:
 Antihistamines such as piriton and phenegan.
 Steam inhalation also promotes vasoconstriction and incourages drainage.
 Local heat application may also help to relieve pain and congestion.
 If acute infection persists,the maxillary sinus may be irrigated
 The ethymoid and sphenoid sinuses can be drained indirectly with the poetz displacement
method a technique that uses gravity to displace thick purulent material with thin
irrigating fluid.
 If these irrigating techniques fail to relieve symptoms one or more sinuses may require
surgery
NURSING DIAGNOSES:
 Altered oral mucous membrane.
 Axiety.
 Fear.
 High risk of infections.
 Inefective breathing pattern.
 Knowledge deficit
 Pain.
NURSING INTERVENTIONS:
ENVIRONMENT:
 I will nurse the patient in clean environment which is non irritating to promote comfort
and rest.
 I will also nurse the patient preferably in a surgical ward for easy access to surgical
interventions.
 I will ensure that the environment is kept quite to promote rest.
 I will also ensure that the environment is well lite for easy observation of purulent
discharge.
 I will provide a dust free environment to avoid patient being irritated.
POSITION:
 I will nurse the patient in the semi fowlers position to relieve edema and pain.

 I will not elevate head of bed for more than 30 degreesas it may cause congestion in the
maxilly sinuses.
PSYCHOLOGICAL CARE:
 I will explain the disease process to the patient to alley anxiety.
 I will explain all interventions being done to patient to promote cooperation.
 I will also involve the relatives in the care of patient in order for him to feel loved.
 I will also ensure privacy at all times to promote nurse patient relationship.
 I will also allow both relatives and patient to air out there views to relieve tension.
PAIN MANAGEMENT:
 I will do all nursing procedures in blocks to promote rest.
 I will also give prescribed analgesics to relieve pain.
 I will also provide diversional therapy to divert the patients mind away from pain.
 I will also apply warm compress at least four times daily to relieve pain and promote
drainage.
 I will also apply ice compress or a rubber glove filled with ice chips over the nose and ice
saline gauze over the eyes to relieve pain and oedema.
OBSERVATOINS:
 I will monitor for excessive drainage and bleeding.
 Monitor the colour of drainage and consistency.
 Observe the breathing pattern of the patient to ensure that its patent.
 I will watch for vomiting, chills, fever, oedema of the forehead or eyelids, blurred double
vision and personality changes which could indicate complications.
 Check the vital signs such as temperature, pulse, respirations and blood pressure to
evaluate the condition of the patient.
NUTRITION/ELIMINATION;
 Usually patient is on normal diet.
 However encourage patient to eat diet rich in proteins, carbohydrates, and vitamins to
promote quick wound healing.
Advise patient to take a lot of fluids to promoted drainage and prevent

constipation.
 Encourage the patient to eat high roughage diet to prevent straining at stool.
 Monitor intake and out put to evaluate kidney functioning.
HYGIENE:
 I will frequently change the dressing to prevent infections.
 I will clean the wound using aseptic technique to prevent secondary infection.
 I will monitor the consistency, amount, and colour of drainage however expects scant
bright red drainage with some clots.

 Provide meticulous and frequent mouth wash since patient is breathing through the
mouth.
 Assist patient with assisted bath to promote comfort.
IEC:
DRUG ADHERANCE:
 I will inform the about drug adherence including side effects, action and dosage. I will
advise him to continue taking drugs even if symptoms subside to prevent resistance.
KNOWLEDGE:
 I will reinforce the patients understanding on sinusitis. I will teach the patient the signs
and symptoms of sinusitis and complications. That is in order for the patient not to be
confused between the side effects and the disease process.
PREVENTION OF INFECTION
 I will advise the patient to refrain from smoking. I will also teach him on the proper
disposal of tissues and do hand washing to prevent spread of infection.
HYGIENE:
 If the patient has undergone surgery I will teach him and the relatives on how to clean
the wound at home to prevent bad odour and to promote self esteem.
FOLLOW UP CARE:
 I will tell my patient to come on the stipulated date to help to monitor the progress of the
disease so as for the doctor to change treatment if the condition is not improving. I will
also advise him to come back if signs and symptoms persist for example constant frontal
headache.
TONSILITIS
Definition
Inflammatory infection of the tonsils usually with haemolytic streptococci (streptococcus) or

viruses.
Signs and symptoms
The symptoms are
 trouble in swallowing,
 Enlarged lymph nodes on the neck.
 Ear pain
 Fever, chills
 Headache
 Sore throat - lasts longer than 48 hours and may be severe
 Tenderness of the jaw and throat

 Voice changes, loss of voice
Medical management
Exams and Tests
The health care provider will look in the mouth and throat for swollen tonsils. The tonsils are
usually reddened and may have white spots on them. The lymph nodes in the jaw and neck may
be swollen and tender to the touch.
Tests that may be done include:
 Rapid strep test

 Throat swab culture
Treatment
The infection, which usually lasts about five days, is treated with bed rest and antiseptic
gargling. Sulfa drugs or other antibiotics are prescribed in severe bacterial infections to prevent
complications. Streptococcal infection can spread to nearby structures. Complications may
include abscess, nephritis, and rheumatic fever. Tonsils that become chronically inflamed and
enlarged require surgical removal (tonsillectomy
If the cause of the tonsillitis is bacteria such as strep, antibiotics are given to cure the infection.
The antibiotics may be given once as a shot, or taken for 10 days by mouth.
If antibiotic pills are used, they must be taken for entire amount of time prescribed by the doctor.
DO NOT stop taking them just because the discomfort stops, or the infection may not be cured.
Rest to allow the body to heal. Fluids, especially warm (not hot), bland fluids or very cold fluids
may soothe the throat. Gargle with warm salt water or suck on lozenges (containing benzocaine
or similar ingredients) to reduce pain.
Over-the-counter medications may be used to reduce pain and fever. Do NOT give a child
aspirin. Aspirin has been linked to Reye syndrome.
Surgical management
A tonsillectomy is a surgical procedure in which the tonsils are removed. Sometimes the
adenoids are removed at the same time.
Indications
Tonsillectomy may be performed when the patient:
 Experiences frequent bouts of acute tonsillitis. The number requiring tonsillectomy varies
with the severity of the episodes. One case, even severe, is generally not enough for
most surgeons to decide tonsillectomy is necessary.
 Has chronic tonsillitis, consisting of persistent, moderate-to-severe throat pain.

 Has multiple bouts of peritonsillar abscess.
 Has sleep apnea (stopping or obstructing breathing at night due to enlarged tonsils or
adenoids)
 Difficulty eating or swallowing due to enlarged tonsils (very unusual reason for
tonsillectomy)
 Produces tonsilloliths in the back of their mouth.
Adenoidectomy
 Adenoidectomy is the surgical removal of the adenoids. They may be removed for
several reasons, including impaired breathing through the nose and chronic infections or
earaches. The surgery is common. It is most often done on an outpatient basis under
general anesthesia. Post-operative pain is generally minimal and prevented with an
abundance of icy or cold foods, though dairy foods such as ice cream should be
avoided, as they coat the back of the throat, encouraging the body to produce phlegm,
which can interfere with healing. The procedure can sometimes be combined with a
tonsillectomy if needed. Recovery time can range from several hours to two or three
days (though as age increases so does recovery time).
 Adenoidectomy is often performed on children aged 1-6, as adenoids help the body's
immune system. Adenoid become vestigial organs in adults.
Complications
 Blocked airway from swollen tonsils

 Dehydration from difficulty swallowing fluids
 Kidney failure
 Peritonsillar abscess or abscess in other parts of the throat
 Pharyngitis - bacterial
 Pharyngitis - viral
 Post-streptococcal glomerulonephritis
 Rheumatic fever and related cardiovascular disorders
EPISTAXIS OR NOSEBLEED
Definition
Is the relatively common occurrence of hemorrhage from the nose, usually noticed when the
blood drains out through the nostrils. There are two types: anterior (the most common), and
posterior (less common, more likely to require medical attention). Sometimes in more severe
cases, the blood can come up the nasolacrimal duct and out from the eye. Fresh blood and clotted
blood can also flow down into the stomach and cause nausea and vomiting. It accounted for only
4 of the 2.4 million deaths in the U.S. in 1999. Perhaps the most well-known Epistaxis-related
death was that of Attila the Hun. He drank a colossal amount of alcohol on his wedding night
after his parley with Pope Leo I, suffered a nosebleed in his sleep and was suffocated by the
blood.

Etiology
The cause of nosebleeds can generally be divided into two categories, local and systemic factors,
although it should be remembered that a significant number of nosebleeds occur with no obvious
cause.
Most common factors

 Blunt trauma (usually a sharp blow to the face, sometimes accompanying a nasal
fracture)
 Foreign bodies (such as fingers during nose-picking)
 Inflammatory reaction (e.g. acute respiratory tract infections, chronic sinusitis,
allergic rhinitis or environmental irritants)
 Anatomical deformities (e.g. septal spurs or Hereditary hemorrhagic

telangiectasia)
 Insufflated drugs (particularly cocaine)
 Intranasal tumors (e.g. Nasopharyngeal carcinoma or nasopharyngeal
angiofibroma)
 Low relative humidity of inhaled air (particularly during cold winter seasons)
 Nasal cannula O2 (tending to dry the olfactory mucosa)
 Nasal sprays (particularly prolonged or improper use of nasal steroids)
 Otic barotrauma (such as from descent in aircraft or ascent in scuba diving)
 Surgery (e.g. septoplasty and Functional Endoscopic Sinus Surgery)
 Leech infestation
 Allergies
 Infectious diseases (e.g. common cold)
 Hypertension
 Drugs – Aspirin, Fexofenadine/Allegra/Telfast, warfarin, ibuprofen, clopidogrel,

isotretinoin, desmopressin, ginseng and others
 Alcohol (due to vasodilation)
 Anemia
 Connective tissue disease
 Blood dyscrasias
 Envenomation by mambas, taipans, kraits, and death adders
 Heart failure (due to an increase in venous pressure)
 Hematological malignancy
 Idiopathic thrombocytopenic purpura
 Pregnancy(rare)
 Vascular disorders
 Vitamin C or Vitamin K deficiency
 von Willebrand's disease
Pathophysiology
Nosebleeds are due to the rupture of a blood vessel within the richly perfused nasal mucosa.
Rupture may be spontaneous or initiated by trauma. Nosebleeds are reported in up to 60% of the
population with peak incidences in those under the age of ten and over the age of 50 and appears
to occur in males more than females. An increase in blood pressure (e.g. due to general
hypertension) tends to increase the duration of spontaenous epistaxis. Anticoagulant medication
and disorders of blood clotting can promote and prolong bleeding. Spontaneous epistaxis is more
common in the elderly as the nasal mucosa (lining) becomes dry and thin and blood pressure
tends to be higher. The elderly are also more prone to prolonged nose bleeds as their blood
vessels are less able to constrict and control the bleeding.
The vast majority of nose bleeds occur in the anterior (front) part of the nose from the nasal
septum. This area is richly endowed with blood vessels (Kiesselbach's plexus). This region is
also known as Little's area. Bleeding further back in the nose is known as a posterior bleed and is
usually due to rupture of the sphenopalatine artery or one of its branches. Posterior bleeds are
often prolonged and difficult to control. They can be associated with bleeding from both nostrils
and with a greater flow of blood into the mouth.
Treatment
The flow of blood normally stops when the blood clots, which may be encouraged by direct
pressure applied by pinching the soft fleshy part of the nose. This applies pressure to Little's
area, the source of the majority of nose bleeds and promotes clotting. Pressure should be firm
and be applied for at least five minutes and up to 20 minutes; tilting the head forward will help
decrease the chance of nausea and airway obstruction. Swallowing excess blood can irritate the
stomach and cause vomiting. Local application of an ice pack to the forehead or back of the neck
or sucking an ice cube has seen widespread practice, but has been shown to not have any
statistically significant effects on nasal mucosal blood flow. There are conflicting opinions in the
use of ice or nasal packing in the treatment of nose bleeds. Most suggest there is no detriment to
using ice or nasal packing when initial efforts to pinch the nose fail, while others advise against
it.
The local application of a vasoconstrictive agent has been shown to reduce the bleeding time in
benign cases of epistaxis. The drugs oxymetazoline or phenylephrine are widely available in
over-the-counter nasal sprays for the treatment of allergic rhinitis, and may be used for this
purpose.
Other products available to promote coagulation include Coalgan (in Europe) or NasalCEASE
(in the US). These are a calcium alginate mesh or swabs that is inserted in the nasal cavity to
accelerate coagulation. Also there is QuikClot nosebleed available in the U.S. that is a
hemostatic OTC formula.
If these simple measures do not work then medical intervention may be needed to stop bleeding,
possibly by an otolaryngologist (ENT doctor). In the first instance this can take the form of
chemical cautery of any bleeding vessels or packing of the nose with ribbon gauze or an
absorbent dressing (called anterior nasal packing). Such procedures are best carried out by a
medical professional. Chemical cauterisation is most commonly conducted using local
application of silver nitrate compound to any visible bleeding vessel. This is a painful procedure
and the nasal mucosa should be anaesthetised first, preferably with the addition of topical
adrenaline to further reduce bleeding. If bleeding is still uncontrolled or no focal bleeding point
is visible then the nasal cavity should be packed with a sterile dressing, which by applying
pressure to the nasal mucosa will tamponade the bleeding point. Ongoing bleeding despite good
nasal packing is a surgical emergency and can be treated by endoscopic evaluation of the nasal
cavity under general anaesthesia to identify an elusive bleeding point or to directly ligate (tie off)
the blood vessels supplying the nose. These blood vessels include the sphenopalatine, anterior
and posterior ethmoidal arteries. More rarely the maxillary or external cartoid artery can be
ligated. The bleeding can also be stopped by intra-arterial embolization using a catheter placed in
the groin and threaded up the aorta to the bleeding vessel by an interventional radiologist.
Continued bleeding may be an indication of more serious underlying conditions.
Chronic epistaxis resulting from a dry nasal mucosa can be treated by spraying saline in the nose
three times per day, lubricating the nose with ointments or creams, such as vasoline, and
installing a humidifier in the bedroom.
Application of a topical antibiotic ointment to the nasal mucosa has been shown to be an
effective treatment for recurrent epistaxis. One study found it to be as effective as nasal cautery
in the prevention of recurrent epistaxis in patients without active bleeding at the time of
treatment - both had a success rate of approximately 50 percent.
Nosebleeds are rarely dangerous unless prolonged and heavy. Nevertheless they should not be
underestimated by medical staff. Particularly in posterior bleeds a great deal of blood may be
swallowed and thus blood loss underestimated. The elderly and those with co-existing
morbidities, particularly of blood clotting should be closely monitored for signs of shock.
Recurrent nosebleeds may cause anemia due to iron deficiency.
DEAFNESS
A hearing impairment or deafness is a full or partial decrease in the ability to detect or
understand sounds. Caused by a wide range of biological and environmental factors, loss of
hearing can happen to any organism that perceives sound. "Hearing impaired" is often used to
refer to those who are deaf, although the term is viewed negatively by members of Deaf culture,
who prefer the terms "Deaf" and "Hard of Hearing".
Sound waves vary in amplitude and in frequency. Amplitude is the sound wave's peak pressure
variation. Frequency is the number of cycles per second of a sinusoidal component of a sound wave.
Loss of the ability to detect some frequencies, or to detect low-amplitude sounds that an organism
naturally detects, is a hearing impairment
Loudness, frequency, and discrimination deficiencies
Hearing sensitivity is indicated by the quietest sound that an individual can detect, called the
hearing threshold. In the case of people and some animals, this threshold can be accurately
measured by a behavioral audiogram. A record is made of the quietest sound that consistently
prompts a response from the listener. The test is carried out for sounds of different frequencies.
There are also electro-physiological tests that can be performed without requiring a behavioral
response.

Normal hearing thresholds are not the same for all frequencies in any species of animal. If
different frequencies of sound are played at the same amplitude, some will be loud, and others
quiet or even completely inaudible. Generally, if the gain or amplitude is increased, a sound is
more likely to be perceived. Ordinarily, when animals use sound to communicate, hearing in that
type of animal is most sensitive for the frequencies produced by calls, or, in the case of humans,
speech. This tuning of hearing exists at many levels of the auditory system, all the way from the
physical characteristics of the ear to the nerves and tracts that convey the nerve impulses of the
auditory portion of the brain.
A hearing impairment exists when an individual is not sensitive to the sounds normally heard by
its kind. In human beings, the term hearing impairment is usually reserved for people who have
relative insensitivity to sound in the speech frequencies. The severity of a hearing impairment is
categorized according to how much louder a sound must be made over the usual levels before the
listener can detect it. In profound deafness, even the loudest sounds that can be produced by the
instrument used to measure hearing (audiometer) may not be detected.
There is another aspect to hearing that involves the quality of a sound rather than amplitude. In
people, that aspect is usually measured by tests of speech discrimination. Basically, these tests
require that the sound is not only detected but understood. There are very rare types of hearing
impairments which affect discrimination alone.
Types and causes of hearing impairment
Hearing impairment comes from different biologic causes. Most commonly, the ear is the
affected part of the body.
Conductive
Conductive hearing loss occurs when sound is not conducted properly through the outer ear,
middle ear, or both. It is generally a mild to moderate impairment, because sound can still be
detected by the inner ear. More severe impairments can occur, particularly in Otosclerosis.
Generally, with pure conductive hearing loss, the quality of hearing (speech discrimination) is
good, as long as the sound is amplified loud enough to be easily heard.
Conductive hearing loss has a variety of causes:
 Ear canal obstruction

 Middle ear abnormalities:
o Tympanic membrane
o Ossicles
 Inner ear abnormalities:
o Superior canal dehiscence syndrome
 Other:
o Otosclerosis

Sensorineural hearing loss
Sensorineural hearing loss is due to insensitivity of the inner ear, the cochlea, or to impairment
of function in the auditory nervous system. It can be mild, moderate, severe, or profound, to the
point of total deafness. This is classified as a disability under the ADA and if unable to work is
eligible for disability payments.
The great majority of human sensorineural hearing loss is caused by abnormalities in the hair
cells of the organ of Corti in the cochlea. There are also very unusual sensorineural hearing
impairments that involve the VIIIth cranial nerve, the Vestibulocochlear nerve or the auditory
portions of the brain. In the rarest of these sorts of hearing loss, only the auditory centers of the
brain are affected. In this situation, central hearing loss, sounds may be heard at normal
thresholds, but the quality of the sound perceived is so poor that speech can not be understood.
Most sensory hearing loss is due to poor hair cell function. The hair cells may be abnormal at
birth, or damaged during the lifetime of an individual. There are both external causes of damage,
like noise trauma and infection, and intrinsic abnormalities, like deafness genes.
Sensorineural hearing loss that results from abnormalities of the central auditory system in the
brain is called Central Hearing Impairment. Since the auditory pathways cross back and forth on
both sides of the brain, deafness from a central cause is unusual.
Typical causes are discussed in following subsections.
Long-term exposure to environmental noise

Noise-induced hearing loss
Populations of people living near airports or freeways are exposed to levels of noise typically in
the 65 to 75 dB(A) range. If lifestyles include significant outdoor or open window conditions,
these exposures over time can degrade hearing. The U.S. EPA and various states have set noise
standards to protect people from these adverse health risks. The EPA has identified the level of
70 dB(A) for 24 hour exposure as the level necessary to protect the public from hearing loss and
other disruptive effects from noise, such as sleep disturbance, stress-related problems, learning
detriment, etc. (EPA, 1974).
Noise-Induced Hearing Loss (NIHL) typically is centered at 3000, 4000, or 6000 Hz. As noise
damage progresses, damage starts affecting lower and higher frequencies. On an audiogram, the
resulting configuration has a distinctive notch, sometimes referred to as a "noise notch." As
aging and other effects contribute to higher frequency loss (6–8 kHz on an audiogram), this
notch may be obscured and entirely disappear.
Louder sounds cause damage in a shorter period of time. Estimation of a "safe" duration of
exposure is possible using an exchange rate of 3 dB. As 3 dB represents a doubling of intensity
of sound, duration of exposure must be cut in half to maintain the same energy dose. For
example, the "safe" daily exposure amount at 85 dB A, known as an exposure action value, is 8
hours, while the "safe" exposure at 91 dB(A) is only 2 hours (National Institute for Occupational
Safety and Health, 1998). Note that for some people, sound may be damaging at even lower
levels than 85 dB A. Exposures to other ototoxins (such as pesticides, some medications
including chemotherapy, solvents, etc.) can lead to greater susceptibility to noise damage, as well
as causing their own damage. This is called a synergistic interaction.
Some American health and safety agencies (such as OSHA and MSHA), use an exchange rate of
5 dB. While this exchange rate is simpler to use, it drastically underestimates the damage caused
by very loud noise. For example, at 115 dB, a 3 dB exchange rate would limit exposure to about
half a minute; the 5 dB exchange rate allows 15 minutes.
While OSHA, MSHA, and FRA provide guidelines to limit noise exposure on the job, there is
essentially no regulation or enforcement of sound output for recreational sources and
environments, such as sports arenas, musical venues, bars, etc. This lack of regulation resulted
from the defunding of ONAC, the EPA's Office of Noise Abatement and Control, in the early
1980s. ONAC was established in 1972 by the Noise Control Act and charged with working to
assess and reduce environmental noise. Although the Office still exists, it has not been assigned
new funding.
Most people in the United States are unaware of the presence of environmental sound at
damaging levels, or of the level at which sound becomes harmful. Common sources of damaging
noise levels include car stereos, children's toys, transportation, crowds, lawn and maintenance
equipment, power tools, gun use, and even hair dryers. Noise damage is cumulative; all sources
of damage must be considered to assess risk. If one is exposed to loud sound (including music) at
high levels or for extended durations (85 dB A or greater), then hearing impairment will occur.
Sound levels increase with proximity; as the source is brought closer to the ear, the sound level
increases.
Genetic
Hearing loss can be inherited. Both dominant genes and recessive genes exist which can cause
mild to profound impairment. If a family has a dominant gene for deafness it will persist across
generations because it will manifest itself in the offspring even if it is inherited from only one
parent. If a family had genetic hearing impairment caused by a recessive gene it will not always
be apparent as it will have to be passed onto offspring from both parents. Dominant and
recessive hearing impairment can be syndromic or nonsyndromic. Recent gene mapping has
identified dozens of nonsyndromic dominant (DFNA#) and recessive (DFNB#) forms of
deafness.
 The most common type of congenital hearing impairment in developed countries is

DFNB1, also known as Connexin 26 deafness or GJB2-related deafness.
 The most common dominant syndromic forms of hearing impairment include Stickler
syndrome and Waardenburg syndrome.
 The most common recessive syndromic forms of hearing impairment are Pendred
syndrome, Large vestibular aqueduct syndrome and Usher syndrome.
 The congenital defect microtia can cause full or partial deafness depending upon the
severity of the deformity and whether or not certain parts of the inner or middle ear are
affected.
Disease or illness
 Measles may result in auditory nerve damage
 Meningitis may damage the auditory nerve or the cochlea
 Autoimmune disease has only recently been recognized as a potential cause for cochlear
damage. Although probably rare, it is possible for autoimmune processes to target the
cochlea specifically, without symptoms affecting other organs.Wegener's granulomatosis
is one of the autoimmune conditions that may precipitate hearing loss.
 Mumps (Epidemic parotitis) may result in profound sensorineural hearing loss(90
Decibel|dB or more), unilateral (one ear) or bilateral (both ears).
 Presbycusis is a progressive hearing impairment accompanying age, typically affecting
sensitivity to higher frequencies (above about 2 kHz).
 Adenoids that do not disappear by adolescence may continue to grow and may obstruct
the Eustachian tube, causing conductive hearing impairment and nasal infections that can
spread to the middle ear.
 AIDS and AIDS-related complex|ARC patients frequently experience auditory system
anomalies.
 HIV (and subsequent opportunistic infections) may directly affect the cochlea and central
auditory system.
 Chlamydia may cause hearing loss in newborns to whom the disease has been passed at
birth.
 Fetal alcohol syndrome is reported to cause hearing loss in up to 64% of infants born to
alcoholic mothers, from the ototoxic effect on the developing fetus plus malnutrition
during pregnancy from the excess alcohol intake.
 Premature birth results in sensorineural hearing loss approximately 5% of the time.
 Syphilis is commonly transmitted from pregnant women to their fetuses, and about a third
of the infected children will eventually become deaf.
 Otosclerosis is a hardening of the stapes (or stirrup) in the middle ear and causes
conductive hearing loss.
 Superior canal dehiscence, a gap in the bone cover above the inner ear, can lead to low-
frequency conductive hearing loss, autophony and vertigo
Medications
Some medications cause irreversible damage to the ear, and are limited in their use for this
reason. The most important group is the aminoglycosides (main member gentamicin).
Various other medications may reversibly affect hearing. This includes some diuretics, aspirin
and NSAIDs, and macrolide antibiotics.
Extremely heavy hydrocodone (Vicodin or Lorcet) abuse is known to cause hearing impairment.
Commentators have speculated that radio talk show host Rush Limbaugh's hearing loss was at
least in part caused by his admitted addiction to narcotic pain killers, in particular Vicodin and
OxyContin.[4]
Exposure to Ototoxic Chemicals
Ototoxicity
In addition to medications, hearing loss can also result from specific drugs; metals, such as lead;
solvents, such as toluene; and asphyxiants. [5] These are mostly industrial chemicals, uncommon
in residencies. Combined with noise, these ototoxic chemicals have an additive effect on a
person’s hearing loss. [5] Hearing loss due to chemicals starts in the high frequency range and is
irreversible. It damages the cochlea with lesions and degrades central portions of the auditory
system. [5] For some ototoxic chemical exposures, particularly styrene,[6] the risk of hearing loss
can be higher than being exposed to noise alone. Controlling noise and using hearing protectors
are insufficient for preventing hearing loss from these chemicals. However, taking antioxidants
helps prevent ototoxic hearing loss, at least to a degree.[6] The following list provides an accurate
catalogue of ototoxic chemicals [5][6]:
 Drugs
o anti-malarial, antibiotics, anti-inflammatory (non-steroidal), antineoplastic,
diuretics
 Solvents
o toluene, styrene, xylene, n-hexane, ethyl benzene, white spirits/Stoddard, carbon
disulfide, fuels, perchloroethylene, trichloroethylene, p-xylene
 Asphyxiants
o carbon monoxide, hydrogen cyanide
 Metals
o lead, mercury, organotins (trimethyltin)
 Pesticides/Herbicides
o paraquat, organophosphates
Physical trauma
 There can be damage either to the ear itself or to the brain centers that process the aural
information conveyed by the ears.
 People who sustain head injury are especially vulnerable to hearing loss or tinnitus, either
temporary or permanent.
 Exposure to very loud noise (90 dB or more, such as jet engines at close range) can cause
progressive hearing loss. Exposure to a single event of extremely loud noise (such as
explosions) can also cause temporary or permanent hearing loss. A typical source of
acoustic trauma is an excessively loud music concert.
Categories of hearing impairment
Hearing loss is categorized by its severity and by the age of onset. Two persons with the same
severity of hearing loss will experience it quite differently if it occurs early or late in life.
Furthermore, a loss can occur on only one side (unilateral) or on both (bilateral).
Types
As discussed above, there are three major types of hearing loss: neural/sensorineural, conductive,
or a combination of both. Treatment depends upon the type of hearing loss that is present.
Quantification of hearing loss

Hearing exam

The severity of hearing loss is measured by the degree of loudness, as measured in decibels, a
sound must attain before being detected by an individual. Hearing loss may be ranked as mild,
moderate, severe or profound. It is quite common for someone to have more than one degree of
hearing loss (i.e. mild sloping to severe). The following list shows the rankings and their
corresponding decibel ranges:
 Mild:
o for adults: between 25 and 40 dB
o for children: between 20 and 40 dB
 Moderate: between 41 and 55 dB
 Moderately severe: between 56 and 70 dB
 Severe: between 71 and 90 dB
 Profound: 90 dB or greater
The quietest sound one can hear at different frequencies is plotted on an audiogram to reflect
one's ability to hear at different frequencies. The range of normal human hearing (from the
softest audible sound to the loudest comfortable sound) is so great that the audiogram must be
plotted using a logarithmic scale. This large normal range, and the different amounts of hearing
loss at different frequencies, make it virtually impossible to accurately describe the amount of
hearing loss in simple terms such as percentages or the rankings above.
Measuring hearing loss in terms of a percentage is debatable in terms of effectiveness, and has
been compared to measuring weight in inches. Though in specific legal situations, where
decibels of loss are converted via a recognized legal formula, one can infer a standardized
"percentage of hearing loss" which is suitable for legal purposes only.
Another method for determining hearing loss, is the Hearing in Noise Test (HINT). HINT
technology was developed by the House Ear Institute, and is intended to measure an ability to
understand speech in quiet and noisy environments. Unlike pure-tone tests, where only one ear is
tested at a time, HINT evaluates hearing using both ears simultaneously (binaural), as binaural
hearing is essential for communication in noisy environments, and for sound localization.
Age of onset of deafness
The age at which the deafness develops is crucial to spoken language acquisition. Post-lingual
deafness are far more common than pre-lingual deafness.
If the hearing loss occurs at a young age, interference with the acquisition of spoken language
and social skills may occur. Hearing aids, which amplify the incoming sound, may alleviate
some of the problems caused by hearing impairment, but are often insufficient. Cochlear
implants artificially stimulate the VIIIth Nerve by providing an electric impulse substitution for
the firing of hair cells. Cochlear implants are not only expensive, but require sophisticated
programming in conjunction with patient training for effectiveness. People who have hearing
impairments, especially those who develop a hearing problem in childhood or old age, require
support and technical adaptations as part of the rehabilitation process.
Pre-lingual deafness
Prelingual deafness
Prelingual deafness is hearing impairment that is sustained prior to the acquisition of language,
which can occur as a result of a congenital condition or through hearing loss in early infancy.
Prelingual deafness impairs an individual's ability to acquire a spoken language, but children
born into signing families have no delay in language development. Most pre-lingual hearing
impairment is acquired via either disease or trauma rather than genetically inherited, so families
with deaf children nearly always lack previous experience with sign language.
Post-lingual deafness
Post-lingual deafness where hearing loss is adventitious after the acquisition of speech and
language, usually after the age of six. It may develop due to disease, trauma, or as a side-effect of
a medicine. Typically, hearing loss is gradual and often detected by family and friends of the
people so affected long before the patients themselves will acknowledge the disability. Common
treatments include hearing aids and learning lip reading.
Hard-of-hearing
People who are hard of hearing have varying amounts of hearing loss but usually not enough to
be considered deaf. How people classify themselves relative to hearing loss or deafness is a very
personal decision and reflects much more than just their ability to hear.
The phrase hard of hearing, normally used as an adjective, can also be used as a noun, referring
to people with hearing impairment as the hard of hearing. People who consider themselves
culturally Deaf prefer the term "hard of hearing" or "deaf", and perceive "hearing impaired" as an
insult.
Hearing impaired persons with partial loss of hearing may find that the quality of their hearing
varies from day to day, from one situation to another, or not at all. They may also, to a greater or
lesser extent, depend on both hearing aids and lip-reading. They may perhaps not always be
aware of it, but they do admit it is important to see the speaker's face in conversation.
Many people with hearing loss have better hearing in the lower frequency ranges (low tones),
and cannot hear as well or at all in the higher frequencies. Some people may merely find it
difficult to differentiate between words that begin with consonantal sounds such as the fricatives
or sibilants, z, or th, or the plosives d, t, b, or p. They may be unable to hear thin, high-pitched or
metallic noises, such as birds chirping or singing, clocks ticking, etc. Often, they are able to hear
and understand men's voices better than women's.
Others will find their condition much worse if circumstances in their immediate environment
affect the way they are able to use their hearing aids, or prevent them from employing their
speech reading skills. A room with a high ceiling and a lot of reverberation will affect the sound
of a speaker's voice adversely. The position of the listener, too, can make a difference; for
example, if only the listener's ineffectual ear is turned towards the speaker, then the listener will
have trouble hearing. Difficulties can also arise for the listener trying to lip-read, if the speaker is
sitting with his back against the light-source and is in this way obscuring his face. A rule of
thumb is that bright lighting is to the hearing-impaired what noise is to the hearing: a source of
distraction.

The speaker's accent; a topic with many potentially unfamiliar words; the softness of his/her
voice; a speech impediment; a habit of holding a hand in front of his/her mouth or turning his/her
face away at times: all these tendencies cause problems for the hard-of-hearing, especially when
they have to rely on lip-reading. Rustling papers and turning pages are the noises that hearing
aids pick up first.
Noisy situations are especially difficult, because hearing loss affects not only the ability to hear
sounds, but also the ability to localize and filter out background noise.
Unilateral hearing loss
People with unilateral hearing loss (single sided deafness/SSD) can hear typically (or better) in
one ear, but have trouble hearing in the other ear. Problems with this type of deficit is inability to
localize sounds (i.e. unable to tell where traffic is coming from) and inability to process out
background noise in a noisy environment, such as in a restaurant.
Social impact
Pre-lingual impairment
: Prelingual deafness
In children, hearing loss can lead to social isolation for several reasons. First, the child
experiences delayed social development that is in large part tied to delayed language acquisition.
It is also directly tied to their inability to pick up auditory social cues. This can result in a deaf
person becoming generally irritable. A child who uses sign language, or identifies with the Deaf
sub-culture does not generally experience this isolation, particularly if he/she attends a school for
the deaf, but may conversely experience isolation from his parents if they do not know sign
language. A child who is exclusively or predominantly oral (using speech for communication)
can experience social isolation from his or her hearing peers, particularly if no one takes the time
to explicitly teach her social skills that other children acquire independently by virtue of having
normal hearing. Finally, a child who has a severe impairment and uses some sign language may
be rejected by his or her Deaf peers, because of an understandable hesitation in abandoning the
use of existent verbal and speech-reading skills. Some in the Deaf community can view this as a
rejection of their own culture and its mores, and therefore will reject the individual preemptively.
Post-lingual impairment
Those who lose their hearing later in life, such as in late adolescence or adulthood, face their
own challenges, living with the adaptations that make it possible for them to live independently.
They may have to adapt to using hearing aids or a cochlear implant, develop speech-reading
skills, and/or learn sign language. The affected person may need to use a TTY (teletype),
interpreter, or relay service to communicate over the telephone. Loneliness and depression can
arise as a result of isolation (from the inability to communicate with friends and loved ones) and
difficulty in accepting their disability. The challenge is made greater by the need for those
around them to adapt to the person's hearing loss.

Many relationships have suffered because of the anger that occurs when there is general
miscommunication between family members. Generally, it's not only the person with a hearing
disability that feels isolated, but others around them who feel they are not being "heard" or paid
attention to, especially when the hearing loss has been gradual. Many people opt not to choose
hearing aids for fear of looking old, since hearing loss is usually associated with old age, which
equals ineffectiveness in some societies. Family members then feel as if their hearing loss
partner doesn't care about them enough to make changes to reduce their disability and make it
easier to communicate.
Hearing loss in children
12% of children aged 6–19 years have permanent hearing damage from excessive noise
exposure. The American Academy of Pediatrics advises that children should have their hearing
tested several times throughout their schooling:
 When they enter school

 At ages 6, 8, and 10,
 At least once during middle school
 At least once during high school
Besides screening children for hearing loss, schools can also educate them on the perils of
hazardous noise exposure. Research has shown that people who are educated about noise-
induced hearing loss and prevention are more likely to use hearing protectors at work or in their
private lives.
Medical treatments
Approaches
In addition to hearing aids there exist cochlear implants of increasing complexity and
effectiveness. These are useful in treating the mild to profound hearing impairment when the
onset follows the acquisitions of language and in some cases in children whose hearing loss
came before language was acquired. Recent research shows variations in efficacy but some
studies show that if implanted at a very young age, some profoundly impaired children can
acquire effective hearing and speech, particularly if supported by appropriate rehabilitation such
as auditory-verbal therapy
Gene therapy
A 2005 study achieved successful re-growth of cochlea cells in guinea pigs. It is important to
note, however, that the re-growth of cochlear hair cells does not imply the restoration of hearing
sensitivity as the sensory cells may or may not make connections with neurons that carry the
signals from hair cells to the brain. A 2008 study has shown that gene therapy targeting Atoh1
can cause hair cell growth and attract neuronal processes in embryonic mice. It is hoped that a
similar treatment will one day ameliorate hearing loss in humans.
OPTHALMOLOGY QUESTIONS
TRACHOMA:
DEF:
This is chronic conjunctivitis caused by an organism called Chlamydia trachomatis,characterized
by foreign body sensation and mucopurulent discharge.
MODE OF TRANSMITION:
It is determined by 5ds and 5fs that is:
5ds:
 Dry climate.
 Dust.
 Dirty.
 Density(over clowded areas).
 Discharge.
5fs:
 Flies.
 Fingers.
 Formites.
 Feaces.
 Food.
CLINICAL FEATURES:
SYMPTOMS:
 Foreign body sensation.
 Occussional tearing.
 Eye discharge.
 Occussional lacrimatio especially in the evening and morning.
SIGNS:
 Cobble stones on inverting the upper eye lid.
 Congestion of the upper eye lid.
 Purples(smile purple like, more than 5 confirms trachoma).
ON THE CORNEA:
 Superficial keratitison slit lump examination.
 Herbert’s follicles are present in the limbus area.
 down wards to the papillary area.
WORLD HEALTH CLASSIFICATION OF TRAUCOMA:

 F-Trachoma follicular formation (5 or more follicles).
 I-Intense inflammation.
 S- Trachoma scaring.
 T-Trachiasis misdirection of at least one eye lash, rubbing on the cornea.
 O- Corneal opacity.
MANAGEMENT ACCORDING TO WORLD HEALTH ORGANISATION:

 S-Surgery.
 A-Antibiotics.
 F-Facial hygiene.
 E-Environmental measures.
INVESTIGATIONS.
 History taking that will review chronic conjutivitis or coming from the community that is
dry and dirty and crowded.
 Physical examination that will review more than five follicles on the conjunctiva.
 Slit lump to review the opacity of the cornea.
 Eye swab to isolate the causative organisms.
 Tonometry to rule out glaucoma.
 Visual acult to review the initial vision of the eye.
TREATMENT:
 Azithromycin 20mgs/kg bwt stat.
 1% erythromycin eye ointment qid for 6weeks.
 1%Tetracycline eye ointment qid by 6weeks.
 Tetracyclin or Erythromycin 250-500mgs qid for 3-4weeks.
 Doxycyclin 100mgs bd for 3-4 weeks.
 Panadol 500-1000mgs tds by 3days.
SURGERY:
 Can be done (total plate rotation)to control the eye lid.
ANTIBIOTICS:
 Are given to treat active infection which is there.
FACIAL HYGIENE:
 Is done to avoid facial infections.
ENVIRONMENTAL MEASURES.
 This includes proper exposure of gabbage, VIP, Proper or good water supply.
Such as tap water, deep wells.
COMPLICATIONS:
 Corneal opacity.
 Trachiasis.
 Impared vision.
 Blindness.
 Madriasis(loss of eye lashes).
 Poliosis(whitening of eye lashes).
NURSING CARE:
AIMS;
1. To control the spread of infections.
2. To promote comfort of the patient.
3. To prevent complications.
IEC:
1. Promote facial hygiene.
2. Explain the disease process to the patient and the community as a whole.
3. Proper disposal of garbage.
4. Avoid overcrowding.
5. Meticulous hand washing.
6. Proper use of formites.
7. Use of VIP toilets.
8. Good water supply to the community.
9. Early diagnosis and treatment of any eye problems.
10. Avoid touching of the eyes with dirty hands.
ENUCLEATION:
DEF:
Enucleation is the surgical removal of the eye ball,which could be due to tumour or severe eye
infection.
INDICATIONS:
 Severe eye trauma.
 Malignant tumours of the eye.
 A painful blind eye.
 For cosmetic purposes.
The surgery may involve the entire eye and related structures.The removal of contents of the eye
ball only is called evisceration.
PRE-OPERATIVE CARE OF THE PATIENT UNDER GOING ENUCLEATION.

Patient is admitted 2-3days before surgery in a surgical eye unit,tofacilitate for investigations and
preparing the patient for surgery,psychologically,emotionally,physically and spiritually.so as the
patient to with stand the effects of surgery.
PSYCHOLOGICAL CARE:
Patient is explained about his/her disease process,the reasons for admission and possible
surgery to be done.The patient is explained to about the post operative appearance,he is also
told that there are obital implants,prothesises and the fitting procedure that can be done.the
nurse also allows the patient to verbalise his fears and worries,as self concept will be changed
by loss of the eye so the grieving process is normal for these individuals however,in case where
the the eye as caused severe pain,the patient may look forward to relief provided by the surgery.
IVESTIGATIONS:
 Full blood count to evaluate the amount of blood in the patient.
 X-ray of the skull to view the extent of damage.
 Computer tomography for the head to view the extent and demarcation of damage.
 Blood SUGER levels are also testedto rule out diabetes mellitus.
IMMEDIATE PRE-OPERATIVE CARE:

The patient/significant others are asked to sign the consent form.This is a legal document that
protects both the surgeon and the patient.
The patient is told to stop eating 6-8hrs to prevent the patient from vomiting as the general
anaesthesia may be used according to the preference of the surgeon others could use local
anaethesia.
SHAVING:
 All the beads and eye blows are shaved to reduce the infections.
 Hair is gathered and put in a cape.
OBSERVATIONS:
 Vital signs are done to act as baseline data for comparison.
 Observe level of fear or anxiety is monitored and reported.
 The patient face is washed with hibitane soap and dried.
LABBLELING:
 The patient is labbled,indicating the name,age,sex,ward ,indication of surgery and the
diagnosis.
REMOVAL OF JEWELLIES:
Patient jewelries are removed and given to significant others or kept by the sisters cupboard,if
the patient is alone safely.
GOWNING:
 Patient is gowned in theatre gown and the theatre team informed that the patient is ready.
PATIENTS DOCUMENTS:
 All patients documents are collected and taken together with patient to theatre suchas
patients file,lab results and x-ray forms.
HANDOVER OF THE PATIENT TO THEATRE NURSE:

 Handover the patient and all his documents to the theare nurse.
CARE OF RELATIVES:

 Explain to the relatives that the patient will be taken care of by the theare staffs,and
show them the lounge where they can sit waiting for there relative to come out of the
theatre.
BACK TO THE WARD:

 Prepare the post-oparative bed waiting for the patient to come back from theatre.
POST-OPARETIVE CARE:
ENVIRONMENT:
 Patient will be nursed in a clean and well made bed in the eye ward preferably in the side
ward.
POSITION:
Patient will be nursed in the propped up position with the head of bed elevated,depending on the
anaesthesia which was used, the patient can also be nursed in semi fowlers position with the
head of bed elevated and the head tilted to the side to promote secretions drainage the and
preventing.
The tounge from failing backwards.
TRABECULECTOMY
Mr. Lumbama has of late been complaining of having blurred vision and progressive visual loss. The
doctor strongly suspects the possibility of secondary glaucoma and considers doing a trabeculectomy.
a) Define trabeculectomy 5%
b) With aid of a well labelled diagram, describe the flow of aqueous humour in the eye 20%
c) Identify five 5 signs and symptoms that the patient may present with 15%
d) Mention two investigations that the Doctor may carry out to confirm the diagnosis 10%
e) Discuss in detail the management of a patient with glaucoma 50%
DEFINITION
Trabeculectomy is an opening made into the trabecular mess to allow fluid to flow out so as to help in
decreasing intra ocular pressure
Glaucoma can be divided roughly into two main categories
 "Open angle" Open angle, chronic glaucoma tends to progress at a slower rate and the
patient may not notice that they have lost vision until the disease has progressed
significantly.
 "Closed angle" glaucoma. Closed angle glaucoma can appear suddenly and is often painful;
visual loss can progress quickly but the discomfort often leads patients to seek medical attention
before permanent damage occurs.
Diagram showing the flow of aqueous humor in the eye here.

Signs and symptoms
Open-angle Glaucoma It is painless and does not have acute attacks. The only signs are gradually
progressive visual field loss, and optic nerve changes (increased cup-to-disc ratio on fundoscopic
examination).
Closed-angle Glaucoma). About 10% of patients with closed angles present with acute angle closure
crises characterized by sudden ocular pain, seeing halos around lights, red eye, very high intraocular
pressure (>30 mmHg), nausea and vomiting, sudden decreased vision, and a fixed, mid-dilated pupil.
Acute angle closure is an ocular emergency.
Investigations
 measurements of the intraocular pressure via tonometry,

 changes in size or shape of the eye, anterior chamber angle examination or gonioscopy,
 Examination of the optic nerve to look for any visible damage to it, or change in the cup-to-disc
ratio and also rim appearance and vascular change.
MANAGEMENT
Objectives
 The modern goals of glaucoma management are to avoid glaucomatous damage, nerve damage,
preserve visual field and total quality of life for patients with minimal side effects.
 This requires appropriate diagnostic techniques and follow up examinations and judicious
selection of treatments for the individual patient. Although intraocular pressure is only one of the
major risk factors for glaucoma, lowering it via various pharmaceuticals and/or surgical
techniques is currently the mainstay of glaucoma treatment. Vascular flow and neurodegenerative
theories of glaucomatous optic neuropathy have prompted studies on various neuroprotective
therapeutic strategies including nutritional compounds some of which may be regarded by
clinicians as safe for use now, while others are on trial.
Medical management
 Intraocular pressure can be lowered with medication, usually eye drops. There are several
different classes of medications to treat glaucoma with several different medications in each
class.
 Poor compliance with medications and follow-up visits is a major reason for vision loss in
glaucoma patients..
 The possible neuroprotective effects of various topical and systemic medications are also being
investigated.
 Prostaglandin analogs like latanoprost (Xalatan), bimatoprost (Lumigan) and travoprost

(Travatan) increase uveoscleral outflow of aqueous humor.
 Less-selective sympathomimetics such as epinephrine decrease aqueous humor production
through vasoconstriction of ciliary body blood vessels.
 Miotic agents (parasympathomimetics) like pilocarpine work by contraction of the ciliary muscle,
tightening the trabecular meshwork and allowing increased outflow of the aqueous humour.
Ecothiopate is used in chronic glaucoma.
 Carbonic anhydrase inhibitors like dorzolamide (Trusopt), brinzolamide (Azopt), acetazolamide
(Diamox) lower secretion of aqueous humor by inhibiting carbonic anhydrase in the ciliary body.
 Physostigmine is also used to treat glaucoma and delayed gastric emptying.
Surgical management
Trabeculectomy
The most common conventional surgery performed for glaucoma is the trabeculectomy. Here, a partial
thickness flap is made in the scleral wall of the eye, and a window opening made under the flap to remove
a portion of the trabecular meshwork. The scleral flap is then sutured loosely back in place. This allows
fluid to flow out of the eye through this opening, resulting in lowered intraocular pressure and the
formation of a bleb or fluid bubble on the surface of the eye. Scarring can occur around or over the flap
opening, causing it to become less effective or lose effectiveness altogether. One person can have
multiple surgical procedures of the same or different types.
CORNEAL ULCERS
Milambo a welder comes to your clinic with complaints of pain in the eyes. You suspect that he could
have a corneal ulceration and you begin a series of investigations to determine the cause of pain.
a) Define corneal ulcers 5%

b) State five other possible causes of corneal ulceration other than the one mentioned 10%
c) Explain five(5) investigations that could lead you to the diagnosis of corneal ulcers 20%
d) Discuss the medical management of a patient with corneal ulcers 45%
e) Mention four 4 likely complications of corneal ulceration 20%
Definition.
A corneal ulcer, or ulcerative keratitis, or eyesore is an inflammatory or more seriously, infective

condition of the cornea involving disruption of its epithelial layer with involvement of the corneal stoma.
CAUSES
1. Trauma, particularly with vegetable matter,
2. Chemical injury,
3. Contact lenses
4. Infections.
5. Entropion,
 Corneal dystrophy,
 keratoconjunctivitis sicca (dry eye).
Many micro-organisms cause infective corneal ulcer. Among them are bacteria, fungi, viruses, protozoa,
and chlamydia:
 Bacterial keratitis is caused by Staphylococcus aureus, Streptococcus viridans, Escherichia coli,

Enterococci, Pseudomonas, Nocardia and many other bacteria.
 Fungal keratitis causes deep and severe corneal ulcer. It is caused by Aspergillus sp., Fusarium
sp., Candida sp., as also Rhizopus, Mucor, and other fungi. The typical feature of fungal keratitis

is slow onset and gradual progression, where signs are much more than the symptoms. Small
satellite lesions around the ulcer are a common feature of fungal keratitis and hypopyon is usually
seen.
 Viral keratitis causes corneal ulceration. It is caused most commonly by Herpes simplex, Herpes
Zoster and Adenoviruses. Also it can be caused by coronaviruses & many other viruses. Herpes
virus causes a dendritic ulcer, which can recur and relapse over the lifetime of an individual.
 Protozoa infection like Acanthamoeba keratitis is characterized by severe pain and is associated
with contact lens users swimming in pools.
 Chlamydia trachomatis can also contribute to development of corneal ulcer.
Symptoms
 Corneal ulcers are extremely painful due to nerve exposure,

 Can cause tearing,
 squinting,
 Vision loss of the eye.
 There may also be signs of anterior uveitis, such as miosis (small pupil), aqueous flare (protein in
the aqueous humour), and redness of the eye. An axon reflex may be responsible for uveitis
formation — stimulation of pain receptors in the cornea results in release inflammatory mediators
such as prostaglandins, histamine, and acetylcholine.
Diagnosis
Diagnosis is done by
 Direct observation under magnified view of slit lamp revealing the ulcer on the cornea.
 The use of fluorescein stain, which is taken up by exposed corneal stoma and appears green,
helps in defining the margins of the corneal ulcer, and can reveal additional details of the
surrounding epithelium.
 Doing a corneal scraping and examining under the microscope with stains like Gram's and KOH
preparation may reveal the bacteria and fungi respectively.
 Microbiological culture tests may be necessary to isolate the causative organisms for some cases.
Other tests that may be necessary include a Schirmer's test for keratoconjunctivitis sicca
 Analysis of facial nerve function for facial nerve paralysis.
Treatment
 Proper diagnosis is essential for optimal treatment. Bacterial corneal ulcer requires intensive
fortified antibiotic therapy to treat the infection.
 Fungal corneal ulcers require intensive application of topical anti-fungal agents.
 Viral corneal ulceration caused by herpes virus may respond to antiviral like topical acyclovir
ointment instilled at least five times a day.
 Supportive therapy like pain medications is given, including topical cycloplegics like atropine or
homatropine to dilate the pupil and thereby stop spasms of the ciliary muscle. Superficial ulcers
may heal in less than a week.

 Deep ulcers and descemetoceles may require conjunctival grafts or conjunctival flaps, soft
contact lenses, or corneal transplant.
 Proper nutrition, including protein intake and Vitamin C are usually advised. In cases of
Keratomalacia, where the corneal ulceration is due to a deficiency of Vitamin A, supplementation
of the Vitamin A by oral or intramuscular route is given.
 Drugs that are usually contraindicated in corneal ulcer are topical corticosteroids and anesthetics -
these should not be used on any type of corneal ulcer because they prevent healing, may lead to
superinfection with fungi and other bacteria and will often make the condition much worse.
RETINAL DETACHMENT
Mwale a known case repeated elevation of intra ocular pressure suffers yet another injury to his
eye resulting in the detachment of the retina.
a) Define retinal detachment

b) Mention two types of retinal detachment
c) Outline six (6) signs and symptoms of retinal detachment
d) Discuss in detail the management of a patient with retinal detachment
e) State five possible complications of retinal detachment
Definition.
 Retinal detachment – A retinal detachment occurs due to a break in the retina that allows fluid
to pass from the vitreous space into the sub retinal space between the sensory retina and the
retinal pigment epithelium.
TYPES OF DETACTMENT
Retinal breaks are divided into three types - holes, tears and dialyses.
 Holes form due to retinal atrophy especially within an area of lattice degeneration.
 Tears are due to vitreoretinal traction.
 Dialyses which are very peripheral and circumferential may be either tractional or atrophic,
the atrophic form most often occurring as idiopathic dialysis of the young.
1. Exudative, serous, or secondary retinal detachment – An Exudative retinal detachment occurs

due to inflammation, injury or vascular abnormalities that results in fluid accumulating
underneath the retina without the presence of a hole, tear, or break. In evaluation of retinal
detachment it is critical to exclude Exudative detachment as surgery will make the situation
worse not better.
2. Tractional retinal detachment – A tractional retinal detachment occurs when fibrous or fibro
vascular tissue, caused by an injury, inflammation or revascularization, pulls the sensory retina
from the retinal pigment epithelium.
Symptoms

A retinal detachment is commonly preceded by a posterior vitreous detachment which gives rise to these
symptoms:
 flashes of light (photopsia) – very brief in the extreme peripheral (outside of center) part of vision
 a sudden dramatic increase in the number of floaters
 a ring of floaters or hairs just to the temporal side of the central vision
 a slight feeling of heaviness in the eye
Although most posterior vitreous detachments do not progress to retinal detachments, those that do
produce the following symptoms:
 a dense shadow that starts in the peripheral vision and slowly progresses towards the central
vision
 the impression that a veil or curtain was drawn over the field of vision
 straight lines (scale, edge of the wall, road, etc.) that suddenly appear curved (positive Amsler
grid test)
 central visual loss
(None of this is to be confused with the broken retina which is generally the tearing of muscle and nerve
behind the eye)
Treatment of Retinal Detachment
There are several methods of treating a detached retina which all depend on finding and closing the
breaks which have formed in the retina. All three of the procedures follow the same 3 general principles:
1. Find all retinal breaks

2. Seal all retinal breaks
3. Relieve present (and future) vitreoretinal traction
 Cryopexy and Laser Photocoagulation
Cryotherapy (freezing) or laser photocoagulation are occasionally used alone to wall off a small
area of retinal detachment so that the detachment does not spread.
 Scleral buckle surgery
Scleral buckle surgery is an established treatment in which the eye surgeon sews one or more
silicone bands (bands, tyres) to the sclera (the white outer coat of the eyeball). The bands push the
wall of the eye inward against the retinal hole, closing the break or reducing fluid flow through it
and reducing the effect of vitreous traction thereby allowing the retina to re-attach. Cryotherapy
(freezing) is applied around retinal breaks prior to placing the buckle. Often subretinal fluid is
drained as part of the buckling procedure. The buckle remains in situ. The most common side
effect of a scleral operation is myopic shift. That is, the operated eye will be shorter sighted after
the operation. Radial scleral buckle is indicated to U-shaped tears or Fishmouth tears and
posterior breaks. Circumferential scleral buckle indicated to multiple breaks, anterior breaks and
wide breaks. Encircling buckles indicated to breaks more than 2 quadrant of retinal area, lattice
degeration located on more than 2 quadrants of retinal area, undetectable breaks, and proliferative
vitreous retinopathy.
 Vitrectomy
Vitrectomy is an increasingly used treatment for retinal detachment. It involves the removal of
the vitreous gel and is usually combined with filling the eye with either a gas bubble ( SF6 or C3F8
gas) or silicon oil. Advantages of using gas in this operation are that there is no myopic shift after
the operation and gas is absorbed within a few weeks. Silicon oil (PDMS), if filled needs to
remove after a period of 2–8 months depending on surgeons preference. Silicon oil is more
commonly used in cases associated with proliferative vitreo-retinopathy (PVR). A disadvantage
is that a vitrectomy always leads to more rapid progression of a cataract in the operated eye. In
many places vitrectomy is the most commonly performed operation for the treatment of retinal
detachment.
Prevention
 Retinal detachment can sometimes be prevented. The most effective means is by educating
people to seek ophthalmic medical attention if they suffer symptoms suggestive of a posterior
vitreous detachment. Early examination allows detection of retinal tears which can be treated with
laser or cryotherapy. This reduces the risk of retinal detachment in those who have tears from
around 1:3 to 1:20.
 There are some known risk factors for retinal detachment. There are also many activities which at
one time or another have been forbidden to those at risk of retinal detachment, with varying
degrees of evidence supporting the restrictions.
 Cataract surgery is a major cause, and can result in detachment even a long time after the
operation. The risk is increased if there are complications during cataract surgery, but remains
even in apparently uncomplicated surgery. The increasing rates of cataract surgery, and
decreasing age at cataract surgery, inevitably lead to an increased incidence of retinal detachment.
 Trauma is a less frequent cause. Activities which can cause direct trauma to the eye (boxing,
kickboxing, karate, etc.) may cause a particular type of retinal tear called a retinal dialysis. This
type of tear can be detected and treated before it develops into a retinal detachment. For this
reason governing bodies in some of these sports require regular eye examination.
 Individuals prone to retinal detachment due to a high level of myopia are encouraged to avoid
activities where there is a risk of shock to the head or eyes, although without direct trauma to the
eye the evidence base for this may be unconvincing.
 Some Doctors recommend avoiding activities that increase pressure in the eye, including diving,
skydiving, again with little supporting evidence. According to one medical website, retinal
detachment does not happen as a result of straining your eyes, bending or, heavy lifting.
 Roller coasters and other activities that could cause trauma should be avoided for those who have
had a family history of retinal detachment, but those who are at low risk because of
nearsightedness should be alright, just nothing extreme like skydiving, bungee jumping etc., but
those who have had cataract surgery should not participate in thrill rides or any activity that could
cause trauma to the head or eyes. In order to cause retinal detachment for those at a low risk, one
must hit the head extremely hard like a car accident for instance. For those at high risk, activities
that have nothing to do with the head or eyes would be alright. Therefore, heavy weightlifting
would appear to be fine. However, two recent scientific articles have noted cases of retinal
detachment or maculopathy due to weightlifting (specifically with the Valsalva method), and a
third documented an increase in blood pressure in the eye during weightlifting Moreover, a
recent case-control study focusing on myopic subjects supports the hypothesis that occupational
heavy lifting (or manual handling) requiring Valsalva maneuver may be a risk factor for retinal
detachment
 Activities that involve sudden acceleration or deceleration also increase eye pressure and are
discouraged by some doctors.
CATARACT

Naomi a 65 years old woman is admitted to the eye ward with a complaint of poor visibility in both eyes.
After a thorough investigation the specialist decides that Naomi should undergo surgery in one of the eyes
to remove the lens
a) List (5 ) five possible causes of cataracts in Zambia. 5%

(ii)Draw a well labeled diagram of the eye 10%
b) Discuss pre operative care would you give to your client 45%
c) Discuss the IEC that you would give you client upon discharge 15%
d) Mention five (5) Complication of contact extraction 15 %
MARKING KEY - CATARACT.
List the possible causes of cataract in Zambia

a. Causes (list)
 Aging
 Congenital predisposition
 Eye injuries
 Some diseases such as diabetes mellitus uveitis
 Exposure to radiation.
 Down syndrome
 Renal disorders
 Retinal detachment
 Electronic shock
 Obey skeletal
 Dehydration with chronic diarrhea
 Smokingd
 Glaucoma
 Retinitis
 Hypoprathyrordism
 Atopic dermatitis
 Toxic cataract (chemical toxicity.
State five types of cataract that you may come across

b. Types (state)
 Senile cataract, the most common and it is related lens opacity. The most affected people
are 50 years old and above. If it occurs before this age then it is called “pre-senile
cataract”.
 Congenital cataract, is usually bilateral and be familial or result from intrauterine
infection like Rubella or from drug taken during pregnancy.
 Traumatic cataract- this one may be due to blunt trauma to the eye ball.
 Toxic cataract- this one is due to ingestion or taking of certain drug for a long period of
time (e.g. Corticosteroids)
 Posture sub capsular
 Secondary cataract-this one is associated with disease such as diabetes mellitus, uveitis
Keratits.
 Nuclear cataract
C. PRE-OPERATIVE CARE OF MRS. LUNSONGA

Aims:
 To prepare Mrs. Lunsonga psychologically and physically for operation
 To promote normal function of the eye
Admission
 Welcome Mrs. Lunsonga into the ward. Introduce yourself to her. Introduce other members of
staff and other patient in the war for Lunsonga to familiarize the new environment
 Check Mrs. Lunsonga vital signs to act as baseline date and to assess any deviation from normal.
Record all findings for reference.
Environment
 Provide a clean room to minimize the risk of infection

 Maintain a restful environment by keeping Mrs. Lunsonga room clean and well ventilated and by
minimizing environment irritants e.g. noise, direct light of eyes, and smoking.
Assessment
 Assess Mrs. Lunsonga physical state to dictate any abnormalities or deviations from normal
which may need may need to be corrected before surgery.
 Assess Mrs. Lunsonga nutritional status by checking hair texture , skin status and color of
mucous membrane
 Assess pattern, nail beds for pallor because ventilation is potentially compromised during all
phases of surgery
Preoperative medication
Depending on the finding during assessment:

 Giving the prescribed medication
 Monitor for desired effects and side effects of the drugs
Preoperative Education
 Teach Mrs. Lunsonga some deep breathing and coughing exercise to promote lung expansion
 Teach her about mobility and active body movement to prevent post-operative complications like
deep vein thrombosis.
 Teach her also about cognitive coping strategies to relive tension, overcome anxiety and achieve
relaxation.
Nursing care the day before operation

Psychological care
 refer the question to the highest authority if you cannot do it

 This is done to Continue giving psychological support to allay anxiety
 Reinforce the Doctor’s explanation on the kind of operative its outcome
 Encourage Mrs. Lunsonga to verbalize her concerns and ask questions.
 Answer honestly or relieve tension due to worries.
Consent Form
 Before Mrs. Lunsonga Sign the consent form, ensure that the surgeon has provided a simple and
clear explanation of what cataract extraction entails, expected outcome and possible risk if
operation is not done
 After being sure that Mrs. Lunsonga knows and understands what will happen, then witness the
signing of consent form.
Cardinal control tests

Collect blood sample for:
 Hemoglobin to rule anemia
 Grouping and cross matching in case blood transfusion will be needed.
 Bleeding and clothing time to rule out the bleeding disorder which may have a negative bearing
post operatively.
 Collect urine sample for urinalysis to rule out diabetes mellitus and renal disease which may have
negative bearing in post operative period.
 Chest x-ray or ultra sound to rule out chest infections.
Nutrition and Fluid
 Mrs. Lunsonga will be staved for 6-8s prior to surgery

 For this reason, advise her after she has supper not to take anything by mouth from midnight to
prevent vomiting and aspiration during surgery.
Nursing care the day of operation

Personal care
 Give Mrs. Lunsonga an assisted bath in the morning, to remove sweat and dead epithelial cell on
the body.
 Mrs. Lunsonga will be dressed in a fresh, clean theatre gown to prevent infection
 Advise Mrs. Lunsonga to take off any jewelers to prevent electrocution
 Insert a canula to keep Mrs. Lunsonga vein open for intravenous infusions.
 To prevent mistaken operation, provide an identity band of name, age sex, ward, type of surgery
to be done.
Immediate preoperative observation
 Check vital signs i.e. T, P, R and BP to act as baseline date in intra-operative phase.
 Report and not on Mrs. Lunsonga chart at the front of the file any unusual observation that might
have a bearing on anesthesia or surgery, e.g. raised BP.
Pre Anaesthetic Medication

 As ordered, give pre-anesthetics medication to alley anxiety, decrease the flow of pharyngeal
secretion and to reduce the amount of anesthesia to be given and also to create amnesia for the
event that precede surgery.
Escorting Mrs. Lunsonga to pre-surgical suite

 Complete the pre-operative checklist to be sure that it bears information such as clinical data,
patient preparation and communication assessment.
 Attach together surgical consent form, all laboratory reports or results, x-rays and scan films
other necessary documents.
 Transfer Mrs. Lunsonga form bed to a stretcher cover with sufficient number of blankets to
ensure warmth.
 Once at the hand over Mrs. Lunsonga to the theatre according to the hospital policy
Attending to Mrs. Lunsonga Family

 Come back to the ward and continue reassuring Mrs. Lunsonga family members.
D. Complication of contact extract

 Hemoglobin- into the anterior chamber, thus “hyphema” Occurs to strain on the eye.
 Wound rapture- due to loosing of a suture or pressure on the eye
 Iris prolapsed- may occur at the site of rapture in the incision.
 Infection- for example endophthalmisis due to poor aseptic techniques post operatively.
 Retinal detachment due to vitreous loss.
 Glucose due to adhesion forming between iris and the cornea blocking filtrate angle.
 Anterior uveitis to vitreous loss.
 Shall owing of anterior chamber.
 Blindness
 Astigmatism- loss of refractive indices leading to disruptive change.

General Preoperative Nursing Care.

{Suggested format of your write up when attempting surgery questions}
The questions may appear in the following forms; asking you
 The general preoperative nursing care

 Specific preoperative nursing care
 Immediate preoperative nursing care
 Emergency nursing care
 It important that you begin by giving a brief introduction of the kind of preoperative nursing care
you are going to describe i.e.
 Preoperative nursing care is the care that I will give my patient from the time of admission to a
surgical unit up until the time immediately before the patient is transferred to the operating dept.
 Or
 The immediate preoperative nursing care is the care that I will give to my client immediately
{30min to one hr} before transferring him to the operating dept.
 Specific preoperative nursing care focuses on special preoperative nursing activities which
MUST be done before the patient is taken to Theatre i.e. a patient going for rectal surgery will
need to have an enema done, a patient going for repair of the ureters will need to be catheterized,
but these will not be as necessary as in a patient going for amputation of a finger or cataract
extraction.

Consideration however needs to taken also on the type of anesthesia to be used.
Remember your write up should be in an active form. Put your self as the person who is going to carry
out the nursing activities instead of referring to what the other nurse would have done
Then you need to write your objectives of care {most of these objectives apply to a number of surgical
conditions, so you can use them generally} i.e.
The general objectives of my care during this period are as follows;
 To prepare the patient;

 physically, psychologically, emotionally spiritually so as to be enable him withstand the effects of
surgery and administration of anesthesia and to ensure that he recovers rapidly and safely from
the surgical procedure.
 Anticipate and prevent potential complications during surgery
 To achieve these objectives, I will provide my nursing care in the following manner;
 History {Data collection}.
 On admission, I will obtain subjective and objective information from my patient. This will help
me identify my patient, identify the immediate needs of my patient and thus be able to give a
refocused nursing care plan based on the needs as well as provide an opportunity for giving I.E.C
 {Note history taking is often omitted in many cases, but it forms an integral part in your nursing
care plan}
2. PSYCHOLOGICAL CARE
 This care will help my patient's mind to be ready for surgery.
 I will provide him information on the type of surgery he is to undergo, for example where and
how that surgery will be done, some expectations of that surgery particularly, its benefits in
comparison to other forms of treatment without causing undue anxiety. This will be done using a
simple language which he clearly understands.
 I will provide him an opportunity to ask questions, express his fears or anxiety, as verbalizing can
help reduce tension prior and during surgery.
 If there are any patients nearby who have had similar operations, I will introduce these patients
to him so that they can have a one to one chart and share there experiences
 I will also consider the relatives and significant others in the care plan for the patient so as to
promote a sense of belonging .This will help him uplift his self concept and feel loved
 All procedures to be done him will be explained to him in advance to gain his cooperation
 Privacy will be maintained at all times and all his realistic wishes respected
 An informed consent will be obtained after providing him with all the necessary information
concerning his surgery.
4. PHYSICAL PREPARATIONS OF MY CLIENT/PATIET
BOWEL PREPARATION:
 I will begin the bowel preparations, where I will starve my patient at least 8 hours from solid
foods, 6 hours semi solid foods, and 2 hours from fluids before the operation.
 For operations involving the GIT laxatives and enema will be given a day before the operation.
 In an emergency, I will insert an N.G tube o aspirate the contents of the stomach so as to prevent
vomiting and aspiration, which can lead to aspiration pnuemonia
 I will also administer prescribe antibiotics for sterilizing the abdomen.
 {Countercheck with the Doctors orders}
SKIN PREPARATION:
 I will give an antiseptic bath or shower a day prior to surgery or in the morning of the day of
surgery to cleanse him of micro bacteria from the body.
 The site of operation will be shaved, being cleaned with an antiseptic solution and left dry
 I will provide a clean gown to be worn over the body to allow the skin to remain clean
BLADDER CARE
 In Situ
 I will ask my patient to empty the bladder in the morning before surgery
 I will also put an indwelling catheter to allow continuous drainage of the urine. This is important
as it prevents accidental perforation of the bladder in abdominal surgery .It also helps to monitor
the status of urinary output during surgery
OBSERVATIONS:
Do vital signs of TPR to for base line data
o Observe the patient reaction to the idea of surgery
o Observe the pain threshold.
I will put an intravenous infusion line for administration of solutions and medicines during surgery.
 An intravenous line also provides a quick access of the veins when you want to resuscitate the
patient
 It also provides a means of providing nutrition post operatively
GOWNS
 I will give a gown and a head dress to cover the hair. this is to limit micro organism from the
head and body contaminating the incision site
NAME TAG
A name tag or identity band will be placed on the patient forehead or arm bearing his name ,sex age ,and
type of operation to be done
REMOVAL OF VALUABLES
 I will remove the entire valuables such as ring hair pieces dentures or jewelry as some of theses
may easily ignite static electricity in an environment where there will be high concentration of
oxygen.
 some metal valuables also can cause accidental burns or electric shock to the patient where a
diathermy machine is in use
MEDICAL RECORDS
 I will arrange all the necessary medical records for the patient, all the lab and x-ray results which
were ordered, the doctors and nurses documents will accompany the patient as he will be
transferred to the theatre
CARE OF THE RELATIVES

I will inform the relatives of the impending transfer of the patient to theatre and ask them to wait in the
waiting lounge for the return of their relative.

 Once every thing is in place, i will inform the O.T dept that patient is ready for surgery and
arrangement to have him transferred made.
 Soon after the patient has being transferred , I will make a post operative bed in anticipation of
his arrival with all the necessary bed accessories
CONSENT FORM
 Sufficient information needs to be given to the client/patient through out the preparation.
 Refer the notes below on the physical preparation of a pt undergoing elective surgery
 Preparing the client just prior to surgery {immediate preoperative care
 Consult the physician’s orders for preoperative instructions.

 Examine the patient's health record to confirm that all essential information is included such as
 The physician's medical history and physical examination
 Nurses’ documentation
 Urinalysis report
 Blood type and cross match
 Chest X-ray and electro cardiogram
 Other pertinent diagnostic tests
 Medication administration record
 Confirm that an informed consent has been signed by the client
 Use the check list to see what has been done for the patient
 Check the patients identity
 Take and record the vital signs
 Instruct the client to take a shower or an antiseptic bath {follow hospital policy}
 Instruct client to remove all make -up and nail polish
 Provide the client with a clean hospital gown after the bath
 Ask the client to remove all jewelry and other valuables and place them in a secured place, if
client refuses to remove ring, secure it with a tape. Don’t cover nail beds with tape
 Remain alert to the clients anxiety or questions
 Carry out the prescribed orders such as;
 Insertion of I.V line, solutions and medications
 Urinary catheterization
 Naso gastric intubation
 Before giving the preoperative medication
 Instruct the patient to empty his bladder
 Remove all prosthesis from the patient such as
 Dentures
 Eye glasses or contact lenses
 Artificial limbs
 Administer the preoperative medications
 Explain to the patient that they may feel sleepy or have a dry mouth

POST OPERATIVE CARE
OBJECTIVES
 The Nurse’s broader objective is to return the patient to an optimal state of function possible.
 With that in mind, the nurse therefore provides
 Comfort,
 maintains health body systems,
 prevents complications
 And teaches client to manage his own health needs.
THE IMMEDIATE POST OPERATIVE PERIOD
 Surgery ends when the surgeon closes the skin. The client is transported immediately to what is
called the recovery room or post anesthetic care unit. {PACU}
 If the client was at high risk before surgery, has a complication or had a life threatening event
during the surgery, had prolonged exposure to anesthesia, he may be transferred to the intensive
care unit.
 Recovery from anesthesia is the reverse of induction; the client moves from surgical anesthesia
into the stage of excitement and analgesia before consciousness returns
OBJECTIVES IN THE IMMEDIATE POST-OP CARE
 The main objectives in the care of a patient in the immediate post period fall under three aims;
{ABC’s}
 Airway
 Breathing
 Circulation
 Until the patient returns to a state of full consciousness and awareness, the nurse ensures that the
airway is clear or patent. She can do this by removing aspirations {any secretions} from the
mouth, ensuring that the airway is not blocked from a falling tongue or dentures.
 Repositioning patient in Sims position or recovery position aids drainage of secretions.
 The patient should not have labored breathing.
 The breathing needs to be spontaneous and regular; the circulatory function is of prime
importance.
 The nurse also monitors the client’s level of consciousness and awareness.
 Vital signs, color and temperature are checked every 15 minutes.
 Intravenous fluids or blood transfusions should be running as prescribed.
 Body fluids, wound drainage and other critical signs that give clues to the patient’s progress need
to be monitored.
 The physical safety is the other priority in the nursing care as the unconscious patient.
 Is patient enabling to manage his own needs?
 The nurse also needs to provide comfort measures of which the utmost important is pain control.
The pain becomes acute and more intense as the patient recovers. Giving a full prescribed dose of
analgesia before full recovery may depress the CNS dangerously so the recovery room nurse
judges the condition of he client to determine the exact dose of narcotic to be given. So analysis
of the type of anesthesia and dose, vital signs and level of consciousness will be important factors
to consider.
 The nurse thus gives a fractional dose at frequent intervals via the intravenous line.
 Other comfort measures to be done include;
 Changing of patient position,
 regulating patient temperature
 and responding to clients complaints
 Other consideration are to explain to the client the gadgets or equipment such as respirators that
could be mounted on the patient as he recovers to avoid anxiety.
The immediate post operative care is complete when:

 Patient returns to full consciousness;
 Vital signs are stable for at least one hour
 No excessive drainage/bleeding
 No adverse physiologic effects from analgesia
 All recovery room orders have been done
 The surgical unit staff is ready to receive the client
GENERAL POST-OPERATIVE CARE IN THE WARD.
The main objectives for post op care are to:
 Ensure that the patient recovers fully from the effects of surgery and anesthesia
 Returns to his premorbid state as quickly as possible
 Ensure an optimal respiratory function
 Return of bowel and bladder function
 Relief of pain
 Optimal cardiovascular function
 Maintenance of nutritional balance
 Quick wound healing
 Prevention of any complications
ENVIRONMENT
 The PACU communicates with the ward on the impending transfer of the patient and if there is
any need for additional items/equipment to be prepared for the care of the patient
 The patient room is made ready by assembling the necessary equipment and supplies such as the
I.V.pole, suction machine, oxygen machine, bed accessories, drainage receptacles, emesis basin,
disposable pads, and blankets.
 The patient is admitted to the acute bay near the nurses’ station for easy observations.
 The environment should be quiet to ensure undue stress as patient is recovering. It should be well
light, clean and have good ventilation.
 The bed needs to have rails and in low position to avoid accidental falls.
POSITION
 The position of the patient will depend on the type of surgery done. It should be such that it does
not interfere with the patency of the airway, In a number of situations, Position the patient in the
semi prone until fully recovery has taken place after which time the patient can assume a position
he finds comfortable. This prevents secretion from accumulating along the airway or the tongue
from falling back. An idea position also reduces pain and helps to maintain the integrity of the
skin.
 2hrly turnings should be done when a patient is unable to move himself in bed.
 A patient on traction can be assisted to sit up in bed or move slightly side to side to prevent
pressure sore development.
OBSERVATIONS
 Monitor the vital signs of temp, B.P pulse and respirations every 15min. progress to half hourly
and hourly as the condition stabilizes. A lowered B.P may signify post operative bleeding; Low
pulse and respiration rates are suggestive of impending shock. A high temp after 48 hrs may be
suggestive of pot operative infection.
 Observe the general condition of the patient
 Noting the level of consciousness, orientation and ability to move extremities.
 Note skin warmth moisture and color.
 Check the wound site and wound drainage systems. Connect the drainage tubes to gravity or
suction.
 Note if there is any bleeding from the wound site reinforce bandage if necessary.
 Check I.V sites for patency and infusion for correct rate and solutions.
PAIN RELIEF
 Comprehensive preoperative information on the nature of surgery is a sufficient factor in

reducing post operative pain
 Assess pain level, pain characteristics {location and quality}
 Position patient to enhance comfort
 Administer prescribed analgesics .These are usually narcotics such as pethidine or morphine
REST AND ACTIVITY
 Most patients will be reluctant to get of bed after surgery. Reminding them of the importance of
early ambulation is critical in the prevention of post op complications.
 Surgical patients should be out o f bed as soon as possible to prevent atelectasis, hypostatic
pneumonia gastrointestinal discomfort and circulatory problems
 Ambulation increases ventilation
 Passive limb exercises should be done
 Pain is often reduced when early ambulation is done
 Hospital stay and cost are also reduced when a patient is allowed to ambulate early
CARE OF THE WOUND

 An on going inspection of the surgical wound should is done.
 This involves observing the approximation of the wound edges, integrity of the sutures, redness
of the wound discoloration, warmth, swelling, tenderness and drainage.
 Ensure that wound drainage continues if there is a drain
 Increasing or excessive drainage should be reported to the Doctor
 Dressing change should be done following Dr orders
 The first post operative dressing is usually changed by the Dr
 Wound is cleaned on a daily basis with prescribed solutions
 Keep the sutures clean and covered by a dressing
 Sutures are removed on the 7 to the 8 post operative day
 Patient is instructed on how to care about the wound at home
DIET/NUTRITION
Patients may be nil orally the first few days after surgery.
 Nausea hiccups and vomiting is common after anesthesia
 Follow the Dr Orders on how you will proceed I introducing food to the patient.
 Initially patient’s may start with sips of water to keep he moth moistened the progress to intake of
fluid diet.
 Monitor the return of bowel sounds before semi-solid foods and solid food can be given.
 The patient continues on Intravenous infusion usually alternating with dextrose and normal saline
 Maintain a balanced nutritional diet to enhance quick wound healing

ELIMINATION
 Constipation is common among post op cases this may be a result of decreased mobility, reduced
oral intake and some analgesics. In addition patients wound fear to go to the toilet
 Stool softeners can be given
 Inform the Dr if you observe abdominal distension
 Monitor the fluid intake and out put decreased urinary out put could indicate impending shock
MEDICATIONS
 Administer the prescribed analgesics and antibiotics
 Monitor the patients tolerance to drugs and any drug reaction
 Give blood transfusion when ordered
 Intravenous fluids continue as per Dr orders
INFORMATION, EDUCATION AND COMMUNICATION
 The I.E.C should focus on promoting home and community based care
 Teach patient about self care
 Good health living habits
 Continued ambulation
 Good nutrition
 Importance of taking prescribed drugs
 Importance of review
 Community support groups
COMMON POST-OPERATIVE COMPLICATIONS

 Respiratory dysfunction
 Fluid and electrolyte imbalance
 Dehydration
 Bleeding/hemorrhage
 Infection of wound
 Unrelieved pain
 Heart failure
 Hypothermia and hyperthermia
 Urinary retention
 Constipation
 Wound dehiscence

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DEDICATION

With Great Thanks and Love

This SURGERY & SURGICAL NURSING booklet is dedicated to

My Lovely Auntie Mukwae Inonge Justina Kazembe Akashambatwa,

Sweet Parents Muwana Akashambatwa & Alice Nawa Kalaluka;

Beautiful Lovely Friend Kabwe Bwalya.

Love You All

AKASHAMBATWA M. FREEBORN; akashambatwaf@yahoo.com LIVINGSTONE NURSING SCHOOL2009/12 page 1

ITEM PAGE No:

AKASHAMBATWA M. FREEBORN; akashambatwaf@yahoo.com LIVINGSTONE NURSING SCHOOL2009/12 page 2

We can now take look at the breakdown of the paper.

Section A. comprises all aspects of general surgery, surgical nursing.

AKASHAMBATWA M. FREEBORN; akashambatwaf@yahoo.com LIVINGSTONE NURSING SCHOOL2009/12 page 3

THIS SECTION COMPRISES ALL ASPECTS OF ENT, OPTHALMOLOGY AND

AKASHAMBATWA M. FREEBORN; akashambatwaf@yahoo.com LIVINGSTONE NURSING SCHOOL2009/12 page 4

ZAMBIA REGISTERED NURSE FINAL EXAMINATION

WRITE No. OF QUESTIONS ANSWERED/ATTEMPTED

No. No. No. No. No.

No. No. No. No. No.

AKASHAMBATWA M. FREEBORN; akashambatwaf@yahoo.com LIVINGSTONE NURSING SCHOOL2009/12 page 5

which must be returned.

2. Start each question on a new page.

3. Write on both sides of paper.

the spaces provided.

AKASHAMBATWA M. FREEBORN; akashambatwaf@yahoo.com LIVINGSTONE NURSING SCHOOL2009/12 page 6

ANSWER TWO (2) QUESTIONS ONLY FROM THIS SECTION.

BENIGN PROSTATIC HYPERTROPHY

a) (i)Define the term benign prostatic hypertrophy 3%

AKASHAMBATWA M. FREEBORN; akashambatwaf@yahoo.com LIVINGSTONE NURSING SCHOOL2009/12 page 7

Mention {4} four complications of abdominal surgery (15%)

{a} Define Strangulated Hernia (5%)

{a} Define superficial burns (5%)

AKASHAMBATWA M. FREEBORN; akashambatwaf@yahoo.com LIVINGSTONE NURSING SCHOOL2009/12 page 8

i. Define thyroidectomy (5%)

ii. Draw a well labeled diagram of the thyroid gland (15%)

c) Explain five 5 common causes of haemorrhoids (20%)

AKASHAMBATWA M. FREEBORN; akashambatwaf@yahoo.com LIVINGSTONE NURSING SCHOOL2009/12 page 9

b) Explain the following types of wound healing (24%)

II. Second intention

III. Third intention

{a} Define under water seal drainage (5%)

AKASHAMBATWA M. FREEBORN; akashambatwaf@yahoo.com LIVINGSTONE NURSING SCHOOL2009/12 page 10

ANSWER ONE (1) QUESTION ONLY FROM THIS SECTION.

CANCER OF THE BREAST

a) Give four clinical staging of cancer 8%

AKASHAMBATWA M. FREEBORN; akashambatwaf@yahoo.com LIVINGSTONE NURSING SCHOOL2009/12 page 11

a) Define post abortal care (PAC) (5%)

ii) Describe the three types of lochia 12%

ANSWER TWO (2) QUESTIONS ONLY FROM THIS SECTION.

AKASHAMBATWA M. FREEBORN; akashambatwaf@yahoo.com LIVINGSTONE NURSING SCHOOL2009/12 page 12

a) Define acute septic arthritis 5%

a) (i) List (5) five possible causes of cataracts in Zambia. 5%

a) Define gas gangrene 3%

{a} Define gangrene (5%)

a. Define amputation (5%)

d) Explain five (5) complications that may follow mastoidectomy (25%)

AKASHAMBATWA M. FREEBORN; akashambatwaf@yahoo.com LIVINGSTONE NURSING SCHOOL2009/12 page 15

GENERAL NURSING COUNCIL OF ZAMBIA

WRITE No. OF QUESTIONS ANSWERED/ATTEMPTED

No. No. No. No. No.

No. No. No. No. No.

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AKASHAMBATWA M. FREEBORN; akashambatwaf@yahoo.com LIVINGSTONE NURSING SCHOOL2009/12 page 17